Neurosis: symptoms and treatment. obsessive-compulsive disorder

Neurosis obsessive states(obsessional neurosis) Obsessive, that is, existing apart from the will and desire of a person, can be both certain thoughts, memories, ideas, doubts, and actions. Very often, obsessions are the result of a demonic

What is obsessive-compulsive disorder?

Obsessive-compulsive disorder is a disease characterized by obsessive obsessions and compulsions that interfere with normal life. Obsessions are persistent unwanted ideas, fears, thoughts, images, or urges. Compulsions are stereotypically repetitive behaviors. Obsessions often cause anxiety, and compulsions or rituals serve to reduce this anxiety. A person's life can be significantly disrupted due to obsessive-compulsive disorder. Obsessive thoughts or actions can be so time consuming and so painful that it becomes difficult for a person to lead a normal life. From all this, family and social life the patient, as well as the work performed by him. Unfortunately, for the most part, people with OCD do not seek help for their condition because they are either confused, ashamed, or afraid of being seen as "crazy." Thus, many people needlessly suffer.

Can obsessive-compulsive disorder be treated?

Yes. Many people have been treated with a combination of behavioral and drug therapy. Behavioral therapy consists of confronting fearful situations with the aim of reducing anxiety and postponing compulsive behaviors for longer and longer periods of time. long periods time. In some cases, people with OCD "forget" how certain things are normally done. To change their behavior, it is often useful for them to have someone who would be an example of normal behavior. The doctor may prescribe medicines. These drugs are prescribed only for a short time in order to alleviate the condition you experience in the fight against rituals.

obsessive-compulsive disorder

Obsessions (anankasticity, obsessive-compulsive syndrome) appear when the content of thoughts or impulses to action are constantly imposed and cannot be suppressed or repressed, although it is clear that they are meaningless or, at least, unreasonably dominate thoughts and actions. Since these impulses are persistent, they cause overwhelming fear. It is not the content of obsessions that is pathological, but their dominant character and the inability to get rid of them. Picture of manifestations. There are mild phenomena of obsession that belong to the realm of normal psychological, albeit in anancaste personality structures: if melodies, names, rhythms, or rows of words sound incessantly; if it is impossible to interrupt the counting of clock strikes, stairs or carpet patterns; if because of the love of cleanliness, every disorder is perceived painfully; if they think that it is impossible to leave a desk in a mess or a room unwashed; if they think bitterly that a mistake might have been made; if they believe that it is possible to eliminate an undesirable situation in the future by preventing it with a magical formulation, and in this way defend themselves (by exclaiming three times - that, that, that). Also included are obsessive rituals of eating, smoking, going to bed and falling asleep - fixed habits that are not perceived as painful and which, by their deviation or external influences, can be stopped without causing fear.

At the same time, in terms of content, pathological obsession is aimed at insignificant phenomena, in intensity it is very different, but is always accompanied by fear. The patient cannot keep a distance from his fear, he can neither evade nor dodge, he is surrendered to the power of fear. Pathological obsessions are manifested in thinking ( intrusive thoughts, obsessive ideas, obsessions), in the field of feelings, drives and aspirations (compulsive drives, obsessive impulses) and in behavior (compulsive behavior, obsessive actions - compulsions).

The obsessive thoughts of the patient are determined by the fear that he can hit someone, push someone, run someone over, etc. With these obsessive ideas, it is not so much about his own person (as in phobias), but about other people: something can happen to relatives or has already happened, and the patient is to blame (pathological guilt). Obsessive impulses often have such content as the opportunity to harm, and not so much to themselves as to others, for example, to do something with their child and at the same time fall out of the window; with a knife, once it has fallen into the hands, to injure or even kill someone; speak obscene or blasphemous words; to want, think or do forbidden things. Thus, obsessive impulses are predominantly aggressive in color. In healthy people one can sometimes trace similar impulses, for example, when looking at depth - I could throw myself there; or hurt someone; but these ideas are unstable, they are immediately overcome by "healthy thoughts." do not harm yourself or others. However, patients do not "succumb" to their impulses. The matter does not reach the appropriate actions; but they experience it as unfreedom; aggressive impulses that develop so piercingly give rise to a sharply expressed ethical sense of guilt and further fears (fear of conscientiousness) in the patient. Obsessive behavior is expressed, for example, in an obsessive count: everything that happens before your eyes in greater or lesser quantities (train cars, telegraph poles, matches) must be constantly recounted. In obsessive control, everything must be checked - whether the light is off, whether the gas valve is closed, whether the door is locked, whether the letter is thrown correctly, etc. In the obsessive desire for order, the closet with clothes or the desk must be kept in a special order or everyday activities must be carried out in a specific order. A patient with an obsession with cleanliness washes his hands and other parts of the body endlessly, up to the maceration of the skin and the inability to do anything but wash.

The patient resists these obsessive actions, because he considers them meaningless, but to no avail: if he interrupts control, counting, washing, etc., then there is a fear that something bad will happen, misfortune will happen, he will infect someone, etc. e. This fear only increases the obsessive actions, but does not go away. Particularly painful are the contrasting associations between obscene and "sacred" ideas, the constant antagonism between forbidden impulses and ethical prescriptions. The symptoms of obsession tend to expand. First, the closed door is checked 1 - 2 times, and then it is done an uncountable number of times; obsessive fear is directed only to the kitchen knife, and then to any sharp objects. Hand washing is carried out up to 50 times or more often.

origin conditions.

What contributes to obsessional neurosis as a predisposing factor is evident from familial accumulation, correlations between anancaste personality and obsessional symptoms, and between high performance concordance in twins. Anankasticity is the ground in which obsessional symptoms may, but need not, occur. In addition, there are other conditions for the emergence of neuroses: on the one hand, psychodynamic, and on the other, organic-brain. Sometimes they point to minimal brain insufficiency, which is estimated as the cause of partial weakness of the psyche and makes it difficult for a person to distinguish between "important" and "unimportant". In a number of conditions, the organic brain factor occurs more frequently in obsessional neurosis than in other neuroses. This is evidenced by mild neurological abnormalities (especially extrapyramidal symptoms), mild psychoorganic interest, pathological EEG data and computed tomography. If the patient shows similar signs, which explains his psychodynamics, then this cannot be ignored. Conversely, the indication of psychodynamic connections does not give grounds to neglect the diagnosis of organic pathology.

The structure of the personality of a person with an obsessional neurosis is determined by a pronounced contrast between the id and the superego: the sphere of motives and conscience is very predisposed to this. An anancastic type of response occurs as a result of strict upbringing, unwavering observance of order and cleanliness, super-caring accustoming to cleanliness in early childhood, the prohibition of the realization of sexual impulses and the threat of punishment as a general frustration of children's needs, primarily oedipal impulses.

From a Psychoanalytic Perspective, Libido During the Oedipal Phase child development fixed by displacement at an earlier anal phase of development. This regression, interpreted according to the stages of development, is a return to magical thinking; magically colored obsessive actions should eliminate some threats and fears that arise from undecided and repressed sexual and aggressive impulses - an alarming fear of hurting someone (fear of sharp objects, etc.)

Differential Diagnosis

The symptoms of compulsion within the framework of melancholia are recognized by specific melancholic disturbances of impulses, vital symptoms and various course; despite this, often anankastic depression is misdiagnosed as obsessional neurosis. At the beginning of the schizophrenic process, obsessions may dominate, which may give rise to diagnostic doubts, which disappear as the disease progresses. It is important to distinguish between delusions and obsessions: crazy ideas are not evaluated by patients as meaningless, patients are in solidarity with them; in a delusional patient, unlike a patient with obsessions, there is no awareness of their morbid nature. Although such a conceptual distinction is obvious, there are difficulties in practical diagnostics. There are delusional patients with partial criticism and with the feeling that their delusional experiences are essentially meaningless, but they cannot get rid of them. Although obsession is felt as something irresistible, forced, yet in this case it is not about coercion, but about dependence.

