Obsessive States

Obsessive States, psychopathological phenomena, characterized by the fact that certain contents repeatedly arise in the patient's consciousness, accompanied by a distressing feeling of subjective compulsiveness. The patient is fully aware of the absurdity of this thought, wants to get rid of it, but it is "imposed" against their will. It is in this very combination of clear consciousness on the one hand, and the inability to struggle with something "foreign and alien" on the other, that the characteristic feature of O.S. lies (Westphal, Bumke). The forms of O.S. can be ^extremely diverse. Very close to the phenomena observed in many healthy people, especially those in a state of fatigue, is the persistent return to consciousness of certain speech patterns, images, and melodies. Many find it difficult to shake off the need to go through various names, first and last names (onomatomania), others must count all objects that come before their eyes (houses, windows of houses, street lamps, buttons on clothes, etc.) or perform various arithmetic operations with the numbers noticed (arithmomania). Of definitely pathological nature is obsessive reminiscence (of what was read, events from the past, etc.), usually accompanied by a tormenting feeling of inaccuracy and new efforts to fully reproduce what is being remembered. The element of compulsiveness is felt very painfully in the so-called morose ruminations, the need to return thought to idle and irresolvable questions (Griesinger's "Grubelsucht," "mental chewing" or "metaphysical madness" of French authors). Cases of obsessive doubts (maladie du doute) are very widespread: patients suffer from constant uncertainty as to whether this or that action has been performed and done correctly; whether the door or desk drawer has really been locked, whether the letter sent has accidentally fallen past the mailbox, whether the address on it is written correctly, whether the letters have been mixed up when sealing in envelopes, whether the match thrown on the floor is completely extinguished (in physicians - whether the prescription given to the patient is written correctly and whether an error has occurred in placing the comma when indicating the dose of a strongly acting agent). This uncertainty prompts such patients to constantly check their actions, not being satisfied with repeated checking. From this arises a growing day by day desire for ever greater neatness and precision (manie de la propreté).-Close to obsessive doubts are obsessive fears of contamination (mizophobia), often associated with the fear of infection and usually arising after each contact with objects and people not belonging to the patient's daily routine (delire du toucher), or even after certain meetings that were not accompanied by contact. The fear of contamination usually leads to constant washing of hands, the skin of which cracks, becomes covered with abrasions and hurts, which does not prevent patients from spending whole hours at the washstand. Unfounded fears of a certain type of accident are very widespread, for example, fear of being killed by lightning (ceraunophobia), of drowning, of being wrecked in a train. Many patients cannot stand the sight of sharp objects (aichmophobia). Of a special nature are fears that the patient may have done something bad, criminal or reckless. A number of obsessive fears are associated with certain situations (situational phobias). These include the fear of height or depth (hypophobia, bathophobia), which is close to the fear of accidents: patients cannot look down even from a small elevation, are afraid to walk across bridges, etc., and such fear is most often of a complex nature and contains the idea of falling, a rudimentary motor impulse to throw oneself from a height ("as if pulled down") and fear of the possibility of carrying out this impulse. The element of contrast, characteristic of this phobia, is sometimes even more sharply expressed in other obsessive fears: namely, gentle, conscientious people often suffer from the fear that they may develop a desire to commit a crime, to kill their children; namely, when a person wants to create in themselves a feeling of reverence or adoration, so-called "blasphemous" thoughts - abusive words or representations of indecent content relating to the object of reverence, etc. (contrast obsessive representations).-The classic form of situational fears is fear of open spaces (agoraphobia): fear of going out onto wide streets, walking through squares, generally of being in an open place; sometimes this fear disappears if the patient is accompanied by someone, be it a child or a dog. The opposite phenomenon is the fear of being left alone in a room (claustrophobia). Some cannot stand being in a crowd, cannot attend meetings, in the theater, at concerts for fear that at the necessary moment they will not be able to leave. There are people who cannot stand traveling by railroad. Extremely common is the panic fear of certain animals and fear of darkness (nyctophobia).-Concern for one's health represents one of the most abundant sources of obsessive fears. Very common fears of infection lead to fear of contracting syphilis (syphilophobia), rabies, etc. Many patients fear going mad. Close to hypochondriacal fears is the fear of being buried alive (tafofobia). An extensive group of obsessive fears is caused by the idea that for one reason or another attention will be directed at the patient. Orators, lecturers, actors on stage often experience an irresistible fear of appearing before an audience (Rampenfieber of German authors). In some, such a fear arises generally at the thought that someone is looking at them (phobie du regard, fear of the gaze), to the point that they find themselves unable to eat, write, or do anything in the presence of others. Vain and shy people often suffer from the thought that they must appear ugly (dysmorphophobia) or that their clothes, however they adjust them, have some defects. A very frequent and practically important group is the fear of