From the obsessive to the obstinate personality

The obsessive ones

After the separation, patient 1 took charge of the child the couple had in common. He has a stable income and has decided not to return to work until the child starts school. He has no history of hypochondria, but, obsessed with the risk of his son "picking up some germ," his life has turned into a living hell. He also fears any domestic accident. He does not socialize with anyone, does not let his son out of his sight, and is incapable of leaving him alone with anyone. He tirelessly cleans the house, washes his hands, keeps watch to make sure there is no small object on the floor or anywhere else that his son might swallow, checks the gas tap and checks that the doors are locked to prevent the child from inadvertently escaping from the living room where he must remain. He considers it safer. If he does not clean more, it is so he can keep an eye on him. He tries to avoid any potential risk, however remote it may seem. For example: if he gets up in the middle of the night to eat something, he has to put his pajamas in the wash because a crumb might have fallen on them, which could attract an ant, which in turn could get into his son's ear and hurt him. One cannot say that he is delusional, but… "in that moment it doesn't seem like nonsense to me."

Patient 2 is a university student who, over the past few years, has become obsessed with his studies. A brilliant student, his grades are among the best in his cohort. However, he is always accompanied by the feeling that his exams "will go badly" as well as the feeling of "not having done enough." He studies a great deal, sleeps little, barely allows himself to rest, and feels exhausted. As the end of the academic year approaches, he suffers anxious episodes that prevent him from concentrating, which distresses him even further. As a teenager he played football and used to feel guilty about his team's defeats.

Patient 3's wife is desperate. He thinks of nothing but work and at home he is constantly on his phone or computer. They sometimes have dinner with friends, but he always wants to return home "to keep turning work over in his mind." His work performance is good, the company is entirely satisfied with it, but he takes any setback in an entirely personal way.When talking about himself he uses terms such as "pigheaded" or "rigid," alluding to his inflexibility. He does not like change and resists altering his schedule. Austere; his family considers him miserly, but he sees it as a display of "ability to adapt to circumstances." His family members complain that he treats them poorly. He acknowledges this, but considers it simply "an excess of sincerity and a lack of tact." He considers himself a good person, with a great memory, who tries to instill in his son values such as sacrifice, respect, coexistence, and effort. He believes that his generosity toward his wife has not been reciprocated.

Patient 4 has a perfect family, a perfect life, a perfect company, and perfectly controls his anxiety through breathing exercises. The only problem is that he becomes obsessed with things, cannot stop turning them over in his mind,overdemandsand overwhelms those around him with his relentlessness. It is the only thing that makes him have a hard time, given that everything is fine.

Patient 5 is a hospitality businessman. Anxious, he thinks of nothing but his business throughout the entire day. He finds it extremely difficult to delegate, since no one does things the way he wants them done, so he personally takes on a large share of the responsibilities himself, such as purchasing.Abnormally miserly, he monitors down to the last cent spent in his household. He literally fears ending up collecting cardboard boxes off the street. He devisessavings plans that are somewhat far-fetched: he wants to give his home to one of his sons and go live with the other one to help him with his mortgage payments.Outside the domestic environment, he tends to think that everyone around him "is an idiot." His handful of friends is more than enough for him; he resists meeting new people and, generally speaking, does not trust others. He believes his sharp intuition allows him to prejudge people, since he is rarely wrong. As a rule, he prefers not to trust at first, which is why he behaves with excessive formality. When offended, he gets angry (only sometimes) more than is normal, and does not easily forget. He sees himself as a person who is hard toward the suffering of others, cold, and not inclined to express feelings of tenderness.

Patient 6 delayed pregnancy for many years in order to prioritize professional success. She explains that she has always demanded a great deal of herself, always giving more. She fears failure. In recent years she no longer places the same importance on work, ever since she became obsessed with the goal of getting pregnant. That determination absorbs her every thought and causes her tremendous anguish. She has not succeeded. She lives in a constant state of anxiety about not letting anyone down. She acknowledges that other people's opinions worry her greatly, and especially the possibility that they might identify her as a failure. She explains that when she falls apart, her mind clouds over, her self-esteem collapses, and she feels incapable of doing anything.

Patient 7 fled in his adolescence from a troubled family, where he frequently received death threats. He has worked very hard to get ahead in life and describes himself as productive, competitive, and high-strung. He suffers from several illnesses and has undergone numerous surgical procedures. He claims to have an extraordinary tolerance for physical pain, which has never prevented him from working.When he is not working, he does not rest either: he fixes a lamp, varnishes, paints the terrace, tidies up. He sleeps poorly. He describes himself as highly self-demanding and does not allow himself to make mistakes, although he is lenient toward the mistakes of others.Some time ago he began to gradually distance himself from his friends. He felt superior to them, especially in terms of his sexual attractiveness. He describes himself as unfaithful and, at the same time, jealous. At work, he feels that people talk about him. He has difficulty taking medication, and his reading of package inserts tends to be alarmist. On one occasion, when I handed him a blood test result, he became absorbed, losing awareness of who was in front of him, and immersed himself in a thorough review of it.