With these obsessive ideas, it is not so much about one's own person (as with phobias), but about other people: something can happen to relatives or has already happened, and the patient is to blame (pathological guilt). Obsessive impulses often have such content as the opportunity to harm, and not so much to themselves as to others, for example, to do something with their child and at the same time fall out of the window; with a knife, once it has fallen into the hands, to injure or even kill someone; speak obscene or blasphemous words; to want, think or do forbidden things. Thus, obsessive impulses are predominantly aggressive in color. In healthy people one can sometimes trace similar impulses, for example, when looking at depth - I could throw myself there; or hurt someone; but these ideas are unstable, they are immediately overcome by “healthy thoughts”. do not harm yourself or others. However, patients do not "succumb" to their impulses. The matter does not reach the appropriate actions; but they experience it as unfreedom; aggressive impulses that develop so piercingly give rise to a sharply expressed ethical sense of guilt and further fears (fear of conscientiousness) in the patient. Obsessive behavior is expressed, for example, in an obsessive count: everything that happens before your eyes in greater or lesser quantities (train cars, telegraph poles, matches) must be constantly recounted. In obsessive control, everything must be checked - whether the light is off, whether the gas valve is closed, whether the door is locked, whether the letter is thrown correctly, etc. In the obsessive desire for order, the closet with clothes or the desk must be kept in a special order or everyday activities must be carried out in a specific order. A patient with an obsession with cleanliness washes his hands and other parts of the body endlessly, up to the maceration of the skin and the inability to do anything but wash.

The patient resists these obsessive actions, because he considers them meaningless, but to no avail: if he interrupts control, counting, washing, etc., then there is a fear that something bad will happen, misfortune will happen, he will infect someone, etc. e. This fear only increases the obsessive actions, but does not go away. Particularly painful are the contrasting associations between obscene and "sacred" ideas, the constant antagonism between forbidden impulses and ethical prescriptions. The symptoms of obsession tend to expand. First, the closed door is checked once, and then this is done an uncountable number of times; obsessive fear is directed only to the kitchen knife, and then to any sharp objects. Hand washing is carried out up to 50 times or more often.

In the process of psychotherapy, it is important to break the vicious circle of "frightening thoughts-fear of going crazy." Obsessive-compulsive disorder is a neurosis, not a psychosis, that is, people "do not go crazy at the same time," but experience severe emotional discomfort, distrust in their thoughts and actions, fear for themselves or their loved ones. Unfortunately, often it is fear that prevents you from contacting a specialist in time and interrupting the development and chronicization of a neurosis. Therefore, it is important at the first stages of the development of neurosis to consult a psychotherapist in a timely manner >>

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obsessive psychosis

Obsessive-compulsive disorder is a disease characterized by polymorphism of psycho-emotional states, obsessive thoughts, memories, doubts that arise against the background of a clear consciousness, understanding by the patient of alien painful conditions and the desire to fight them. Obsessive states relate to the intellectual (obsession), emotional (phobia) and motor (impulse) spheres. Obsessive phenomena can be abstract (futile philosophizing, obsessive counting, etc.) and figurative (memories, doubts, fears, movements, etc.).

Psychopathies include diseases classified as minor borderline psychiatry and considered as an anomaly of character (disharmonious and pathological personality). Character pathology is characterized by totality, persistence throughout the life of the patient and low reversibility. Patients do not adapt well to their social environment and inadequately respond to external influences, including those around them, being characterized by conflict and aggressiveness.

According to WHO, there are the following clinical forms psychopathy:

Arising on the basis of a strong type of GNI (excitable, paranoid);

Arising on the basis of a weak type of GNI (asthenic, psychasthenic, hysterical, pathologically closed, affective, etc.).

Psychoses include persistent organic diseases of the cortical parts of the central nervous system, which are different in etiology and pathogenesis, accompanied by painful mental disorders. They are manifested by an inadequate reflection of the surrounding (real) world and a violation of behavior and mental (reflective, cognitive, somatic) activity. Psychoses are accompanied by the appearance of hallucinations, delirium, psychomotor and affective disorders, different in nature and intensity, etc.

Psychoses are characterized by numerous (receptor, closure-associative, affective) mental disorders.

Receptor disorders are manifested by hyperesthesia, hypesthesia, senestopathy, hallucinations (visual, auditory, tactile, olfactory, gustatory, etc.).

Closing-associative disorders are manifested by impaired memory (hypermnesia, hypomnesia, amnesia, memory deception) and thinking (accelerated, slow thinking, viscosity of thought, inability to separate the main from the secondary, speech confusion, painful ideas, obsessive thoughts, doubts, fears, desires, actions rituals, delusions, etc.).

Affective disorders are manifested by pathology of feelings (emotional hyperesthesia, disorders for an insignificant reason, sensitive dullness, sensory impoverishment, pathological affect, increased affectivity, emotional lability, etc.), mood pathology (euphoria, manic affect, depressive affect, apathy, bulimia, polydipsia, anorexia, impulsive attraction, etc.), pathology of attention (weakness of active attention, increased distractibility, absent-mindedness, pathological concentration of attention) and pathology of activity (intensification, weakening and absence or distortion of volitional activity, hypo- and akinesia, impulsive actions, catalepsy, negativism , mutism, etc.).

There are many types of psychoses (oligophrenia, schizophrenia, manic-depressive, involutional, reactive, etc.) and psychopathological syndromes (psychopathic, emotional, catatonic, delusional, paranoid, paranoid, confusion, etc.).

Obsessive-compulsive disorder - symptoms and treatment. Diagnosis of obsessive-compulsive disorder and test

alarm condition, fear of trouble, repeated washing of hands are just a few signs of a dangerous obsessive-compulsive disease. The fault line between normal and obsessive states can turn into an abyss if OCD is not diagnosed in time (from Latin obsessive - obsession with an idea, siege, and compulsive - coercion).

What is obsessive-compulsive disorder

The desire to check something all the time, the feeling of anxiety, fear have varying degrees of severity. It is possible to speak about the presence of a disorder if obsessions (from Latin obsessio - “representations with a negative coloring”) appear with a certain frequency, provoking the occurrence of stereotypical actions called compulsions. What is OCD in Psychiatry? Scientific definitions boil down to the interpretation that it is a neurosis, a syndrome of obsessive-compulsive disorders caused by neurotic or mental disorders.

Oppositional defiant disorder, which is characterized by fear, obsession, depressive mood, lasts for an extended period of time. This specificity of obsessive-compulsive malaise makes the diagnosis difficult and simple at the same time, but a certain criterion is taken into account. According to the accepted classification according to Snezhnevsky, based on the characteristics of the course, the disorder is characterized by:

• a single attack lasting from a week to several years;
• cases of relapse of a compulsive state, between which periods of complete recovery are fixed;
• continuous dynamics of development with periodic intensification of symptoms.

Contrasting obsessions

Among the obsessive thoughts that occur with compulsive malaise, alien to the true desires of the individual himself arise. The fear of doing something that a person is not able to do by virtue of character or upbringing, for example, blaspheming during a religious service, or a person thinks that he can harm his loved ones - these are signs of contrast obsession. Fear of harm in obsessive-compulsive disorder leads to a studious avoidance of the subject that caused such thoughts.

obsessive actions

At this stage, obsessive disorder may be characterized as a need to perform some action that brings relief. Often mindless and irrational compulsions (compulsions) take one form or another, and such wide variation makes it difficult to make a diagnosis. The emergence of actions is preceded by negative thoughts, impulsive actions.