blushing (ereuthrophobia), developing mainly in persons with easily excitable vasomotor reactions. Such people actually blush easily and are brought by this circumstance into ever greater and greater confusion, so that in the end a vicious circle is formed: the fear causes frequent blushing, and the latter intensifies the fear. For many patients, the fear of not being able to hold urine or gas in public is extremely tormenting, in others the stomach rumbles loudly in public, which greatly embarrasses them, in others their hands sweat. All this group of obsessive fears leads to alienation from people and contributes to the development of fear of human society (anthrophobia). A special group of O.S. consists of fears for allegedly threatening close people with misfortune due to certain situations: some patients cannot stay in a room where there is a certain number of certain objects; others think that if they do not perform their morning toilet as they are accustomed to doing, or if they do not close books, do not stamp their foot under certain conditions, then something bad will definitely happen to a close person. This also includes fears of not reading a certain word in a book carefully enough, of not paying attention to certain letters; this fear forces them to return again and again to what has been read. Such fears are close to the usual superstitions of many normal people and, like the latter, serve as a fertile ground for the emergence of extremely peculiar obsessive rituals, the purpose of which is to prevent the impending misfortune and thus destroy the fear. A good example of such "protective" procedures is the ritual described by Freud when going to bed, which developed in a girl: she stopped or removed all clocks from the rooms and arranged flower pots and vases on the desk in such a way that at night they could not possibly fall; at the same time she took care that the door to her parents' room remained half-open. The main part of the ritual concerned the bed: the pillows on it had to be arranged and the eiderdown for covering had to be beaten in a certain way; the act of going to bed was also performed with the observance of a whole series of rules.--Similar in character are the rituals of dressing, washing, and eating of many patients. In complex form they usually already lose their protective value and become independent O.S., sometimes tormenting the patient much more than the original fear. The patient themselves clearly understands the absurdity of their procedures, is extremely ashamed of them, and yet must perform them, because any attempt to resist each time causes a tormenting and difficult to describe feeling that does not give the patient peace and constantly increases up to complete exhaustion.

Some patients become domestic tyrants, continuously forcing members of their family to help them with their procedures; others are ashamed of their obsessive actions and try to mask them as much as possible. - Some obsessive actions and movements may arise primarily, i.e., not being conditioned by the desire to protect oneself from fear; such are the frequent elementary motor obsessions in children (eye blinking, tongue protrusion, etc.). Extremely diverse in their forms of manifestation, Obsessive States can also be very diverse in their severity: in some patients they may be so insignificant that they do not cause them great concern and only slightly limit the freedom of their actions; in others, on the contrary, they do not leave them in peace for a minute and, so to speak, tie them hand and foot, depriving them of any possibility of engaging in their professional activity. In some cases, this latter itself becomes the object of obsessive fear (phobie du metier of the French, Funktionsphobien of the Germans): a tailor is seized with a feeling of fear at the sight of scissors, a barber cannot take razors in his hands, a telegraph operator is afraid of working at the apparatus, an actor is unable to go on stage, a locomotive engineer feels sick specifically on the locomotive. In other patients their fears become so numerous that one has to speak of a universal fear-pantophobia; in others, individual fears eventually recede to the background, but with even greater torment they begin to be seized by the fear of the inevitable appearance of new ones (phobophobia). The diversity of Obsessive States and the complex character of many of them make any classification extremely difficult. Even such an elementary division as into obsessive ideas, fears, and actions (Lowenfeld) turns out to be impossible due to the fact that in a significant number of Obsessive States a combination of all three is found. Friedmann tries to overcome this difficulty by attempting to isolate the primary disorder in each case: affective, intellectual, or impulsive. Magnan distinguished only obsessions (obsessions-obsessive ideas) and compulsive impulses (impulsions); Pitres and Regis-phobias and obsessions, Janet-obsessive ideas (idees obse-dantes) and forced states of agitation (agitations forcees).-Kraepelin divides Obsessive States into 1) obsessive ideas in the proper sense, which do not have a close relationship to the patient's personality, and 2) intimately connected with them-obsessive concerns and fears (phobias). Kraepelin does not recognize a separate group of compulsive impulses. - A more or less clear delimitation of Obsessive States from psychopathological phenomena close to them in form is a matter of relatively recent past. For a long time they were confused with delusional thoughts (for example, Janet recently classified both in one group-idees fixes), even longer with impulsive actions, and to this day they are not always distinguished from 'overvalued ideas'. The main criterion for distinguishing Obsessive States from delusional thoughts and overvalued ideas is considered to be the presence of a critical attitude of the patient toward their condition, the consciousness by them of the unfoundedness of their fears, the meaninglessness of the thoughts that overwhelm them or the