Finding the depressed object in the obsessional: a clinical study

In this paper the author explores the clinical significance of the presence of a depressed internal object in a patient with marked obsessional features, dominating the patient's internal world and restricting relations in external life. After discussing important aspects of the contribution of Freud and later writers to the study of obsessional neurosis, the author provides clinical material that shows the patient's tormented relationship to a feared depressed object that was manifested in the transference. Developing her argument, the author suggests that if the analyst does not fully grasp the primitive anxieties of the underlying state of mind she can be prone to enter into an aggressive enactment with the patient's sadistic superego. This kind of enactment may arouse excitement and triumph in the patient, but actually confirms his doubts and fears about the capacity of his object to contain him.     

History of a Childhood Neurosis and Its Relation to the Adult Superego

The purpose of this paper is to find meaning for the “presence of conscience” observable in the psychoanalytic setting and corresponding evidence for the origins of such ways of thinking, feeling, and remembering. I apply this perspective to the case study of a man who presented as constricted, inhibited, anxious, and self-critical. He was outwardly successful but internally tormented with what can best be described as an obsessional neurosis. His initial symptomatic neurosis was supplanted by a transference neurosis reflecting a childhood obsessional neurosis. In my theory of mind during this analysis, I often saw the original ideas of Freud at work—unconscious sense of guilt, ego ideal, and conscience. The analysand represented over and over the dynamics of the Oedipus stage of development. I made additional observations about character formation and guilt. The analysand terminated his work with me symptom-free. From this case study, I learned that the presence of conscience (guilt and self-denigration), or of superego structure and function in classical terms, is best approached as to origin by following the development of self in reference to the other.     

In the mood to get over yourself: mood affects theory-of-mind use

Understanding others' behavior often involves attributing mental states to them by using one's "theory of mind." We argue that using theory of mind to recognize differences between one's own perspective and another's perspective is a deliberate process of inference that may be influenced by incidental mood. Because sadness is associated with more systematic and deliberate processing whereas happiness is associated with more heuristic processing, we predicted that theory-of-mind use would be facilitated by sadness compared with happiness. Two experiments supported this prediction, demonstrating that participants were more likely to utilize knowledge about others to make inferences about their mental states when they were induced to feel sad than when they were induced to feel happy. These results provide both theoretical insight into the psychological mechanisms that govern theory of mind as well as practical insight into a common source of variability in its use.     

The Experience of Insight Follows Incubation in the Compound Remote Associates Task

The phenomenon of insight is frequently characterized by the experience of a sudden and certain solution. Anecdotal accounts suggest that insight frequently occurs after the problem solver has taken some time away from the problem (i.e., incubation). However, the mechanism by which incubation may facilitate insight problem‐solving remains unclear. Here, we used compound remote associates problems to explore the likely mechanisms by which incubation may facilitate problem‐solving. First, we manipulated problem fixation to explore whether forgetting can explain incubation effects. Second, leveraging previous work linking the experience of insight to unconscious semantic integration, we asked participants to report their experience of insight after each problem solution, including problems solved after a period of distracted incubation. We hypothesized that incubation was not principally important for forgetting but rather frequently causes a shift to a more unconscious semantic integration strategy. Consistent with this we found that initial problem fixation did not predict the improvement in problem‐solving after incubation and that participants were more likely to report insight on problems solved after incubation. Our findings suggest that incubation may facilitate insight problem‐solving leading to a mind‐set shift to a more unconscious problem‐solving strategy involving semantic integration.     

Towards a comprehensive treatment for obsessional thoughts

A systematic treatment approach for obsessional thoughts is proposed. It is based upon an analysis of the chain of convert events and incorporates the distinction between the obsessional idea or fear and the cognitive rituals which follow. Systematic Disruption of covert rituals and Cognitive Restructuring of obsessional ideas are included within the treatment programme. The application of this approach is demonstrated with three cases treated for severe obsessional thoughts and followed up after 2 years.     

Auditory, visual, tactile, olfactory, and bodily hallucinations in patients with obsessive-compulsive disorder

Although much attention has been paid to patients who lack insight into their obsessional beliefs, less importance has been given to individuals with obsessive-compulsive disorder (OCD) who display perceptual disturbances typically found in psychotic disorders, including schizophrenia, schizoaffective disorders, or mood disorders with psychotic features. We would like to call the attention to a phenomenon that has been neglected in the psychiatric literature: the occurrence of hallucinations and related phenomena in patients with OCD. In this case report, we describe five clinical vignettes of patients with OCD with hallucinations in several different sensory modalities, including the auditory, the visual, the tactile, the olfactory, and the cenesthetic ones. Further psychopathological research should clarify the clinical significance of hallucinations among patients with OCD.     