Some of the most common signs of obsessive-compulsive disorder are:

• frequent washing of hands, taking a shower, often with the use of antibacterial agents - this causes fear of pollution;
• behavior when fear of infection forces a person to avoid contact with doorknobs, toilet bowls, sinks, money as potentially dangerous peddlers of dirt;
• repeated (compulsive) checking of switches, sockets, door locks, when the disease of doubt crosses the line between thoughts and the need to act.

Obsessive-phobic disorders

Fear, albeit unfounded, provokes the appearance of obsessive thoughts, actions that reach the point of absurdity. Anxiety, in which an obsessive-phobic disorder reaches such proportions, is treatable, and rational therapy is the four-step method of Jeffrey Schwartz or the study of a traumatic event, experience (aversive therapy). Among the phobias in obsessive-compulsive disorder, the most famous is claustrophobia (fear of closed spaces).

obsessive rituals

When negative thoughts or feelings arise, but the patient's compulsive ailment is far from the diagnosis - bipolar affective disorder, one has to look for a way to neutralize the obsessive syndrome. The psyche forms some obsessive rituals, which are expressed by meaningless actions or the need to perform repetitive compulsive actions similar to superstition. Such rituals the person himself may consider illogical, but an anxiety disorder forces him to repeat everything all over again.

Obsessive Compulsive Disorder - Symptoms

Obsessive thoughts or actions that are perceived as wrong or painful can be harmful physical health. Symptoms of obsessive-compulsive disorder can be solitary, have an uneven severity, but if you ignore the syndrome, the condition will worsen. Obsessive-compulsive neurosis may be accompanied by apathy, depression, so you need to know the signs by which you can diagnose OCD (OCD):

• the emergence of unreasonable fear of infection, fear of pollution or trouble;
• repeated obsessive actions;
• compulsive actions (defensive actions);
• excessive desire to maintain order and symmetry, obsession with cleanliness, pedantry;
• "stuck" on thoughts.

Obsessive Compulsive Disorder in Children

It is less common than in adults, and when diagnosed, compulsive disorder is more often detected in adolescents, and only a small percentage are children of 7 years of age. Gender does not affect the appearance or development of the syndrome, while obsessive-compulsive disorder in children does not differ from the main manifestations of neurosis in adults. If parents manage to notice signs of OCD, then it is necessary to contact a psychotherapist to select a treatment plan using medications and behavioral, group therapy.

Obsessive Compulsive Disorder - Causes

A comprehensive study of the syndrome, many studies have not been able to give a clear answer to the question about the nature of obsessive-compulsive disorders. Can affect a person's well-being psychological factors(stress, problems, fatigue) or physiological (chemical imbalance in nerve cells).

If we dwell on the factors in more detail, then the causes of OCD look like this:

1. stressful situation or traumatic event;
2. autoimmune reaction (a consequence of streptococcal infection);
3. genetics (Tourette syndrome);
4. violation of brain biochemistry (decrease in the activity of glutamate, serotonin).

Obsessive Compulsive Disorder - Treatment

Practically full recovery is not excluded, but long-term therapy will be required to get rid of obsessive-compulsive neurosis. How to treat OCD? Treatment of obsessive-compulsive disorder is carried out in a complex with sequential or parallel application of techniques. Compulsive personality disorder in severe OCD requires drug treatment or biological therapy, and for mild - use the following methods. This is:

• Psychotherapy. Psychoanalytic psychotherapy helps to cope with some aspects of compulsive disorder: correcting behavior during stress (exposure and warning method), training in relaxation techniques. Psychoeducational therapy for obsessive-compulsive disorder should be aimed at deciphering actions, thoughts, identifying the causes, for which family therapy is sometimes prescribed.
• Lifestyle correction. Mandatory revision of the diet, especially if there is a compulsive eating disorder, getting rid of bad habits, social or professional adaptation.
• Physiotherapy at home. Hardening at any time of the year, swimming in sea ​​water, warm baths of medium duration followed by rubbing.

Medical treatment for OCD

A mandatory item in complex therapy, requiring a careful approach from a specialist. The success of medical treatment for OCD is associated with the right choice drugs, duration of administration and dosage in case of exacerbation of symptoms. Pharmacotherapy provides for the possibility of prescribing drugs of one group or another, and the most common example that can be used by a psychotherapist to recover a patient is:

• antidepressants (paroxetine, sertraline, citalopram, escitalopram, fluvoxamine, fluoxetine);
• atypical antipsychotics (risperidone);
• normotimics (Normotim, Lithium carbonate);
• tranquilizers (diazepam, clonazepam).

Video: obsessive-compulsive disorder

The information presented in the article is for informational purposes only. The materials of the article do not call for self-treatment. Only a qualified doctor can make a diagnosis and make recommendations for treatment based on individual features specific patient.

obsessive-compulsive disorder

Obsessional neurosis - mental disorder, which is based on obsessive thoughts, ideas and actions that arise in addition to the mind and will of a person. Obsessive thoughts often have content alien to the patient, however, despite all efforts, he cannot get rid of them on his own. Diagnostic algorithm includes a thorough questioning of the patient, his psychological testing, the exclusion of organic CNS pathology using neuroimaging methods. The treatment uses a combination drug therapy(antidepressants, tranquilizers) with psychotherapy methods (method of "stopping thoughts", autogenic training, cognitive behavioral therapy).

obsessive-compulsive disorder

Obsessional neurosis was first described in 1827. Domenic Esquirol, who gave it the name "disease of doubt". Then the main feature of the obsessions that haunt the patient with this type of neurosis was determined - their alienation to the patient's consciousness. Currently, 2 main components of the clinic of obsessive-compulsive disorder have been identified: obsessions (obsessive thoughts) and compulsions (obsessive actions). In this regard, in practical neurology and psychiatry, the disease is also known as obsessive-compulsive disorder (OCD).

Obsessional neurosis is not as common as hysterical neurosis or neurasthenia. According to various sources, they suffer from 2 to 5% of the population of developed countries. The disease has no gender predisposition: it is equally often observed in both sexes. It should be noted that isolated obsessions (for example, fear of heights or fear of insects) are also observed in healthy people, however, they do not have such an uncontrollable and irresistible character as in patients with neurosis.

Causes

According to modern researchers, obsessive compulsive disorder is based on metabolic disorders of such neurotransmitters as norepinephrine and serotonin. The result is a pathological change in thought processes and increased anxiety. In turn, disturbances in the work of neurotransmitter systems can be caused by hereditary and acquired factors. In the first case, we are talking about inherited anomalies in the genes responsible for the synthesis of substances that are part of the neurotransmitter systems and affect their functioning. In the second case, among the trigger factors of OCD, one can name various external influences that destabilize the work of the central nervous system: chronic stress, acute psychotrauma, TBI and other severe injuries, infectious diseases (viral hepatitis, Infectious mononucleosis, measles), chronic somatic pathology (chronic pancreatitis, gastroduodenitis, pyelonephritis, hyperthyroidism).

Probably, obsessive compulsive disorder is a multifactorial pathology in which hereditary predisposition is realized under the influence of various triggers. It is noted that people with increased suspiciousness, hypertrophied concern about how their actions look and what others think about them, people with great conceit and his reverse side- self-deprecation.

Symptoms and course of neurosis

basis clinical picture obsessional neurosis are obsessions - irresistibly obsessive thoughts (imaginations, fears, doubts, cravings, memories) that cannot be "thrown out of the head" or ignored. At the same time, patients are quite critical of themselves and their condition. However, despite repeated attempts to overcome it, they do not achieve success. Along with obsessions, compulsions arise, with the help of which patients try to reduce anxiety, distract themselves from annoying thoughts. In some cases, patients carry out compulsive acts covertly or mentally. This is accompanied by some absent-mindedness and slowness in the performance of official or domestic duties.