Patient 8 holds a temporary position in public administration and, in his free time, prepares for civil service examinations in order to secure a permanent post. He allows himself virtually no leisure activities, as he feels bad when he is not making good use of his time. His study plan is very demanding, and he despairs when he fails to meet the goals he has set. At the same time, he feels bad about neglecting household chores and leaving his partner to take care of them.Too busy, he has lost contact with his friends and his social circle.

Patient 9, an immigrant, has left her child in her country of origin. She is responsible for a team of IT workers within a large company and is not happy with any of her subordinates. She works tirelessly, well beyond her theoretical working hours. Sometimes at night as well, and even on weekends. She has not taken a vacation in several years. She is incapable of stopping until the problem she is dealing with has been completely resolved. When she stops working she feels unwell, she often cries, and she consoles herself by drinking too much beer. She feels that her efforts go unrecognized. In recent months, an illness has forced her to take sick leave from work. She has become depressed.

His family pushed him to seek consultation due to his bad temper and his tendency to drive those around him to the edge. Patient 10 dropped out of school when he was young — he did not like it — in order to work as a laborer in a family business. Over time, working long hours, more than anyone else, he has risen to become the manager, to the full satisfaction of the family group. However, it is in the domestic sphere where his obsessive functioning has overflowed, especially regarding the upbringing and safety of his only child. Since becoming a father he no longer spends all day at the company. His need to control the household is excessive. Everything must be orderly and placed where he has decided; he is convinced that his is the correct order. He monitors by phone what is going to be eaten, whether a particular food item has been put out to defrost, and so on. Everything must be done his way. His insistence on certain matters is exhausting. The disproportionate outbursts of anger over "having to repeat things" undermine the household's harmony. He has an opinion about everything, including matters he knows little about. The marriage has entered a critical stage, but the patient resists separation out of fear of losing control of the situation. He wants to avoid chaos.

All of these patients would normally be classified as obsessive, one of the most prevalent personality disorders in the general population (10). The majority of obsessive individuals have an obsession with something: domestic responsibilities, work, or studies. There are also those obsessed with sport, although we have not included any examples.

None of these vignettes corresponds to a real patient. However, each one has been drawn up entirely from fragments of flesh-and-blood patients, who provided the raw material from which they were crafted. The vignettes contain small distortions in the anecdotal details. The aim was, without altering what is essential, to prevent the potential identification of the individuals portrayed.

All of them knew themselves to be obsessive or obsession-ridden, yet none came seeking to stop being so. They came on account of depression, anxiety, insomnia, or excessive irritability. Some sought consultation because their family members demanded it of them, worn out by their attitudes and behaviors.

Parallel personality disorders

Most authors understand that the term "personality" refers to those stable behavioral predispositions in which individuals differ from one another. We know that when faced with the same situation, different individuals will most likely react in different ways. It is evident that, at least in part, these differences depend on each person's "way of being" or personality. We are referring to those characteristics that tend not to change excessively, neither according to context nor with the passage of time.

In reality, personality differences are not an exclusively human phenomenon. They have also been observed in the animal world, especially among primates. Each animal species has its own species-specific behavioral patterns (redundant as that may sound), but within those limits, variations exist among specimens, and these variations often have a lasting character. Thus, some chimpanzees are more or less curious than others, more or less gluttonous, aggressive, independent, submissive, friendly, more or less inclined to play with the young, to wander alone, etc. Each one has its own personality.

Human beings are not only aware that each person has their own behavioral particularities, but we find them striking, we are interested in them, and we never tire of discussing them. Anthropologists attest that it was already a daily custom among our hunter-gatherer ancestors.

At first, Psychology applied itself to the scientific study of personalities through the use of multiple-choice questionnaires. "Trait" is the term that began to be used to identify each of those characteristics in which differences between subjects occur. Traits are usually not dichotomous — something one either has or does not have — but rather a continuum along which it is possible to place oneself at different points. For example, in the trait "disagreeableness," each individual can be situated between a maximum (as disagreeable as can be) and a minimum (not at all disagreeable, extremely pleasant).

At least since Kurt Schneider (23), Psychiatry adopted the idea that the personality of some individuals deviates strongly from the mean and that, furthermore, it does so in an abnormal way. In the traditional psychiatric approach to the matter of pathological personality, this does not constitute a formless magma, or a single diagnosis, but is instead divided into concrete entities. Psychiatric classification was initially "typological," which implies that a patient's belonging to type A excludes that same subject's belonging to type B. This strictly typological approach would gradually dissolve over time, so that today the diagnosis of two or more personality disorders in the same individual is accepted.