The exclusion of the other2

The author begins by noting that the subject of obsessions and obsessional neurosis seems to have fallen out of favour with the analytic community in spite of the important part it played in the formation of Freud's theories, and notwithstanding the significance of its mechanisms in the maturation of the ego. He then discusses some theoretical considerations regarding the development of the taboo on touching and, by extension, contact. Attention is drawn to the parallels with autistic functioning emphasised by other authors. Particular importance is attached to the distinction between internal and external reality that arises during the anal‐sadistic phase and that leads to polarisation and splitting in obsessional neurosis. Following a discussion of the transference' countertransference situation with obsessional patients and of their concretistic experience in the treatment situation, as also featured in the literature, an extensive case history exemplifies the author's contentions and shows how the patient concerned developed during the course of his analysis. After pointing out the importance of the avoidance of identifications as a mechanism of obsessional defence, the author concludes the paper with a brief comparison of obsessional and hysteriform functioning and a characterisation of the obsessional defence as the excessive recourse to perverted thought functions so as to ward off paranoid anxieties.     

The capacity to symbolise: Ideas and implications

Through a literature review and clinical examples of session material and dreams, this paper explores aspects of the origin and development of the capacity to symbolise. The literature review considers Freud’s thinking on symbols in dreams, hysteria and obsessional neurosis, Klein’s discovery of the importance of unconscious phantasy, Bion’s ideas on the psychotic part of the mind and Bick’s seminal ideas on skin as an important symbolic boundary between psyche and soma. The clinical material in this paper is used to demonstrate the capacity to symbolise, reasons for the impairment of this capacity, and how the translation of symbols through interpretation in a therapeutic setting can enable the symbols to acquire meaning. It includes examples both of the author’s work with adults and of other clinicians’ work with a child and an adolescent in a psychotic state of mind. The paper’s aim is to consolidate the idea that the capacity to symbolise grows out of an optimal early parent/child relationship and that the awareness of the significance of the symbols when they have been interpreted is of crucial importance.     

Worry and obsessional symptoms: a correlational analysis.

Several studies have suggested that worry and obsessional symptoms are systematically associated. In the present study, the relationship between worry and obsessional symptoms was confirmed. Measures included a worry content measure, a worry visual analogue scale, a modification of the everyday checking behaviours scale, and the MOCI. Worry was found to be more consistently associated with checking and doubting, than washing and slowness. It is suggested that worry and obsessional symptoms both occur in response to stress. In addition, it is suggested that worry and checking are functionally similar, and Generalised Anxiety Disorder may represent a 'cognitive' variant of obsessional checking.     

Converting a Freudian analysis into a Jungian one: obsession,addiction, and an answer from Job

In his analyses of obsessional patients, Sigmund Freud suggested that they suffered from intrusive cognitions and compulsive activities. Early psychoanalysts delineated the phenomenology of obsessionality, but did not differentiate what is currently termed obsessive‐compulsive disorder from obsessional personality. However, it was widely recognized that the success of psychoanalysis with obsessional patients was limited due to rigid characterological defences and transference resistances. The present paper examines the case of a middle‐aged obsessional academic who had been treated for nearly twenty years in a ‘classical' Freudian psychoanalysis prior to entering Jungian analysis. It examines how persistent focus on Oedipal conflicts undesirably reinforced the transference resistance in this obsessional man, and suggests that focusing instead on diminishing the harshness of the super‐ego via the therapeutic alliance, and fostering faith in the salutary aspects of unconscious processing has led to salutary results in this case. The biblical book of Job is adopted as ancient instruction in how to address the scrupulosity and addictive mental structuring of obsessionality in analysis.     

Evaluation of an inference-based approach to treating obsessive-compulsive disorder

This study evaluated an inference-based approach (IBA) to the treatment of obsessive-compulsive disorder (OCD) by comparing its efficacy with a treatment based on the cognitive appraisal model (CAM) and exposure and response prevention (ERP). IBA considers initial intrusions in OCD (e.g. "Maybe the door is open", "My hands could be dirty") as idiosyncratic inferences about possible states of affairs arrived at through inductive reasoning. In IBA such primary inferences represent the starting point of obsessional doubt, and the reasoning maintaining the doubt forms the focus for therapy. This is unlike CAM, which regards appraisals of intrusions as the maintaining factors in OCD. Fifty-four OCD participants, of whom 44 completed, were randomly allocated to CAM, ERP or IBA. After 20 weeks of treatment all groups showed a significant reduction in scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Padua Inventory. Participants with high levels of obsessional conviction showed greater benefit from IBA than CAM. Appraisals of intrusions changed in all treatment conditions. Strength of primary inference was not correlated with symptom measures except in the case of strong obsessional conviction. Strength of primary inference correlated significantly with the Y-BOCS insight item. Treatment matching for high and low conviction levels to IBA and CAM, respectively, may optimize therapy outcome.     