The severity of symptoms can vary from mild, practically not affecting the quality of life of the patient and his ability to work, to significant, leading to disability. With mild severity, acquaintances of a patient with obsessive-compulsive disorder may not even guess about his existing disease, attributing the quirks of his behavior to character traits. In severe advanced cases, patients refuse to leave the house or even their room, for example, to avoid infection or contamination.

Obsessive compulsive disorder can proceed according to one of 3 options: with the constant persistence of symptoms for months and years; with a relapsing course, including periods of exacerbation, often provoked by overwork, illness, stress, unfriendly family or work environment; with steady progression, expressed in the complication obsessive syndrome, the appearance and aggravation of changes in character and behavior.

Types of obsessions

Obsessive fears (fear of failure) - a painful fear that it will not work out properly to perform this or that action. For example, go out in front of the public, remember a learned poem, have sexual intercourse, fall asleep. This also includes erythrophobia - the fear of blushing in front of strangers.

Obsessive doubts - uncertainty about the correctness of the implementation various activities. Patients suffering from obsessive doubts constantly worry about whether they turned off the tap with water, turned off the iron, whether they indicated the address in the letter correctly, etc. Pushed by uncontrollable anxiety, such patients repeatedly check the performed action, sometimes reaching complete exhaustion.

Obsessive phobias - have the widest variation: from fear of getting sick with various diseases (syphilophobia, cancerophobia, heart attack, cardiophobia), fear of heights (hypsophobia), closed spaces (claustrophobia) and too open areas (agoraphobia) to fear for their loved ones and fear of turning to yourself someone's attention. Common phobias among OCD patients are fear of pain (algophobia), fear of death (thanatophobia), fear of insects (insectophobia).

Obsessive thoughts - names stubbornly "climbing" into the head, lines from songs or phrases, surnames, as well as various thoughts that are opposite to the patient's life ideas (for example, blasphemous thoughts in a believing patient). In some cases, obsessive philosophizing is noted - empty endless reflections, for example, about why trees grow taller than people or what will happen if two-headed cows appear.

Intrusive memories - memories of some events that arise against the patient's wishes, which, as a rule, have an unpleasant coloring. This also includes perseverations (obsessive ideas) - bright sound or visual images (melodies, phrases, pictures) that reflect a psychotraumatic situation that happened in the past.

Obsessive actions - repeatedly repeated in addition to the will of the sick movement. For example, squinting eyes, licking lips, straightening hair, grimacing, winking, scratching the back of the head, rearranging objects, etc. Some clinicians separately distinguish obsessive drives - an uncontrollable desire to count or read something, rearranging words, etc. this group also includes trichotillomania (hair pulling), dermatillomania (damage to one's own skin), and onychophagia (compulsive nail biting).

Diagnostics

Obsessive-compulsive disorder is diagnosed on the basis of patient complaints, neurological examination data, psychiatric examination and psychological testing. It is not uncommon for patients with psychosomatic obsessions to be treated unsuccessfully by a gastroenterologist, internist or cardiologist for somatic pathology before being referred to a neurologist or psychiatrist.

Significant for the diagnosis of OCD are daily obsessions and / or compulsions that take at least 1 hour per day and disrupt the patient's usual course of life. The patient's condition can be assessed using the Yale-Brown scale, a psychological study of personality, and pathopsychological testing. Unfortunately, in some cases, psychiatrists diagnose OCD patients with schizophrenia, which entails improper treatment, leading to the transition of neurosis into a progressive form.

Examination by a neurologist can reveal hyperhidrosis of the palms, signs of autonomic dysfunction, tremor of the fingers of outstretched hands, and a symmetrical increase in tendon reflexes. If a cerebral pathology of organic origin is suspected (intracerebral tumor, encephalitis, arachnoiditis, cerebral aneurysm), MRI, MSCT or CT of the brain is indicated.

Treatment

It is possible to effectively treat obsessive-compulsive disorder only by following the principles of an individual and integrated approach to therapy. It is advisable to combine drug and psychotherapeutic treatment, hypnotherapy.

Drug therapy is based on the use of antidepressants (imipramine, amitriptyline, clomipramine, St. John's wort extract). The best effect is provided by third-generation drugs, the action of which is to inhibit serotonin reuptake (citalopram, fluoxetine, paroxetine, sertraline). With a predominance of anxiety, tranquilizers (diazepam, clonazepam) are prescribed, with a chronic course - atypical psychotropic drugs (quetiapine). Pharmacotherapy of severe cases of obsessive-compulsive disorder is carried out in a psychiatric hospital.

Of the methods of psychotherapeutic influence, cognitive-behavioral therapy has proven itself well in the treatment of OCD. According to her, the psychotherapist first identifies the patient's obsessions and phobias, and then gives him the installation to overcome his anxieties by becoming face to face with them. The exposure method has become widespread, when the patient, under the supervision of a psychotherapist, is faced with a disturbing situation to make sure that nothing terrible will follow. For example, a patient with a fear of getting infected with germs who constantly washes his hands is instructed not to wash his hands in order to make sure that no illness occurs.

A part of complex psychotherapy can be a method of "stopping thoughts", consisting of 5 steps. The first step is to determine the list of obsessions and psychotherapeutic work on each of them. Step 2 is to teach the patient the ability to switch to some positive thoughts when obsessions occur (remember a favorite song or imagine a beautiful landscape). In step 3, the patient learns to stop the obsession by saying aloud the command to stop. Doing the same thing, but saying “stop” only mentally is the task of step 4. The last step is to develop the patient's ability to find positive aspects in emerging negative obsessions. For example, if you are afraid of drowning, imagine yourself in a life jacket next to the boat.

Along with these methods, individual psychotherapy, autogenic training, and hypnosis treatment are additionally used. In children, fairy tale therapy and game methods are effective.

The use of psychoanalytic methods in the treatment of obsessive-compulsive disorder is limited because they can provoke outbursts of fear and anxiety, have a sexual connotation, and in many cases of obsessive-compulsive disorder have a sexual accent.

Forecast and prevention

Complete recovery is rare. Adequate psychotherapy and drug support significantly reduce the manifestations of neurosis and improve the patient's quality of life. Under adverse external conditions (stress, severe illness, overwork), obsessive-compulsive disorder may reappear. However, in most cases, after years there is some smoothing of symptoms. In severe cases, obsessive-compulsive disorder affects the patient's ability to work, a 3rd group of disability is possible.

Given the character traits that predispose to the development of OCD, it can be noted that a good prevention of its development will be a simpler attitude towards oneself and one's needs, life for the benefit of the people around.

Obsessive-compulsive disorder - treatment in Moscow

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OBSESSIVE DISORDERS

Obsessive disorders, primarily obsessive fear, were described by ancient doctors. Hippocrates (5th century BC) gave clinical illustrations of such manifestations.

Doctors and philosophers of antiquity attributed fear (phobos) to the four main "passions" from which diseases originate. Zeno of China (336-264 BC) in his book On the Passions defined fear as the expectation of evil. To fear, he also ranked horror, timidity, shame, shock, fear, torment. Horror, according to Zeno, is fear, leading to stupor. Shame is the fear of dishonor. Shyness is the fear of taking action. Shock is the fear of an unfamiliar performance. Fear is fear from which the tongue is taken away. Anguish is the fear of the obscure. The main types of obsessive-compulsive disorders were clinically described much later.

In the 30s of the XVIII century, F. Lepe (F. Leuret) described the fear of space. In 1783, Moritz published his observations of the obsessive fear of apoplexy. In more detail, some types of obsessive disorders are given by F. Pinel in one of the sections of his classification called "mania without delirium" (1818). B. Morel, considering these disorders as emotional pathological phenomena, designated them by the term "emotive delirium" (1866).