If we fix our attention on the specific personality disorders listed in manuals and classifications, we come across a curious fact: some of them bear a close relationship to some of the psychiatric illnesses proper. Thus:

• hysteria (or hysterical neurosis) with the hysterical personality (histrionic from the DSM-III onward),
• schizophrenia with the schizoid personality (and with the schizotypal personality, identified more recently),
• paranoia, with the paranoid personality,
• and phobic neurosis with the avoidant personality.

Between personality and illness, two basic types of relationship are assumed:

1. On the one hand, statistical association. It is assumed that among subjects with personality A, the development of illness A' must be far more frequent than in the general population; and that among subjects with illness A', a prior history of personality A must be more frequent than in the rest. The possibility that the illness might trigger a personality change is never considered. In summary: A ⇒ A'.
2. On the other hand, personality and illness must resemble each other; there would exist a phenomenological similarity between symptom and trait, the latter being more generalized and diffuse, more resistant to change, and more egosyntonic. That is: A ≈ A'.

The obsessive personality, according to some studies, is the most frequent personality disorder in the general population and could affect almost one in every 13 adults, at least in the United States (10). It has probably not received attention commensurate with its high prevalence and the significant repercussions it entails.

The disorder would be nothing more than the trait-version of obsessive-compulsive neurosis. But is that so? Does this relationship, which is taken for granted, really exist? A certain phenomenological resemblance is undeniable. It is plain to see that both (obsessive illness and the corresponding personality) share the abnormal tendency to concentrate all thoughts and all activity on a restricted field of interests, and to endlessly "go over the same ground"; but sometimes appearances can be deceiving.

To begin with, a brief historical overview.

Obsessive Personalities

Janet's Psychasthenia (1903)

The origins of the obsessive personality are usually traced back to psychasthenia, a diagnosis conceived and developed by Janet in 1903 that did not outlive him except as a historical reference.

Janet set out the clinical picture and his etiological considerations on psychasthenia in several books and over the course of several years. To review them, we will confine ourselves to the work "Les névroses" (15), published in 1909. In this work he attempted to condense his views on the two neuroses that had drawn his attention throughout the preceding years: hysteria and his psychasthenia.

This section may strike the reader as excessively lengthy and even tedious. For those who prefer to skip it, we offer the conclusion in advance, a very simple one: the clinical description of psychasthenia bears no relation to the obsessive personality. To attribute such a foundational role to it is an error. At most, it was a forerunner of the future "neurotic character."

Psychasthenia encompasses an extremely broad range of psychiatric symptoms of all kinds, though the most clearly hysterical ones (conversive and dissociative) as well as psychotic ones are excluded. On the other hand, anankastic symptomatology is, by far, the most prominent element in the overall picture.

The Neuroses

The term "neurosis" was coined in the second half of the 18th century by the Scottish physician and scholar William Cullen (6) to refer to one of the four great Classes into which he sought to distribute the totality of human diseases. Each class was in turn divided into orders, families, genera, and species, following Linnaeus's method. The three remaining classes were pyrexiae (diseases with fever), cachexiae (diseases resulting from bad habits), and locales (localized diseases).

In turn, he included within neuroses "...all diseases of sensation and movement in which pyrexia does not constitute a part of the definitive illness; and all those which do not depend on a local affection of the organs, but on a more general affection of the nervous system."

Cullen did nothing more than carry forward the ideas of Sydenham, who had attributed a central role to the nervous system in the functioning of the organism and in the genesis of disease. Sydenham discarded classical theories such as that of humoral imbalances or that of uterine movements. In turn, he inaugurated the broad chapter of "nervous diseases," which Cullen would rename "neuroses" (for a long time both expressions were interchangeable).

As might be expected, given that this was nothing less than one of the four great Classes into which all diseases were divided, the list of conditions it included was truly extensive. Janet (15), citing Sandras (1851), enumerates them: vomiting, diplopia, amaurosis, deafness, convulsions, nervous state, periodic intermittent affections, hysteria, eclampsia, tetanus, hydrophobia, hallucinations, somnambulism, lethargy, catalepsy, melancholy, nostalgia, hypochondria, transient delirium of the passions, certain intoxications, certain fevers, chorea…

Throughout the 19th century, disagreements followed one after another. At no point was a full consensus reached, either on the very concept of neurosis or on the morbid conditions that ought to be sheltered under that umbrella.

"[...] Grasset, in the fourth edition of his Traité des maladies nerveuses, of 1894, adds not only Parkinson's disease, but also Basedow's exophthalmic goiter. M. Raymond, in his last articles of 1907, did not hesitate to append the psychasthenia that I had described in 1905…" (15).

