Obsessional neuroses are characterized by obsessional thinking and compulsive behaviour (see p. 959) together with varying degrees of anxiety, depression and depersonalization.
They account for some 2% of referrals to psychiatrists and have a prevalence in the general population of about 1 in 1000.
Withdrawal syndrome with benzodiazepines.
The obsessions and compulsions are so persistent and intrusive that they greatly impede the patient’s functioning and cause considerable distress. There is a constant need to check that things have been done correctly and no amount of reassurance can remove the small amount of doubt that persists-the so-called folie de doute. Some rituals are derived from superstitions, such as repetitive actions done a required number of times, with the need to start again at the very beginning if interrupted.
When severe, obsessional neuroses last for many years and are very resistant to treatment. However, obsessional symptoms commonly appear in the setting of other disorders, most notably anxiety neurosis, depression, schizophrenia and organic cerebral disorders, and disappear rapidly with the resolution of such disorders.
Minor variants of morbid obsessional symptoms can be noted fairly frequently in people who are not regarded as ill or in need of treatment. The mildest grade is that of obsessional personality traits such as over-conscientiousness, tidiness, punctuality and other attitudes and behaviours indicating a strong tendency towards rigidity, conformity and inflexibility. Such individuals are perfectionists, have a poor tolerance of shortcomings in others and take pride in their high standards. When such traits are so marked that they override and dominate other aspects of the personality, in the absence of clear-cut obsessional thinking and compulsive rituals, the picture becomes that of an obsessional personality disorder.
Obsessional neuroses are found in 5-7% of the parents of obsessional patients. Such a finding may of course reflect environmental as well as genetic causes.
Neuroimaging data suggest that abnormalities exist in the frontal lobe and basal ganglia while pharmacological and neuroendocrinological research indicates there may be abnormalities in serotonin function in patients with OCD (obsessive-compulsive disorder). More recently the possibility
of abnormalities within the dopaminergic and cholinergic systems has been raised.
Freud suggested that symptoms result from repressed impulses of an aggressive or sexual nature. He also suggested that they occur as a result of regression to the anal stage of development an idea consistent with the obsessional patient’s frequent concern over excretory functions and dirt.
This suggests that obsessional rituals are the equivalent of avoidance responses. However, anxiety actually increases rather than falls after some rituals, which is against such a theory .
A form of behaviour therapy that is particularly effective in the treatment of obsessional rituals is response prevention. Patients are instructed not to carry out their rituals; initially there is a rise in distress but with persistence both the rituals and the distress diminish. Patients are encouraged to practise keeping them under control while returning to situations that normally make them worse.
Another approach known as modelling involves demonstrating to the patient what is required and encouraging the patient to follow this example. In the case of hand-washing rituals, this might involve holding an allegedly contaminated object and carrying out other activities without washing, the patient being encouraged to follow suit. When obsessional thoughts accompany rituals, thought stopping is advocated. In this procedure the patient is taught to arrest the obsessional thought by arranging a sudden intrusion (e.g. snapping an elastic band, clicking the fingers).
Anxiolytic drugs provide short-term symptomatic relief. Any coexisting depression should be treated with an antidepressant. One tricyclic antidepressant believed to have a specific action against obsessional symptoms is clomipramine, but studies suggest that the drug effects are modest and only occur in patients with definitive depressive symptoms.
Psychosurgery is sometimes recommended in cases of severe obsessional neurosis. The development of stereotactic techniques has led to the replacement of the earlier, crude leucotomies with more precise surgical interventions such as subcaudate tractotomy and limbic leucotomy, with lesions placed in the cingulate area and the ventromedial quadrant of the frontal lobe. These are undertaken to relieve patients of obsessional symptoms unresponsive to other treatments. Psychosurgery is now only performed in specialist centres, and formal and detailed consent requirements are laid down in England and Wales in the Mental Health Act 1983.
Two-thirds of cases improve within a year. The remainder run a fluctuating course. The prognosis is worse when the personality is obsessional and the symptoms are severe.