R. Kraft-Ebing in 1867 coined the term "obsessive representations" (Zwangsvorstellungen); in Russia, I. M. Balinsky proposed the concept of "obsessive states" (1858), which quickly entered the lexicon of Russian psychiatry. M. Falre-son (1866) and Legrand du Solle (1875) singled out painful conditions in the form of obsessive doubts with fear of touching various objects. Subsequently, descriptions of various obsessive disorders began to appear, for which various terms were introduced: idees fixes (fixed, fixed ideas), obsessions (siege, obsession), impulsions conscientes (conscious drives) and others. French psychiatrists often used the term "obsessions", in Germany the terms "anancasm", "anancasts" (from the Greek Ananke - the goddess of fate, fate) were established. Kurt Schneider believed that anankastic psychopaths more often than others show a tendency to reveal obsessions (1923).

The first scientific definition of obsessions was given by Karl Westphal: Under the name of obsessions one should mean such representations that appear in the content of the consciousness of a person suffering from them against and contrary to his desire, with the intellect unaffected in other respects and not being conditioned by a special emotional or affective state; they cannot be eliminated, they interfere with the normal flow of ideas and disrupt it; the patient consistently recognizes them as unhealthy, alien thoughts and resists them in his healthy mind; the content of these representations can be very complex, often, even for the most part, it is meaningless, is not in any obvious relationship with the previous state of consciousness, but even to the sickest person it seems incomprehensible, as if flying to him from the air ”(1877).

The essence of this definition, exhaustive, but rather cumbersome, was subsequently not subjected to fundamental processing, although the question of the absence of any significant role of affects and emotions in the occurrence of obsessive disorders was considered debatable. V.P. Osipov considered this thesis of K. Westphal to be not entirely accurate, but nevertheless noted that the opinion of V. Griesinger and other competent scientists coincided with the opinion of K. Westphal. D. S. Ozeretskovsky (1950), who studied this problem quite thoroughly, defined obsessive states as pathological thoughts, memories, doubts, fears, drives, actions that arise independently and against the wishes of the patients, moreover, irresistibly and with great constancy. Subsequently, A. B. Snezhnevsky (1983) gave a clearer designation of obsessions, or obsessive disorders.

The essence of obsessions lies in the forced, violent, irresistible emergence of thoughts, ideas, memories, doubts, fears, aspirations, actions, movements in patients with the realization of their pain, the presence of a critical attitude towards them and the fight against them.

In clinical practice obsessive disorder they are divided into those that are not associated with affective experiences (“abstract”, “abstract”, “indifferent”) and affective, sensually colored (A. B. Snezhnevsky, 1983). In the first group of "neutral" in relation to the affect of obsessive disorders, the most common phenomena of "obsessive sophistication" are described earlier than others. The author of their selection is W. Griesinger (1845), who also gave a special designation to such a phenomenon - Grubelsucht. The term "obsessive philosophizing" (or "futile philosophizing") was suggested to V. Griesinger by one of his patients, who constantly thought about various subjects that had no meaning and believed that he was developing "philosophizing of a completely empty nature." P. Janet (1903) called this disorder "mental chewing gum", and L. du Solle - "mental chewing gum" (1875).

V. P. Osipov (1923) gave vivid examples of this kind of obsessive disorder in the form of continuously arising questions: “why does the earth rotate in a certain direction, and not in the opposite direction? What would happen if she turned in the opposite direction? Would people live the same way or differently? Wouldn't they be different? What would they look like? Why is this scrap four-story? If it had three floors, would the same people live in it, would it belong to the same owner? Would it be the same color? Would he have been on the same street? S. S. Korsakov (1901) refers to a clinical example given by Legrand du Soll.

“Sick, 24 years old, famous artist, musician, intelligent, very punctual, enjoys an excellent reputation. When she is on the street, she is haunted by such thoughts: “Will someone fall from the window at my feet? Will it be a man or a woman? Will this man hurt himself, will he be killed to death? If he gets hurt, will he hurt his head or legs? Will there be blood on the sidewalk? If he immediately kills himself to death, how will I know? Should I call for help, or run, or say a prayer, what prayer to say? Will they blame me for this misfortune, will my students leave me? Will it be possible to prove my innocence? All these thoughts crowd her mind and greatly excite her. She feels herself trembling. She would like someone to reassure her with an encouraging word, but “so far no one suspects what is happening to her.”

In some cases, such questions or doubts concern some very insignificant phenomena. So, the French psychiatrist J. Bayarzhe (1846) tells about one patient.

“He developed a need to ask about all sorts of details about the beautiful women he met, if only by chance. This obsession has always been there. when the patient saw a beautiful lady anywhere, and he could not help but act according to the need; and on the other hand, it was connected, of course, with a mass of difficulties. Gradually, his situation became so difficult that he could not calmly take a few steps down the street. Then he came up with this method: he began to walk with his eyes closed, he was led by an escort. If the patient hears the rustle of a woman's dress, he immediately asks if the person he met is beautiful or not? Only after receiving the answer from the escort that the oncoming woman is ugly, the patient could calm down. So things went pretty well, but one night he was riding on the railway, suddenly he remembered that, being at the station, he did not find out whether the person who sold the tickets was beautiful. Then he woke up his companion, began to ask him whether that person was good or not? He, barely waking up, could not immediately figure it out and said: “I don’t remember.” This was enough to make the patient so excited that it was necessary to send a trusted person back to find out what the appearance of the saleswoman was, and the patient calmed down after he was told that she was ugly.

The described phenomena, as can be seen from the examples, are determined by the appearance in patients, against their will, of endless questions of random origin, these questions have no practical significance, they are often unsolvable, follow one after another, arise obsessively, in addition to desire. According to the figurative expression of F. Meschede (1872), such intrusive questions penetrate the patient's mind like screwing in an endless screw.

An obsessive count, or arrhythmomania, is an obsessive desire to accurately count and keep in mind the number of steps taken, the number of houses met along the way, poles on the street, passers-by men or women, the number of cars, the desire to add up their numbers, etc. Some patients decompose into syllables words and whole phrases, select individual words for them in such a way that an even or odd number of syllables is obtained.

Obsessive reproductions or reminiscences are designated by the term onomatomania. This phenomenon was described by M. Charcot (1887) and V. Magnan (1897). Pathology in such disorders is expressed in an obsessive desire to recall completely unnecessary terms, the names of heroes in works of art. In other cases, various words, definitions, comparisons are compulsively reproduced and recalled.

One patient, S. S. Korsakova (1901), sometimes in the middle of the night had to look in old newspapers for the name of a horse that had once won a prize - so strong was his obsessive thought associated with remembering names. He understood the absurdity of this, but did not calm down until he found the right name.

Contrasting ideas and blasphemous thoughts can also become obsessive. At the same time, ideas arise in the minds of patients that are opposite to their worldview, ethical attitudes. Against the will and desire of patients, thoughts of harming loved ones are imposed on them. Religious people have thoughts of a cynical content, obsessively attached to religious ideas, they run counter to their moral and religious attitudes. An example of "abstract" obsessions of unreal content is the following clinical observation by S. I. Konstorum (1936) and his co-authors.