Now, as neurological pathologies were being isolated and described with ever greater precision, they tended to break away one by one from their matrix. As a consequence, neurosis progressively ceased to be the exceedingly broad Class that Cullen had conceived, and was transformed into a far more restricted family confined to the field of psychiatry: anxiety neurosis, phobic neurosis, hysterical neurosis, obsessive neurosis, character neurosis, hypochondriacal neurosis, compensation neurosis… as well as other more anecdotal varieties.

"But the majority of authors add nothing to the domain of neuroses; on the contrary, they take away from it. Many phenomena formerly called neuropathic are attributed to diatheses, to infectious diseases, to intoxications, to compressions, irritations, traumas acting upon the cerebral or spinal emergence of the nerves, or at some point along their course. Thus it is that tetanus, long considered a type of neurosis, has come to be an infectious disease related to the Nicolaïef bacillus, that angina pectoris has come to be a disease of the coronary arteries, etc."15).

If, on the one hand, the repertoire of specific neuroses tended gradually to diminish, the definition of the concept had run aground at a point that was not satisfactory, yet from which there was no clear way out.

"Sandras understands by nervous diseases 'all those in which the functions of the nervous system are altered, without it being possible, in the current state of our knowledge, to find, as an original cause, a material, localized, and necessary alteration of the organs'"15).

This definition by exclusion suffered from significant drawbacks. If the absence of lesions is what truly characterizes neuroses, then we would enter into the absurdity of a disease without bodily alterations, something that was inconceivable. On the other hand, if the matter is that the lesions have not yet been identified, it would remain to be clarified whether a single localization underlies the multiple symptoms of neuroses, or whether the condition involves an affectation of different points of the brain (and, consequently, distinct diseases).

There existed, in any case, a novel explanation, according to which the cause of neuroses was not to be sought in any cerebral lesion, but rather lay in the psychological realm. Throughout the nineteenth century, observations had accumulated from alienists, psychologists, and magnetizers, all pointing to the same conclusion: it is in thoughts, emotions, and feelings that the genesis of neurotic symptoms must be sought.

This explanation did not satisfy Janet, who continued to think in terms of a necessary organic etiology. What he was willing to admit was that, in their outward manifestation, the neuroses (the few that remained at the dawn of the twentieth century) shared a common denominator. It was this shared element that inclined him to think either in terms of a single disease, or of a set of closely related diseases.

Janet's original theory states that it is the "functions" (feeding, intellectual functions, visceral functions…) that become altered in neuroses. These functions are made up of a multiplicity of elements ranging from the simplest to the most complex; the latter necessarily develop after the former have been acquired. If we take feeding as an example of a function, gastric secretion would be one of its simplest elements. Bringing food to one's mouth would be situated at a higher level. And properly deploying the full set of norms and rituals required at a formal dinner with strangers would be situated at the highest rung of the hierarchy, that of the behaviors that develop last. This theory, briefly outlined, would explain the frequent onset during adolescence, the worsening that coincides with the most delicate moments in people's lives (such as marriage), or the greater difficulty in locating the causative lesion, given that it would have a far more diffuse seat in the cerebral cortex. In other words, according to Janet, neuroses would be the consequence of a failure in the maturational process of the functions. The arrest would have occurred precisely at the moment of acquiring the highest and most complex elements of each of them. This explains that sense — expressed by family members — of infantilism, of an early halt in biographical development.

Janet positioned his psychasthenia as a variant of a single illness, the neurosis, or as forming part of a group of closely related illnesses, the neuroses. But the matter that concerns us now is another: is it truly in psychasthenia that we must look for the birth, or at least the prefiguration, of obsessive personality disorder?

To answer this question we will take into consideration each of the elements that Janet integrated into the clinical picture. In this way, it will be possible for us to assess the extent to which those elements anticipated the traits of the current obsessive personality.

The symptoms of psychasthenia

Psychasthenics are characterized, first and foremost, by certain ideas that the author calls "obsessions of the psychasthenics." These are defined in opposition to the "fixed ideas" that arise in hysterical patients during dissociative episodes. Indeed, whereas the latter are forgotten once the critical episode has ended, psychasthenics are fully conscious of their obsessions. In any case, they may have difficulty recounting them, as they find them uncomfortable and embarrassing (an anticipation of the egodystonic character that would in time be attributed to them).

Obsessive ideas — according to the author — are often accompanied by two phenomena: impulses (or "impulsions") and irrepressible doubts.

The current concept of obsessive idea is broader than Janet's and includes:

The greater part of what Janet labeled as obsessions.

A good part of what the author called impulses or impulsions (the so-called impulsion phobias). The rest of Janet's impulses correspond to the compulsions of current OCD or to episodes of genuine impulsive loss of control.

Finally, Janet's "irrepressible doubts" are today also included among obsessive ideas.

In other words: what for Janet are phenomena that accompany obsessions, is currently considered to be, for the most part, also obsessions.

Likewise, Janet developed the characteristic themes or contents of obsessions. The exposition of many of them remains fully relevant.