Primary obsessional slowness

Although most examples of slowness observed in patients with obsessional disorders can be regarded as secondary to checking rituals, it is suggested that there is a real but rare dysfunction in which the slowness is primary. The proposal is supported by information from standardized interviews and small scale experiments on 10 obsessional patients who were severely handicapped by their slowness. Unsystematic results encourage the hope that this type of disorder is moderately responsive to a simple therapeutic programme of prompting, shaping and pacing.     

Narcissism and Dependency in the Obsessional-Hysteric Marriage

Marriages in which one partner is an obsessional neurotic and the other an hysteric lead to certain patterns of difficulty and conflict that are functions both of the character structure of each and of their interaction. The central dynamic task of marriage is the development and integration of constructive and viable patterns of intimacy. Both the obsessional and the hysteric have serious problems with intimacy and introduce into the marriage distortions and limitations of experience which restrict or even bar intimacy. This paper will examine some of the interpersonal and transactional dynamics considered especially important in such relationships.     

Responsibility attitudes and interpretations are characteristic of obsessive compulsive disorder

The cognitive-behavioural theory of Obsessive Compulsive Disorder (OCD) proposes that a key factor influencing obsessional behaviour is the way in which the intrusive cognitions are interpreted. The present paper reports an investigation of links between clinical symptoms (of anxiety, depression and obsessionality) and responsibility beliefs. These beliefs include not only measures of general responsibility attitudes (assumptions) but also more specific responsibility appraisals consequent on intrusive cognitions. The characteristics of two new questionnaires specifically designed to measure these beliefs were assessed in patients suffering from Obsessive Compulsive Disorder, in patients suffering from other anxiety disorders and in non-clinical controls. The scales measuring negative beliefs about responsibility were found to have good reliability and internal consistency. Comparisons between criterion groups indicate considerable specificity for both assumptions and appraisals with respect to OCD. There was also good evidence of specificity in the association between responsibility cognitions and obsessional symptoms across groups, and that this association was not a consequence of links with anxiety or depressive symptoms. Although the two measures were correlated, they each made unique contributions to the prediction of obsessional symptoms. Overall, the results are consistent with the hypothesis that responsibility beliefs are important in the experience of obsessional problems.     

Evaluation of an Inference‐Based Approach to Treating Obsessive‐Compulsive Disorder

This study evaluated an inference‐based approach (IBA) to the treatment of obsessive‐compulsive disorder (OCD) by comparing its efficacy with a treatment based on the cognitive appraisal model (CAM) and exposure and response prevention (ERP). IBA considers initial intrusions in OCD (e.g. “Maybe the door is open”, “My hands could be dirty”) as idiosyncratic inferences about possible states of affairs arrived at through inductive reasoning. In IBA such primary inferences represent the starting point of obsessional doubt, and the reasoning maintaining the doubt forms the focus for therapy. This is unlike CAM, which regards appraisals of intrusions as the maintaining factors in OCD. Fifty‐four OCD participants, of whom 44 completed, were randomly allocated to CAM, ERP or IBA. After 20 weeks of treatment all groups showed a significant reduction in scores on the Yale‐Brown Obsessive Compulsive Scale (Y‐BOCS) and the Padua Inventory. Participants with high levels of obsessional conviction showed greater benefit from IBA than CAM. Appraisals of intrusions changed in all treatment conditions. Strength of primary inference was not correlated with symptom measures except in the case of strong obsessional conviction. Strength of primary inference correlated significantly with the Y‐BOCS insight item. Treatment matching for high and low conviction levels to IBA and CAM, respectively, may optimize therapy outcome.     

A Structural Analysis of the Obsessional Character: A Fairbairnian Perspective

This paper reviews the object relations model of W.R.D. Fairbairn and applies it to the understanding of the obsessional personality. Fairbairn's model sees attachment to good objects as the immutable component of normal development. Parental failures are seen as intolerable to the child and trigger the splitting defense that isolates (via repression) the frustrating aspects of the object along with the part of the child's ego that relates only to that part-object. This fundamental defense protects the child from the knowledge that he is dependent on indifferent objects and preserves his attachment. The split-off part-self and part-object structures are too disruptive to remain conscious, yet despite being repressed make themselves known through repetition compulsions and transference. The specific characteristics of families that produce obsessional children impact the child's developing ego structures in similar ways. This style of developmental history creates predictable self and object configurations in the inner world, which then translate via repetition compulsion into obsessional behavior in adulthood.     