“Sick G., 18 years old. There were no psychoses in the family. The patient himself at the age of 3, having received a long-desired toy, unexpectedly hit his mother on the head with it. From the age of 8 - pronounced phobias: fear of the death of loved ones, fears of certain streets, water, numbers, etc. At school, he brilliantly studied literature, poorly - in other subjects. In the pubertal period, peculiar thoughts and states began to pursue: he began to be afraid of fire (matches, a kerosene lamp) for fear of burning, burning his eyebrows, eyelashes. If I saw a person lighting a cigarette on the street, my mood would deteriorate for the whole day, I could not think of anything else, the whole meaning of life seemed to be lost. Recently, the fire of the patient worries less. After graduating from school, he suffered from pleurisy, at that time fear appeared when reading lying down - it seemed that eyebrows were pouring onto the book. It began to seem that eyebrows are everywhere - on the pillow, in bed. It was very annoying, spoiled the mood, threw me into a fever, and it was impossible to get up. At that time, a kerosene lamp was burning behind the wall, it seemed to him that he felt the heat radiate from it, felt how his eyelashes were burned, his eyebrows were crumbling. After discharge, he got a job as an instructor in a magazine, but he was afraid to be in the sun so as not to burn his eyebrows. The work was to his liking. I could easily cope with it if obsessive thoughts about shedding my eyebrows on book and paper did not interfere. Gradually, other obsessions appeared, associated with fears for their eyebrows. He began to be afraid to sit against the wall, as “eyebrows can stick to the wall.” He began to collect eyebrows from the tables, dresses and "set them in place." Soon he was forced to leave work. I rested at home for two months, did not read, did not write. Kerosene began to be afraid less. On vacation, he felt good, but the thought of shedding his eyebrows did not leave him. Wash the table many times a day to wash off "eyebrows from the face and hands." Soaked eyebrows so that they do not crumble from drying. When walking home from the station for 3 km, he covered his eyebrows with his hands so that they would not be burned by a kerosene lamp burning at home. He himself considered this abnormal, but he could not get rid of such fears. Soon he got a job again, in winter he wore a demi-season coat, since it seemed that eyebrows were on the winter one. Then he began to be afraid to enter the room, it seemed that there were eyebrows on the tables that would fly at him, which would force him to wash. I was afraid to touch the folder with my hand. In the future, there was a fear of getting into the eyes of glass. He left work, mostly lies at home, “struggles with thoughts”, but cannot get rid of them.

Obsessive doubts described by M. Falre (1866) and Legrand du Solle (1875) are close to obsessive fears. These are most often doubts about the correctness of their actions, the correctness and completeness of their actions. Patients doubt whether they locked the doors, put out the light, closed the windows. Omitting the letter, the patient begins to doubt whether he wrote the address correctly. In such cases, there are multiple checks of their actions, while using various methods to reduce the time of rechecks.

In some cases, doubts arise in the form of obsessive ideas in contrast. This is uncertainty about the correctness of the actions performed with a tendency to act in the opposite direction, realized on the basis of an internal conflict between equivalent, but either unattainable or incompatible desires, which is accompanied by an irresistible desire to free oneself from an unbearable situation of tension. Unlike re-control obsessions, in which "anxiety back" prevails, obsessive doubts by contrast are formed on the basis of actual anxiety, they extend to events occurring in the present. Doubts of contrasting content are formed as an isolated phenomenon without connection with any other phobias (B. A. Volel, 2002).

An example of obsessive doubts in contrast is, for example, the insolubility of the “love triangle” situation, since being with a beloved is accompanied by ideas about the inviolability of the family way of life, and, conversely, being in the family circle is accompanied by painful thoughts about the impossibility of parting with the object of affection.

S. A. Sukhanov (1905) gives an example from the clinic of obsessive doubts, describing one schoolboy who, having prepared his lessons for the next day, doubted whether he knew everything well; then he began, testing himself, again repeating what he had learned, doing this several times in the evening. Parents began to notice that he was preparing for lessons until the very night. When questioned, the son explained that he lacked confidence that everything was done as it should, he doubted himself all the time. This was the reason for going to the doctors and conducting special treatment.

A vivid case of this kind was described by V. A. Gilyarovskiy (1938). One of the patients he observed, who suffered from obsessive doubts, was treated by the same psychiatrist for three years, and at the end of this period, having come to see him by a different route, he began to doubt whether he had got to another doctor with the same surname and name. To reassure himself, he asked the doctor three times in a row to give his last name and three times to confirm that he was his patient and that he was treating him.

Especially often and in the most diverse form obsessive fears, or phobias, are encountered in practice. If simple phobias, according to G. Hoffmann (1922), are a purely passive experience of fear, then obsessive phobias are fear or a negative emotion in general, plus an active attempt to eliminate the latter. Obsessive fears most often have an affective component with elements of sensuality, imagery of experiences.

Earlier than others, fear of large open spaces, fear of squares, or "areal" fear, according to E. Kordes (1871), was described. Such patients are afraid to cross wide streets, squares (agoraphobia), because they fear that at this moment something fatal, irreparable may happen to them (they will fall under a car, it will become ill, and no one will be able to help). This can lead to panic, horror, discomfort in the body - palpitations, coldness, numbness of the limbs, etc. A similar fear can develop when entering enclosed spaces (claustrophobia) and in the midst of a crowd (anthropophobia). P. Janet (1903) proposed the term agoraphobia to designate all position phobias (agora-, claustro-, anthropo- and transport phobias). All these types of obsessive phobias can lead to the emergence of so-called panic attacks, which arise suddenly, are characterized by a vital fear, most often the fear of death (thanatophobia), generalized anxiety, sharp manifestations of a vegetative psychosyndrome with palpitations, disorders heart rate, difficulty breathing (dyspnea), avoidance behavior.

Obsessive fears can be very diverse in terms of plot, content and manifestation. There are so many varieties that it is not possible to list them all. Almost every phenomenon of real life can cause a corresponding fear in patients. Suffice it to say that with the change of historical periods, phobic disorders change and “renew”, for example, even such a phenomenon of modern life as the fashion for buying Barbie dolls that has swept all countries has generated a fear of acquiring such a doll (barbiphobia). Yet the most persistent are fairly common phobias. So, many people are afraid to be on an elevated place, they develop a fear of heights (hypsophobia), others are afraid of loneliness (monophobia) or, conversely, being in public, fear of speaking in front of people (social phobia), many are afraid of injury, an incurable disease, infection with bacteria , viruses (nosophobia, carcinophobia, speedophobia, bacteriophobia, virusophobia), any pollution (mysophobia). Fear may develop sudden death(thanatophobia), fear of being buried alive (taphephobia), fear of sharp objects (oxyphobia), fear of eating (sitophobia), fear of going crazy (lyssophobia), fear of blushing in public (ereitophobia), described by V. M. Bekhterev (1897) “an obsessive smile” (fear that a smile will appear on the face at the wrong time and inopportunely). An obsessive disorder is also known, consisting in the fear of someone else's gaze, many patients suffer from a fear of not keeping gases in the company of other people (pettophobia). Finally, the fear may turn out to be total, all-encompassing (panphobia) or the fear of fear may develop (phobophobia).

Dysmorphophobia (E. Morselli, 1886) - fear of bodily changes with thoughts of imaginary external deformity. The frequent combination of ideas of physical handicap with ideas of attitude and depression of mood is typical. There is a tendency to dissimulation, the desire to "correct" a non-existent deficiency (dysmorphomania, according to M. V. Korkina, 1969).

Intrusive actions. These disorders manifest themselves in different ways. In some cases, they are not accompanied by phobias, but sometimes they can develop along with fears, then they are called rituals.