absurdity of the acts they commit and their desire to fight them. An obsessive idea, according to many psychiatrists, is always alien to the train of thought of the patient, introduces a splitting into their psyche and because of this becomes especially tormenting for them, while 'overvalued ideas' and delusional thoughts are intimately connected with the entire personality of the patient and despite often their obvious contradiction and inconsistency with reality are accepted by them without any criticism. Although this distinction is basically correct, in a number of cases it turns out to be difficult to draw; moreover: since it has been established that Obsessive States are a frequent phenomenon in schizophrenia, one has to take into account the indisputable fact of the gradual transformation of obsessive ideas into delusional ones. But even where there is no such transformation, many definite obsessive fears (for example of hypochondriacal content) meet with a critical attitude from the patient only in a calm state, when they are absent; at the moment of their appearance, the latter turns out to be completely under their power, e.g., really believes that he has a sick heart and that he may have a fatal attack at any moment. In these cases, it is often quite impossible to draw a distinction between obsessive fear and the hypochondriac overvalued idea, which is sometimes dormant and sometimes flares up in the consciousness, about the mortal danger threatening the life and health of the patient.-The criterion of alienness to the train of thought also turns out to be unsuitable in relation to obsessive doubts, which usually represent only an intensification of the general uncertainty in one's actions in an anxious and suspicious patient. Sometimes one has to speak of a conflict in the consciousness of the patient and of the presence in the latter of a dual simultaneous attitude toward their obsessions, conditioned on the one hand by the feeling of the immediate persuasiveness of the fear or doubt they are experiencing, and on the other-by their contradiction to common sense and logic. Friedmann compares such states with the struggle of fields of vision in a stereoscope. The boundaries separating obsessive actions from impulsive acts are also not fully defined. The criterion here is similar to the one that separates obsessive ideas from delusional ones. Impulsive acts proceed from the actual internal urge of the personality to steal, kill, set fire, etc. The struggle with this urge is carried out only because of its inconsistency with moral requirements and the prohibition imposed by society. Urges of this kind in Obsessive States are denied by most psychiatrists; the fear of the possibility of committing a crime (or throwing oneself from a height, committing suicide) in Obsessive States, according to Kraepelin for example, is based only on the vivid representation of the corresponding terrible fact. As for obsessive actions (rituals), their origin is considered secondary, since they represent protective adaptations against fears; their performance is usually very tormenting for the patient and if it gives them satisfaction, it is only in the sense that it reduces their fears. In reality however there are cases where it is extremely difficult to decide whether to classify them as obsessive or as impulsive acts. Korsakov for example tells about a girl who experienced an irresistible* desire to expose herself to extreme risk: seeing a knife, she felt the need to cut her arm with it; seeing a pin or an needle-to place it vertically in her mouth and press her jaws; on the fourth floor she would stand on the windowsill and balance in such a way as to be in extreme danger of falling. But also with regard to a number of obsessive procedures many authors rightly note that the character of their performance shows not only the desire to protect oneself from fear but also the urge to overcome some impulse. The history of the development of the concept of Obsessive States reveals another controversial aspect-the question of the intellectual or emotional basis of these phenomena. Old psychiatrists spoke not of Obsessive States but of obsessive ideas or obsessive representations. This term was first used by Kraepelin-Ebing in 1867, however to denote a completely different phenomenon (the influence of depressive affect on the content of thoughts). As early as 1868 Grasinger used it in its present meaning to denote cases of obsessive pedantry. In 1877 in an article on obsessive ideas Westphal gave a definition of obsessive ideas, for a long time considered classic: 'Obsessive ideas are those which, with the complete preservation of the intellect in other respects and not being conditioned by emotional and affective state, acquire against the will of the corresponding person a dominant position in consciousness, resist every attempt to remove them, disrupt and cross (durchkreuzen) the normal course of ideas. In addition these are ideas which the patient always considers abnormal, alien to him and which he resists with his healthy consciousness'. In this definition attention is drawn to the assertion about the absence of emotional conditioning, against which Jastrowitz objected at that time and which is in sharp contradiction with the views of French authors Pitres and Regis (1897), who insisted on the position that emotion is an essential component of Obsessive States; they say: 'mentally remove fear and anxiety from Obsessive States, and nothing will remain of them; but if you remove the idea or impulse, preserving anxiety and fear, Obsessive States will remain in their essence'. Bumke (Witke; 1906) basically adhered to Westphal's point of view and, although later he made some corrections to his initial views, still to this day describes Obsessive States in the chapter on disorders of thinking. Kraepelin, and after him V. P. Osipov, on the contrary, vigorously defend the point of view of the affective (fear) basis of the disorder in Obsessive States. Friedmann-occupies an intermediate position.