Sacrilegious obsessions and impulses consist of the repetition of mental images that are completely unacceptable to a religious person, or of impulses toward carrying out acts constituting the greatest of sins: sacrilege.

Impulsion toward crime:"[...] they constantly think about some criminal action they do not wish to commit, but toward which they feel tempted"15). Thus described, the impulsions of the psychasthenics barely differ from any other impulse (to set a forest on fire, to commit rape…) to which the patient resists with all their might. But there is a difference. The impulsion phobia, more than a genuine impulse, is a fantasy, an irrational fear that the impulse might arise and, above all, that one might be unable to control it. This difference had already been vaguely glimpsed by Janet: "[...]he imagines himself being drivento rape an elderly woman, on a bench, in front of a church" (15). It is not that he is being driven (by an impulse) and is resisting it; it is simply that he "imagines" himself to be.

Genital obsessions and impulsions. "How many young girls are afraid of finding themselves free, wishing to take refuge in convents, because they imagine themselves being driven to approach their brothers or all the men who come in"15). Among the genital obsessions of psychasthenics, Janet included those of individuals who claim to feel attracted to people of their own sex. In reality, they fear feeling attracted to people of their own sex, and they imaginarily picture the feared situations to themselves. But this would not constitute a true homosexual desire.

The varied section on "obsessions and impulsions of self-shame" includes phenomena that today we would not associate with anancastric clinical practice, whose common denominator is feelings of contempt, remorse, disgust, and —above all— shame, in relation to oneself.

Psychasthenia

"[...] The patient torments and constantly accuses himself for everything he does. He must denigrate and humiliate himself and even punish and torture himself [...] Whether it concerns a disgust related to his intelligence or to his senses, the patients are convinced, or claim to be, that they can neither see nor hear. They want to verify all objects by touching them and touch them again and again. They become obsessed with the thought of madness, claim to be insane and, what is worse, feel compelled to behave like madmen: 'I see houses and people upside down, I talk nonsense, I am going to smash my head against the walls, look at my eyes and you will see my vacant stare'. They have the obsession that their personality has changed and that their memory has been transformed" (15).

In this section he also includes the déjà vu, and another phenomenon —this one indeed— with clear anancastric connotations: "[...] young women tormented by the thought that they do not love their fiancés (15)".

The section on "obsessions of bodily shame" includes other symptomatic pictures that likewise do not correspond, any of them, to the current obsessive-compulsive disorder: nervous anorexias, simple social phobias (fear of blushing, of writing in public…), writer's cramp, sexual aversion, or olfactory reference delusion. Also mentioned are "shame over bladder functions" (social phobia?) and the "obsession relating to abdominal gases in those persons who voluntarily shut themselves away" (which seems close to what is known as olfactory reference delusion).

Hypochondriacal obsessions close the chapter on obsessions. The author mentions fears such as that of swallowing needles, dirt, contamination, contagion, or contracting any disease. These are fears that often have a markedly egodystonic and recurrent character, and that lead to the performance of obsessive rituals.

Finally, Janet speaks to us of "incomplete obsessions," among which he includes pathologies equally foreign to the current obsessive-compulsive disorder, such as dipsomania and morphinomania. Incomplete obsessions are characterized by the presence of an impulse in the absence of the corresponding obsessive idea. Also included in this chapter are the remorse arising from the belief of having committed a crime in the past (delusional depression? false memory syndrome?).

Janet's observations were not limited to the content of obsessive ideas but also to their form. He defined with great precision what that ego-dystonic character consists of, which we attribute to obsessive ideas: "He doubts his idea enormously [...] he does not have the impression that the idea belongs to him [...] it seems to impose itself upon him [...] he lacks certainty, freedom [...] he is prepared to declare that his obsession is ridiculous, which does not prevent him from worrying about it and thinking of it incessantly" (15).

Janet's clinical picture of psychasthenia was not limited to obsessive ideas and the phenomena associated with them (doubts and impulsions), but incorporated other elements such as "psychasthenic verbal agitations." These agitations included, first and foremost, the tendency of some patients to speak incessantly about their obsessive experiences, boring the people around them with their interminable accounts. They also encompassed what we might call "verbal compulsions," in which the patient cannot resist the overwhelming need to enumerate the objects they see, utter obscene words or blasphemies, repeat invented and meaningless words, etc. He also rightly pointed out that the patient may limit themselves to muttering such words or repeating them mentally without anyone noticing.

The tics of neurasthenics referred to brief muscular contractions limited to a small muscle group (mainly in the face). Today we know that such tics are not, strictly speaking, an obsessive phenomenon, although on some occasions they can indeed be associated with OCD.

Janet also included among the tics another type of movement: we are referring to anankastic compulsions which, unlike tics, maintain a vague logical connection with obsessive ideas.