Indifferent obsessive actions are movements made against desire, which cannot be restrained by an effort of will (A. B. Snezhnevsky, 1983). Unlike hyperkinesias, which are involuntary, obsessive movements are volitional, but habitual, it is difficult to get rid of them. Some people, for example, constantly bare their teeth, others touch their face with their hands, others move their tongues or move their shoulders in a special way, exhale noisily through their nostrils, snap their fingers, shake their legs, squint their eyes; patients can repeat any word or phrases unnecessarily - “you understand”, “so to speak”, etc. This also includes some forms of tics. Sometimes patients develop generalized tics with vocalization (Gilles de la Tourette's syndrome, 1885). Some types of pathological habitual actions (nail biting, nose picking, finger licking or sucking) are considered compulsive actions. However, they are related to obsessions only when they are accompanied by the experience of them as alien, painful, harmful. In other cases, these are pathological (bad) habits.

Rituals are obsessive movements, actions that occur in the presence of phobias, obsessive doubts and, first of all, have the meaning of protection, a special spell that protects against trouble, danger, everything that patients are afraid of. For example, in order to prevent misfortune, patients skip the thirteenth page while reading, in order to avoid sudden death they avoid black. Some people carry “protective” items in their pockets. One patient had to clap his hands three times before leaving the house, this “saved” him from a possible misfortune on the street. Rituals are as diverse as obsessive disorders in general. Performing an obsessive ritual (and ritual is nothing more than obsession against obsession) relieves the condition for a while.

Obsessive inclinations are characterized by the appearance, against the will of the patient, of the desire to perform some meaningless, sometimes even dangerous action. Often such disorders manifest themselves in young mothers in a strong desire to harm their baby - to stab or throw it out of the window. In such cases, patients experience extremely strong emotional stress, the "struggle of motives" drives them to despair. Some are horrified when they imagine what will happen if they do what is being forced on them. Obsessive cravings, unlike impulsive ones, are usually not fulfilled.

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"I have described the organization of the mental apparatus, on the basis of which a number of relationships can be presented in a simple and visual form. In other points, for example, those concerning the origin and role of the Superego, there is still quite a lot that is unclear and incomplete. Now one can demand that such a description would be useful and useful in relation to other things, even if it were only a question of considering what is already known in a new light, grouping it differently and describing it more convincingly. Such an application might also be associated with a fortunate return from dry theory to the evergreen tree of experience (1).

In the above-mentioned work, various dependences of the I are depicted, its middle position between the external world and the It, as well as its desire to simultaneously fulfill the will of all its masters. In connection with the train of thought that arose from the other side, regarding the occurrence and prevention of psychoses, I finally arrived at a simple formula that expresses perhaps the most important genetic difference between neurosis and psychosis: neurosis is the result of a conflict between the I and the Id, while psychosis is the analogous outcome of the same disturbance in the relationship between the ego and the external world.

Surely the warning is true that such simple solutions to a problem cannot be trusted. Our wildest expectations also do not go beyond the assumption that this formula is in the most in general terms will turn out to be correct. But even that would be something. A number of conclusions and findings are immediately recalled, apparently confirming our thesis. From the results of all our analyses, the following emerges: transference neuroses arise from the fact that the ego does not want to receive a powerful drive impulse in the id and contribute to its motor completion, or contests with it the object to which it is aimed. In this case, the ego defends itself against it with the help of the repression mechanism; the repressed opposes this fate and, using methods over which the ego has no control, creates a substitute representation for itself, which is imposed on the ego by compromise, that is, a symptom. The ego, feeling that this intruder threatens and disturbs its unity, continues to fight the symptom in the same way as it defended itself against the original instinctual impulse, and all this results in a picture of a neurosis. The objection that the ego, in performing repression, essentially follows the dictates of its superego, which in turn proceed from the influences of the real external world, which have found their representation in the superego, is not accepted. But at the same time, it turns out that the ego fought on the side of these forces, that their demands were stronger in it than the demands of the drives of the id, and that the ego is the force that sets in motion the repression of this part of the id and strengthens the countercathexis of resistance. In the service of Superego and reality, the ego found itself in conflict with the id, and this is the case in all transference neuroses.

On the other hand, it will be just as easy for us, based on our previous understanding of the mechanism of psychosis, to give examples that indicate a violation of the relationship between the ego and the outside world. In Meinert's amentia, an acute hallucinatory confusion and incoherence of thought, the most extreme and perhaps the most surprising form of psychosis, the external world is either not perceived at all, or its perception remains completely inactive (2). Normally, the external world manifests its power over the Self in two ways: firstly, through new actual perceptions, and secondly, thanks to the stock of accumulated memories of previous perceptions, which in the form of an “inner world” act as a property and an integral part of the Self. With amentia, not only does it become impossible to receive new perceptions, but the inner world, which previously represented the outer world in the form of its reflection, loses its meaning (cathexis); The ego arbitrarily creates for itself a new external and internal world, and there are no doubts about two facts: that this new world is built in the spirit of the impulses-desires of the id and that the motive for this break with the external world is a heavy, seemingly unbearable frustration of desires related to reality. It is impossible not to notice the inner affinity of this psychosis with the ordinary dream. But the condition for dreaming is the state of sleep, the characteristics of which include a complete withdrawal from perception and from the outside world (3).

Of other forms of psychosis, of schizophrenia, it is known that their outcome is affective dullness, that is, they tend to refuse all participation in the life of the outside world. With regard to the emergence of delusional formations, some analyzes have shown us that delusion, like a delivered patch, occurs where the gap in the relation of the ego to the outside world originally arose. If the condition of conflict with the outside world is not much more obvious than we now know, then the reason for this is due to the fact that in the picture of psychosis, the manifestations of the pathogenic process are often overlapped by attempts at healing or recovery (4).

The general etiological condition for the emergence of psycho-neurosis or psychosis always remains frustration, the failure to fulfill one of those irresistible childhood desires that are so deeply rooted in our phylogenetically determined organization. Ultimately, this frustration is always external; in a particular case, it may come from that inner instance (in the Superego) that has assumed the role of representing the demands of reality. The pathogenic effect here depends on whether the ego, in such conflicting tensions, remains true to its dependence on the external world and tries to fetter it, or whether the ego allows it to overcome itself and thereby tear it away from reality. But this outwardly simple state of affairs is complicated by the existence of the Superego, which combines the influences of the id and the external world in an as yet not entirely clear combination and, to a certain extent, serves as an ideal prototype of what all aspirations of the ego are directed to, that is, to take -rhenium of its numerous dependencies (5).

The behavior of the Superego should be taken into account - which has not been done so far - in all forms of mental illness. But we can tentatively postulate that there must be such pathological conditions, which are based on the conflict between the Self and the Super-I. Analysis gives us the right to assume that melancholia is a typical example of this group, and then we will resort to the name "narcissistic neuroses" to designate such disorders. If we find motives for separating states such as melancholia from other psychoses, then this will not go against our impressions. But then we will notice that we were able to complete our simple genetic formula without abandoning it. Transference neurosis corresponds to the conflict between ego and id, narcissistic neurosis to the conflict between ego and superego, psychosis to the conflict between ego and the external world. True, we cannot yet say whether we have really received a new understanding or simply added to the collection of our formulas, but I think that the possibility of using this formula should nevertheless give us the courage not to lose sight of the proposed division of the mental apparatus into I, Super-I and It.

The assertion that neuroses and psychoses arise from conflicts between the ego and its various dominant instances, i.e., that they correspond to a defect in the function of the ego, which nevertheless shows a tendency to reconcile all these different demands, must be supplemented by another reasoning. I would like to know under what conditions and by what means the Ego manages to get away from conflicts without illness, which, of course, always exist. This is a new area of ​​research, which, of course, will take into account a variety of factors. However, two points can immediately be distinguished. The outcome of all such situations will undoubtedly depend on economic relations, on the relative magnitudes of competing strivings. And further: I can avoid a breakthrough in one place or another due to the fact that it deforms itself, loses its own integrity, perhaps even splits or disintegrates (6). Thus the inconsistencies, oddities, and silly antics committed by people appear in the same light as sexual perversions, which, once accepted, render repression superfluous.