He asserts that all obsessive states cannot be grouped together under a single definition. Common to all groups (whether primarily intellectual, primarily affective, or primarily impulsive disorders) are defects in thinking, and in the affective group, the rational direction of thoughts is inhibited by the prevailing affect, while the feeling of compulsion is caused by the futile struggle of healthy logic with this affect, whereas in the intellectual forms, the main disorder is the incompleteness of the thinking process itself, and the cause of experiencing obsessiveness is the patient's fruitless efforts to complete the thought and grasp the solution that eludes consciousness.-K. Schneider, agreeing with Friedman that there are obsessive states (obsessive melodies, obsessive counting, obsessive reminiscences, etc.) that apparently have no affective basis, considers these states as not characteristic of cases of true obsessive neurosis, while in cases of incompleteness of the thinking process (obsessive doubts, etc.) he believes the primary basis is undoubtedly fear, which is a consequence of the constant feeling of inadequacy and guilt inherent in such patients. These people live with constant fear of missing something, doing something wrong, and depending on the individual case, these fears find one or another content for themselves. Schneider himself defines obsessive states as follows: 'These are contents of consciousness, characterized by the presence of a subjective feeling of compulsion, which cannot be expelled by an effort of will, although in a calm state they are recognized as meaningless.' According to the author's own indication, this definition does not cover a whole range of cases (e.g., fear of misfortune, responsibility, etc.) that do not contain any meaningless representation or judgment, and in which the meaningless thing is not the obsessive representation itself, but only that it dominates consciousness without reason. Nevertheless, as Schneider rightly notes, such an addition cannot be introduced into the definition itself, because it would provide grounds for classifying a whole range of 'overvalued ideas' as obsessive representations.-The noted disagreements apparently owe their origin mainly to the fact that the concept of obsessive states actually includes heterogeneous phenomena, which, however, are united on the one hand by the common feature of compulsive occurrence in consciousness, and on the other by the fact that they are very often combined in the picture of the same clinical form. The affective theory of the origin of obsessive states has strong support in the views of Freud, who, however, considers only representations and actions as obsessive, not fears. This author believes that in their essence, obsessive states are symbols of sexual experiences from early childhood that caused at the same time as sexual excitement and satisfaction also a painful feeling of remorse, and were then repressed from consciousness. In this repression, the feeling of guilt becomes detached from the content with which it was previously associated and enters into a connection with a new one that symbolically represents the original. This returning sexual symbol in consciousness has a double meaning: on the one hand, it represents the denial of the forbidden impulse and punishment for it, and on the other, it makes it possible to experience the latter again, but not directly, but in a disguised, mitigated form. That there is some connection between many obsessive states and sexual abnormalities was known even before Freud, but the psychogenesis proposed by Freud is at least controversial. In general, the problem of the pathogenesis of obsessive states remains extremely dark and confused. Besides affective factors, their basis can also be assumed to be an innate abnormality of the associative apparatus that directs the action of experiences specifically onto the rails of obsessive thinking and behavior. It must be added that the fixation of obsessiveness often occurs in a form that very much resembles habit formation, in other words, according to the type of Pavlov's conditioned reflexes, although of course the extreme durability and often complete irreducibility of such conditions clearly indicates that the origin of these mysterious pathological phenomena cannot be explained by conditioned reflexes alone. The question of the properties of individual predisposition, on the basis of which obsessive states develop, has not yet been sufficiently clarified. The works of Janet on psychasthenia have prompted a number of authors, including Russians (Gannushkin and Sukhanov, later Yudin), to develop the question of the types of