This chapter includes "verification manias," such as that of the patient who shakes his head over and over again to verify that his hat is still in place, or that of the patient who cannot help touching her own body to prove to herself that she has not gained weight, or the compulsion of the adolescent girl who repeatedly knocked her head three times and touched her ear to check that her earring was still in place and properly fastened. A patient with a "symmetry mania" went jumping from stone to stone in order to provide both his feet with the same sensations. Patients with "symbol manias" perform small gestures or movements that carry, for them, a completely arbitrary meaning. In "temptation manias," the sufferer merely begins a gesture (such as that of a strike) that they never complete. Among "precaution manias," washing compulsions stand out without doubt, though they are not the only ones. "Repetition manias" include the repetition of standardized motor sequences. Other types of compulsions seek to compensate for an imbalance (such as the patient who would seek out a man to shake hands with after having shaken hands with a woman) or to expiate guilt for an act not yet committed (for example, through the incessant repetition of prayers).

The symptoms of neurasthenia that Janet assigned to the chapter on "action and situation phobias" are the following:

Those presentations in which intense anxiety prevents the patient from carrying out a specific task. He provides no examples, but they undoubtedly correspond to "performance anxiety," which in some patients is associated with activities such as examinations, driving, carrying out work-related activities, etc.

"Akinesia algera" can affect individuals who have suffered an accident that has left, as a sequela, more or less intense pain. The terror of reactivating the pain leads them to a significant paralysis, wholly disproportionate.

Patients with basophobia do not dare to walk (?).

Sufferers with akathisia cannot remain still in a chair.

In phobias of objects, anxiety is triggered by the mere sight of a particular object.

Agoraphobia

Claustrophobia

Phobias of social situations, among which erythrophobia may be mentioned.

None of these conditions can truly be placed within the field of obsessive disorders.

The chapter on "algias of psychasthenics" includes those conditions characterized by pain affecting both specific muscles and organs. The pain may be more or less continuous, or it may occur only when the muscle or organ is forced to work, or when subjected to palpation or pressure. Persistent pain may go hand in hand with the conviction of suffering from some illness, such as cancer. The pain can immobilize the patient for months, as well as cause them to refuse to be examined. Itching and skin discomforts of all kinds cause great distress and can sometimes be interpreted as "frogs moving beneath the skin, an unpleasant tongue licking, worms, rotting intestines sliding...". There are patients who find smells distressing (one patient finds that all of them remind him of bodily fluids, another associates them with the fear of inhaling toxic substances…). Still others cannot tolerate noise, which leads them to move house, to soundproof their home, etc. Microphonophobia is characterized by the fact that it is small sounds, not particularly loud ones, that torment the patient. Janet's photophobic patient had such an intolerance to the simple act of seeing that she was forced to cover her eyes completely and to act as though she were blind.

Among the "disgnosias of psychasthenics," Janet placed a rather disparate repertoire of clinical phenomena encompassing alterations in the cognitive and sensory domains and in the "familiarity" of psychic experiences. The first of the "disgnosias" is that of patients who feel that their attention is impaired, distracted, and that they are unable to reflect on what they hear. Another group of patients consists of those who perceive surrounding objects as small, distant, or strange. Another disgnosia is that of those who see objects as doubled, distorted, or transformed. He also mentions those who feel that the surrounding reality is merely imaginary or even a dream. A symptom similar to déjà vu is that of patients who notice that their words, their actions, or their sensations are the repetition of words, actions, or sensations that had already occurred in the past, in the same order and in exactly the same way. Some psychasthenic patients feel as though everything has been reversed, so that what was previously on the right is now on the left and vice versa. Finally, feelings of depersonalization range from a simple sense of strangeness toward oneself, to the feeling of having disappeared, of having been replaced, or, in the most severe cases, of being dead.

In the chapter on "alterations of the instincts and visceral functions," Janet developed an extensive repertoire of symptoms shared with hysterical patients. Among these we can highlight: insomnia, hyperphagia, and polydipsia. "Psychasthenic sitiergia" differed from hysterical anorexia in that the rejection of food would derive from obsessive or phobic ideas: scrupulous defenders of animal life, scrupulous individuals who think they have not done enough to deserve food… Here he also included hypochondriacs, fearful, for example, of widening the stomach or producing too much fecal matter. Unlike hysterical vomiting, that of psychasthenics is self-induced and responds to the need to relieve a discomfort they feel after having eaten. Both hysteria and psychasthenia can present with pollakiuria, but in the second case it tends to derive from rituals that oblige the patient to return repeatedly to the bathroom. As for the "retentions" of psychasthenics, these may be due to shyness, various discomforts, hypochondriacal ideas, or scruples surrounding urination.