In conclusion, the question must be asked what could be a mechanism analogous to repression by which the ego renounces the external world. I think that this question cannot be answered without new research, but its content, like repression, must be the withdrawal of the cathexis emanating from the ego (7).

1 - Wed. the words of Mephistopheles in Goethe's Faust, part I, scene 4.

2 - However, this definition has been corrected to limit it to a passage in chapter VIII of Freud's Outline of Psychoanalysis (1940a, p. 132), published after Freud's death, where it says: happen completely. But it seems to occur only in rare cases, and perhaps never at all. Even about conditions that are so far from the reality of the external world, such as: hallucinatory confusion of consciousness and incoherence of thoughts (amentia) - after their recovery, you learn from patients that even during illness, in the corner of their soul, as they say, was hiding normal person, who, like an outside observer, followed the confusion that the disease caused.

3 - Wed. work "Metapsychological addition to the theory of dreams" (1917).

According to the data of all our analyses, transference neuroses arise because the ego does not want to receive a powerful drive of drives that exist in the id and does not want to assist in the motor reaction of this drive, or this drive is unacceptable for the object that it has. in mind. The ego defends itself against it by means of a repression mechanism; the repressed rebels against its fate and, using paths over which the "I" has no power, creates a substitute formation for itself, which is imposed by the "I" through compromises, that is, a symptom.

Freud Z. Neurosis and Psychosis (1924)

In my recently published work I pointed to the dismemberment of the mental apparatus; On the basis of this division, a whole series of relations can be stated in a simple and illustrative form. In other points concerning, for example, the origin and role of the "super-ego", there is still much that is unclear and inexhaustible. It can be demanded that such a construction be applicable to other issues and contribute to their resolution even if it were only a matter of considering what is already known in a new understanding, grouping it differently and describing it in a more convincing form. With such an application might also be associated a beneficial return from hoary theory to eternally youthful experience.

The above work describes the numerous dependencies of the "I", its mediating role between the outside world and the "It", and its desire to please all its masters at the same time. In connection with the train of thought, on the other hand, which discussed the occurrence and prevention of psychosis, I ended up with a simple formula expressing perhaps the most important genetic difference between neurosis and psychosis: neurosis is a conflict between the ego and the id, psychosis is the analogous outcome of such a disturbance in the relationship between the ego and the outside world.

Of course, we would do well to be distrustful of such a simple solution to the problem. In the same way, our expectation goes no further than this formula, at best, being true only in the crudest terms. But even that would be an achievement. We immediately recall a whole series of views and discoveries that seem to confirm our position. According to the data of all our analyses, transference neuroses arise because the ego does not want to receive a powerful drive of drives that exist in the id and does not want to assist in the motor reaction of this drive, or this drive is unacceptable for the object that it has. in mind. The ego defends itself against it by means of a repression mechanism; the repressed rebels against its fate and, using paths over which the "I" has no power, creates a substitute formation for itself, which is imposed by the "I" through compromises, that is, a symptom. The ego finds that this intruder threatens and disturbs its unity, continues its struggle against the symptom just as it defended itself against the original impulse of the instincts, and all this results in a picture of a neurosis. An objection to this cannot be the pointing out that the “I”, in undertaking repression, follows, in essence, the dictates of its “super-I”, which again originate from such influences of the real external world that have found their representation in the “super-I”. ". However, it turns out that the “I” was on the side of these forces, that their demands were stronger in the “I” than the demands of the drives inherent in the “It”, and that is the force that represses the corresponding part of the “It” and strengthens the counteractivity of the resistance. . Serving the "super-I" and reality, "I" came into conflict with the "It"; this is the state of affairs in all transference neuroses.

On the other hand, it will be just as easy for us, following our view of the mechanism of psychoses that we have up to now, to give examples that indicate a violation of the relationship between the "I" and the external world. In Meinert's amentia, an acute hallucinatory confusion, the most extreme, perhaps the most striking form of psychosis, the external world is either not perceived at all, or its perception remains without any effect. In the normal case, the external world dominates the “I” in two ways: firstly, through ever newer and newer, as relevant as possible perceptions, and secondly, through the treasury of memories of previous perceptions, which form property and an integral part in the form of an “inner world” I". With amentia, not only does it become impossible to receive external perceptions; the inner world, which until now has been a substitute for the outer world in the form of a reflection of it, loses its meaning (activity); The “I” creates for itself, completely independently, a new external and internal world, and two facts indicate with certainty that this new world is built in the spirit of desires emanating from the “It”, and that a heavy, proving unbearable rejection of desires associated with reality , is the motive behind this break with the outside world. It is impossible not to notice the inner affinity of this psychosis with the normal dream. But the condition for dreaming is the state of sleep, the characteristic features of which include a complete withdrawal from perception and from the outside world.

Other forms of psychoses, schizophrenias, are known to result in affective dullness, that is, they lead to a refusal to participate in the outside world. Concerning the genesis of delusional formations, some analyzes have shown us that we find delusions in the form of a patch placed on the place where the original rupture in the relationship of the "I" to the outside world arose. If the existence of a conflict with the external world is not much more conspicuous than we currently know, it has its basis in the fact that in the picture of psychosis the manifestations of the pathogenic process are often covered by manifestations of an attempt at cure or reconstruction.

The general etiological condition for the breakthrough of psychoneurosis or psychosis always remains refusal, failure to fulfill one of those irresistible childhood desires that are rooted so deeply in our phylogenetically determined organization. Ultimately, this refusal is always external; in a particular case, it may come from that internal authority that has taken it upon itself to defend the demands of reality. The pathogenic effect depends on whether the “I” remains true to its dependence on the external world in such a conflicting disagreement and whether the “I” tries to drown out the “It”, or whether the “It” defeats the “I” and thus tears it away from reality. But this seemingly simple state of affairs is complicated by the existence of a “super-ego”, which combines in itself in some as yet unsolved connection the influences emanating from the “it” and from the outside world, which is to some extent an ideal prototype of what all are directed to. aspirations of the “I”, that is, to free it from numerous addictions. In all forms of mental illness, one would have to take into account the behavior of the "super-ego", which until now has not taken place. But we can postulate a priori that it must also give painful irritations, which are based on a conflict between the "I" and "super-I". Analysis gives us the right to assume that melancholia is a typical example of this group, and we designate such disorders by the term "narcissistic neuroses". Having found motives for isolating states such as melancholy from other psychoses, we will not go against our impressions. But then we notice that we can add to our simple genetic formula without abandoning it. Transference neurosis corresponds to the conflict between the ego and the id, narcissistic neurosis to the conflict between the ego and the superego, and psychosis to the conflict between the ego and the external world. Of course, we cannot say in advance whether we really have received something new or whether we have only increased the number of our formulas, but I believe that the possibility of using this formula should nevertheless give us the courage to follow further the proposed division of the mental apparatus into “I”, “ super-I" and "It".

The assertion that neuroses and psychoses arise as a result of the conflict of the ego with various dominant instances, that is, that they correspond to a defect in the function of the ego (and this defect is reflected in the desire to reconcile all these different requirements), this assertion must be supplemented by another reasoning. . It would be desirable to know under what circumstances and in what ways the "I" manages to avoid illness in such always, of course, existing conflicts. This is a new area for research, in which, of course, a wide variety of factors must be taken into account. However, two points can be immediately noted. The outcome of such situations will undoubtedly depend on economic relations, on the relative magnitude of competing strivings. And further: "I" will be able to avoid a breakthrough in some place due to the fact that it itself deforms itself, damages its unity. Thanks to this, the inconsistency, strangeness, stupidity of people appear in the same light as their sexual perversions.