Chronic Thought Suppression

ABSTRACT We conducted several tests of the idea that an inclination toward thought suppression is associated with obsessive thinking and emotional reactivity. Initially, we developed a self-report measure of thought suppression through successive factor-analytic procedures and found that it exhibited acceptable internal consistency and temporal stability. This measure, the White Bear Suppression Inventory (WBSI), was found to correlate with measures of obsessional thinking and depressive and anxious affect, to predict signs of clinical obsession among individuals prone toward obsessional thinking, to predict depression among individuals motivated to dislike negative thoughts, and to predict failure of electrodermal responses to habituate among people having emotional thoughts. The WBSI was inversely correlated with repression as assessed by the Repression-Sensitization Scale, and so taps a trait that is quite unlike repression as traditionally conceived.     

Time series analysis of obsessional behavior and mood during self-imposed delay and response prevention

Time series analysis of more than a year of daily self-report of three subjects showed that self-imposed delay and response prevention was effective in decreasing obsessions and compulsions. The subject-controlled treatment had a varied effect on mood—anxiety decreased in two subjects, but depression increased in one. (A similar worsening of mood after elimination of obsessional behavior was found in a previous case study.) Apparently, successful treatment of obsessional behavior will not necessarily lead to an improvement in mood. Concurrent mood symptoms need to be targeted separately; and, plans should be made to deal with mood symptoms that may occur once obsessional behavior is removed.     

The War Memoirs: Some origins of the thought of W. R. Bion

The work of W. R. Bion changed the shape of psychoanalytic theory in fundamental ways, one of the most important of which was Bion's insight into the nature of normal projective identification. No other psychoanalytic theorist has Bion's ability to represent the horrors of psychic abandonment and the converse, the absolute necessity of the presence of another mind for psychic survival. Through a discussion of Bion's War Memoirs 1917–1919 ( Bion, 1997 ), Attacks on linking and A theory of thinking (1993), this paper explores the link between war, masculinity, the maternal and Bion's sensitivity to the significance of everyday interpersonal contact. It is argued that Bion's apocalyptic experiences as a teenage tank commander gave him shattering insight into the extent to which mind is inter-mind, self is inter-self. Bion's life writing has the quality of survivor insight: 'And only I am escaped alone to tell thee' (Job 1: 14–19), as he returns repeatedly to the events of the day when he 'died ', 8 August 1918. His insight into the elemental passions nature of love, hate and mindlessness are borne of his experiences on the battlefield, and exquisitely crystallized in his repeated explorations of an encounter with a dying soldier.     

Obsessional Disorders: A Developmental Systems Perspective

The paper resumes the discussion of obsessional disorders in view of developments that have followed the 1965 Congress of the International Psychoanalytical Association when the last systematic analytic discussion of the Obsessional Neuroses took place. The paper reexamines principal contributions to that congress in an attempt to understand the failure of psychoanalysis to favorably influence the course of these disorders. It notes the subsequent findings of a burgeoning field of child observation that have called attention to the larger infant-caregiver constitutive system within which the intrapsychic phenomenology of the obsessional neuroses is produced and maintained. It draws attention to the crucial impact of the analyst and his causal theories, insufficiently recognized at the lime, in the co-determination of the course and outcome of analytic treatment and proposes a contextual systems approach to the reconfigured understanding of normal and pathological development.

The paper discusses the special role of cumulative trauma in the infant-caregiver system on the formation of enduring obsessional and compulsive patterns. It suggests that in the traumatic developmental system, endangerment to the self and unbearable pain are ever-present threats lo the child, and protective strategies, including importantly the processes of pathological accommodation, occupy a primary motivational status. It describes the automatic shaping of subsequent experience by the internalization of such processes in template formation. Freud's emphasis on aggression and unconscious guilt in the pathogenesis of the obsessional neuroses system is reexamined in the light of the contextual perspective proposed, and a clinical excerpt is offered to illustrate the thesis of aggression and guilt as contextual products of a traumatic developmental system. Special considerations that enter into the reconfigured analytic treatment of obsessional disorders are proposed, and some observations follow about problems commonly encountered in the new approach.

The paper argues for the systematic extension of the quintessential psychoanalytic tools of empathic-introspective investigation and illumination into the contextualization of inner experience in a fresh approach to the psychoanalytic treatment of these disorders.