The "agitation crises of psychasthenics" are triggered, in some cases, by the obligation to perform an action (such as eating in public) that the patient finds distressing. In hypochondriacs, crises are triggered by actions such as urinating, walking, or moving some part of the body. They believe that this type of action may be harmful to their health. In Janet's description (which to a large extent refers us to anxiety attacks), "agitation crises" present with three orders of symptoms: ruminations, varied movements (self-limiting attempts at motor agitation, which rarely go beyond the breaking of some small object), and visceral disturbances (palpitations and rapid breathing).

The agitation crises are preceded by the "depressive periods of psychasthenics." They constitute, so to speak, the backdrop against which crises episodically break out over shorter spans of time. What defines the depressive periods are the "phenomena of insufficiency": insufficiency of attention, insufficiency of memory, and insufficiency of the will (with the innumerable varieties of abulia). Depersonalization, derealization, indecision, slowness, and the inability to complete acts are also elements characteristic of depressive periods.

Janet speaks of a "psychasthenic mental state," of an emotivity characteristic of psychasthenic patients. How can it be recognized? Palpitations, irregular breathing, or flushing are of no use in distinguishing the anguish of psychasthenic patients from the normal and natural fear in human beings. The difference must be sought elsewhere, which the author captures in two general traits: the loss of the reality function and the diminution of psychic tension.

By "loss of the function of the real," if we descend to a somewhat more concrete level, Janet was referring to elements such as indecision, lack of decisiveness, conviction, and attention. The psychasthenic would be incapable of experiencing feelings suited to the situation, and would live in a permanent sensation of lacking fullness, of unreality. The present is unbearable to them, and they prefer to take refuge in the past, in their fantasies, to psychologize or philosophize. Clumsy, devoid of practical sense, they avoid all kinds of commitments and efforts, given that the demands of reality do nothing but stoke their internal debates, their scruples, and their anxieties.

The "decrease in psychic tension" implies that the psychasthenic patient would be in a state similar to that of fatigue or drowsiness. Consequently, they would experience the same type of phenomena associated with these two conditions, albeit in a more intense and persistent manner. This is how the author interprets the motor disorders, irritability, obsessive daydreams, visceral disturbances, tedium, loss of precision in action, slowness in bringing memories to consciousness… The loss of mental tension would be triggered, in subjects predisposed by heredity, by factors such as intoxication, fatigue, or emotional shocks. The energy that the patient withdraws from the higher cerebral functions is what, in turn, would fuel the explosion of "inferior phenomena."

Psychasthenia does not anticipate the obsessive personality

So much for the summary of the lengthy clinical description of psychasthenia. Is there anything in it that would allow us to assert that it heralded, sketched out, or introduced the future obsessive personality? The answer seems unquestionable: no.

The neuroses, neither

And what can be said of the elements common to all neurotic pathologies (hysteria, psychasthenia and, eventually, other neuroses)? For Janet, neurotics suffer from a general weakness of the nervous system that would express itself in a set of "stigmas."

Neurotics feel weak and dissatisfied with themselves. They think that their feelings, words, and actions amount to little, are incomplete, and go unnoticed. The great stigma of neurotics is boredom; no external stimulus is capable of rousing them from their state.

The neurotic's dissatisfaction leads them to sink into endless lamentations or else to devote all their energy to the search for whatever might rescue them from their situation. The patient may seek the stimulation that relieves their malaise in alcohol, food, walks, or shouting, or may seek the attention, support, and affection of other people. To that end, they will not hesitate to resort to the greatest eccentricities.

Laziness and the tendency toward daydreaming are accompanied by a marked difficulty in sustaining attention and memorizing, so that a frequent first manifestation of neurosis is the abandonment of studies.

The emotional life of neurotics, in Janet's view, is distinguished by a weakening, such that they barely react emotionally to circumstances and do nothing but repeat the same display of emotions over and over again. Indecisive, insecure, and lacking in willpower, they are incapable of initiating any novel activity, and therefore repeat the same routines indefinitely. In general, their actions are slow, they do not finish on time, and they eventually abandon them. Due to their weakness, they are also incapable of confronting or defending themselves. In boarding schools, neurotic children are easily subjected to mockery and humiliation.

Absolutely none of this reminds us of the obsessives we presented at the beginning of this chapter; one might even say they stand at the opposite pole.

The origin of the obsessive personality will have to be sought elsewhere.

Freud (1909)

Freud. Anal character.

"The people I am about to describe deserve our attention for regularly presenting an association of three characteristics: they are orderly, parsimonious and tenacious. Each of these words encompasses a small group of related characteristic traits. The quality of 'orderly' comprises both personal cleanliness and conscientiousness in the discharge of petty duties and trustworthiness [in the sense of being a person 'of one's word']; the opposite of 'orderly' would be, in this sense, careless or negligent. The exaggeration of parsimony may turn into avarice, and tenacity may turn into obstination, to which a tendency toward anger and vindictive inclinations easily attaches itself" (8).