characters that are particularly conducive to the development of obsessive states. At present, it is unanimously recognized that they most easily occur in people who are gentle, indecisive, anxious, unsure of themselves, and prone to constant vacillations and doubts (psychasthenics - Gannushkin, anankasts - Schneider). However, besides people of this type, obsessive states are also often observed in psychopaths of other groups. A number of authors note that the tendency to form obsessive states is often observed in many members of the same family in different generations. Such cases have been described by a number of authors. Obsessive states cannot be considered as belonging to one specific disease, since they can occur in various diseases. Many psychiatrists for a time were inclined to classify obsessive states as symptoms of circular depression or mixed states of manic-depressive psychosis. This opinion was supported, on the one hand, by a number of cases where obsessive states developed in families with a manic-depressive predisposition, and on the other, by the fact that their course is often characterized by periodicity. The fact of the frequent occurrence of obsessive states in depressive patients is indeed confirmed by numerous observations (Kannabich). No less frequently, and perhaps in significantly more cases, obsessive states form an integral part of the symptomatology of schizophrenia, and it often happens that for a certain period the entire picture of the disease consists of the development and deepening of numerous obsessive states. It is often possible to observe with certainty the transformation of obsessive thoughts into delusional ideas in schizophrenics. A distinctive feature of obsessive thoughts and actions in schizophrenia is their relatively small emotional coloring, excessive affectation, and absurdity bordering on the ridiculous, which is usually accompanied by early reduction of work capacity in patients. A number of authors have observed obsessive states, primarily elementary (involuntary return of the same images and turns of speech), in the initial states of epidemic encephalitis and especially in connection with repetitive convulsive movements (Zwangsblicken). Noting in encephalitics in general 'the tendency to retain a once adopted motor setting and the desire to repeat it if the setting is of a nature that quickly ends,' some authors are inclined to explain obsessive representations by damage to the same subcortical mechanisms that explain the motor characteristics of encephalitics. However, the main group of cases with obsessive states is provided by the so-called 'obsessive neurotics,' i.e., psychopathic personalities of one type or another, showing no signs of development of any progressive disease. As noted above, their core is made up of psychasthenics (or anankasts). Accordingly, in most recent manuals, the exposition of the doctrine of obsessive states is combined with the description of this group of psychopaths (K. Schneider, Yudin, Kan). In the genesis of such 'obsessive neuroses,' with the enormous role of constitutional predisposition, great importance also belongs to psychoreactive factors. Despite the frequency of undoubtedly sexual motivation in many cases of 'obsessive neurosis,' in a number of others such motivation can be found only with difficulty, while in them non-sexual sources of their psychogenesis are clearly revealed. This group remains extremely heterogeneous both in its clinical picture and course, and partly in its etiology. There are cases in which the disease seems to depend on the hereditary predisposition of the patient and, developing from early years, does not leave him until deep old age; there are others in which the determining factors are mainly external ones - conditions of upbringing, influence of environment, and psychological conflicts. Between cases of one and the other type, a series of continuous transitions can be found. According to the characterological features of the patients and the content of their obsessions, the following main types of 'obsessive neurotics' can be distinguished. 1. Hypochondriacs; among them, people who, due to fear for their heart, dare not leave the house, especially without escorts and in deserted places (these cases are sometimes incorrectly classified as agoraphobias); also very often fear of infection or going insane; if such fears were not intertwined in the same patients with other forms of obsessiveness, this group would be better excluded from the number of obsessive neuroses altogether, since we are dealing here rather with manifestations of one or another 'overvalued idea' than with obsessive states in the proper sense. 2.

Insecure and indecisive individuals (psychasthenics of Gannushkin); these patients constitute the main group of persons who predominantly give rise to obsessive doubts and intellectualizing. 3. Shy individuals with fear of attracting attention to themselves, blushing, etc. 4. Persons, predominantly inclined toward symbol formation, mainly with obsessive ceremonies, who often differ from the previous groups by their great closed-off nature and lack of understanding (schizoids), and sometimes also by the absence of indecisiveness, which is replaced in them, on the contrary, by a peculiar stickiness, persistence, and aggressiveness (i.e., epileptoid traits). 5. The last group, which is prognostically the most favorable, consists of emotionally labile soft people, prone to rapid mood changes, reacting deeply and strongly to environmental influences; they often give situational and contrasting phobias, although other fears, predominantly of a symbolic nature, are also not uncommon among them. Common to representatives of all these groups is the psychological feature of anxiety, on the basis of which almost all obsessive states develop. As for the place that these 'neurotic' forms occupy in the clinical classification, Gannushkin, in accordance with the gradualness of their formation and the firmness of their fixation, attributes them to the type of psychopathic 'development.' Their course is usually either remitting or slowly progressive in the sense of the appearance of more and more new obsessive states. Often, after reaching a certain level, they then freeze at that level, which gives patients the opportunity to gradually adapt to their morbid condition. The onset of obsessive states usually refers to the period of sexual maturation, although occasionally they appear even in childhood, sometimes before the age of 10. In mature age, they sometimes subside, but often only to reappear with renewed force at the beginning of the age of reverse development. Excitements, overfatigue, and infections (especially often influenza) in women-menstruation usually significantly worsen the condition of patients. There are many known cases where the mentioned factors caused the onset of the disease, which then developed independently of them. The prognosis is the better the more distinct the psychogenesis of the disease and the less expressed its connection with the patient's constitution. In general, it is always doubtful. Even in cases of improvement, one must take into account the probability of a return of the morbid condition. However, since the disease does not destroy the patient's personality, leaving both his intellect and (as long as it does not concern the obsessive states themselves) the emotional-voluntary sphere untouched, most patients get used to developing sufficient protective adaptations to maintain the ability to work; others, however, are forced to give up almost any work. - Treatment represents an extremely difficult task. There is no specific method suitable for all types of obsessive states. Rational psychotherapy is usually powerless, since the patient himself is well aware of the absurdity of his obsessive states. Greater importance has the distraction of his attention, skillful guidance of his behavior, and training in work. Many authors note the good effect of psychoanalysis. However, not a single case of radical cure has been published yet. Some influence may be exerted by hypnosis. - The forensic-medical significance of obsessive states is not great, since most of them have a criminally indifferent content and they all are limited mainly to the inner life of patients. Of course, the mere presence of obsessive states in a subject does not exclude imputability. Lit.: Gannushkin P. and Sukhanov S, On the doctrine of obsessive ideas, Zh. nevropatol. i psikhiatrii, 1902, kn. 3; Janet P., Neuroses, Moscow, 1911; Ivanov-Smolensky A., Obsessive states and phobias, Nauchnaya meditsina, 1922, № 9; Mirelyon L., Obsessiveness, splitting of personality and schizoidia, Trudy Psikhiatr. kliniki Odessk. gos. med. inst., t. I, 1930; Ozereckovsky D., On obsessive ideas in schizophrenia, Trudy Psikhiatricheskoy kliniki 1 MGU, 1925, vypusk 1; Ozereckovsky D. and Dzhagarov M., On the doctrine of obsessive phenomena in epidemic encephalitis, Obozreniye psikhiatrii, 1930, №2; Sklyar N., On the psychopathology of obsessive and related states, Zh. nevropatologii i psikhiatrii, 1908, kn. 1-4; Freud S., Lectures on the introduction to psychoanalysis, t. II, M., 1923; Bumke O., Was sind Zwangsvorgange, Halle a. S., 1906; Friedmann M., Uber die Natur der Zwangs-vorstellungen und ihre Beziehungen zum Willensproblem, Wiesbaden, 1920; Jahrreiss W., Storungen des Denkens (Handbuch der Geisteskrankheiten, hrsg. v. O. Vitke, B. I, B., 1928, lit.); Janet P., Les obsessions et la psychasthenie, P., 1903; Kahn E., Die psychopathischen Personlichkeiten (Handbuch der Geisteskrankheiten, herausgegeben v. O. Vitke, B. V, B., 1928); Kehrer F. und Kretschmer E., Die Veranlagung zu seelischen Storungen, B., 1924; Kronfeld A., Uber seelischen Zwang, Zentralblatt f. d. gesamte Neurologie u. Psychiatrie, B. XIII, 1926; Legrand du Saulle H., Folie du doute avec delire du toucher, P., 1875; Stekel W., Zwang u. Zweifel, T. 1-2, B.-Wien, 1927; Wexberg E., Die Grundstorung der Zwangsneurose, Ztschr. i. d. ges. Neurol. u. Psychiatrie, B. CXXI, 1929; Zwangsneurose, Beriber den IV Kongress fur Psychotherapie in Baden-Baden, ibid., Ref., B. XVII, 1918.