In this brief paragraph Freud introduced us to a psychological type that, with some nuance, corresponds to the modern obsessive personality disorder. However, the name he gave to this character was a different one: "anal." Why anal? What does the anus have to do with a subgroup of particularly perfectionist, parsimonious, and tenacious people?

According to Freud, the maturation process involves a series of consecutive stages in which the libido becomes fixed to different mucous membranes, following a pre-established order. One of these stages is the anal stage, in which the child's main source of pleasure would derive from two activities: the retention of feces and their expulsion.

Well then, the clinical histories of patients with the aforementioned personality traits would have revealed to him that, in their childhood, behaviors linked to anal eroticism would have held a particular importance and duration for them.

Freud. Anal character.

"It is easy to gather from the early childhood history of these individuals that it took them a relatively long time to overcome infantile fecal incontinence, and that even in later childhood they suffered sporadic failures of this function. As children, they seem to have been among those who refuse to empty their bowels when made to sit on the potty, because they derive subsidiary pleasure from defecation, since they tell us that even some years later they enjoyed avoiding defecation, and they recall — though with less reluctance regarding their brothers and sisters than regarding themselves — performing all manner of unseemly acts with the already expelled feces. From these indicators we infer that these individuals were born with a sexual constitution in which the erotogenicity of the anal zone is particularly strong" (8).

Given that these behaviors directly linked to anal pleasure eventually disappear, Freud postulated that character traits would depend on the intervention of secondary mechanisms such as reaction formation or sublimation. In this way, the obstination of the adult would reproduce the obstinacy of the child in retaining feces. The numerous myths, tales, and superstitions that equate money with filth, or directly with feces (such as the Babylonian belief that gold is "the excrement of hell"), also support the relationship Freud found between personality traits and a history of anal hypereroticism.

(As far as I know, no subsequent research has been able to confirm these defecatory antecedents in subjects diagnosed with obsessive personality.)

It should be noted that in his paper Freud did not make a single comment about the relationship between the "anal" personality pattern and the obsessive neurosis that he himself had also identified some years earlier. The only link that is — implicitly — established is etiological: the origins of both must be sought in the same phase of psychosexual development.

The idea would ultimately come to be accepted that these persevering, self-demanding, perfectionistic, and miserly individuals represented the trait-version of obsessive neurosis. It ended up seeming something obvious. It was not worth giving it any further thought.

Ernest Jones (1918)

E. Jones was a Welsh nationalist, neurologist, and psychoanalyst, a prolific author and the first great popularizer of Freudian thought in the English language. In 1918 he published "Anal-Erotic Character Traits" (16). Most authors recognize this chapter as the next major milestone (following Freud's description of the anal character) in the history of the obsessive personality. Indeed, his contribution was no small one:

He described in greater detail the components of infantile anal eroticism and linked each of them to specific traits and behaviors characteristic of adulthood.

He delved more deeply into the traits of the "anal personality" that Freud had limited himself to sketching out some years earlier.

He expanded upon Freud's anal character (adding to the original Freudian description his own contributions and those of Sadger).

Many of these additions — though not all — have been preserved in subsequent clinical descriptions.

The following quotations provide us with a general overview of the components of anal eroticism, according to the author. Upon each of these components, one of two possible defensive mechanisms may act: either sublimation or reaction formation. In turn, each of the possible dyads thus formed (a facet of anal eroticism + a defensive mechanism) during childhood is related to a range of behaviors characteristic of the adult.

"The mucous membrane lining the anus and the anal canal possesses the capacity to give rise, when stimulated, to sexual sensations, just as does the one covering the entrance to the alimentary tract. The sensations vary in intensity with the strength of the stimulus, a fact often taken advantage of by children, who will at times obstinately postpone the act of defecation in order to increase the pleasurable sensation when it occurs, forming a habit that may lead to chronic constipation in adulthood" (16).

"If we consider first the child's attitude toward the act itself [...] we find that there are two typical traits that are never absent [...] One is the child's insistence on obtaining as much pleasure as possible from the act, the other is the effort to retain the greatest possible control over it, in opposition to the educational efforts imposed upon him from his surroundings.

The first of these endeavors is carried out by postponing defecation as long as possible. Children have been seen going to the extreme of squatting down and plugging the orifice with their heel in order to retain the feces until the last possible moment, and then defecating with intense concentration, showing themselves at that moment to be bothered by any outside influence that might disturb them" (16).

"One can separate, specifically, the interest [...] placed in the act itself of defecation from that placed in the product of that act" (16).

"The most typical product of the sublimation of the tendency to retain [feces] is the character trait of greed [...] the refusal to give and the desire to hoard…" (16).

"[...] tenacity is undoubtedly related to the first of the two interests mentioned [that lent to the act of defecating] and the sense of order to the second [that placed in the product, that is, the feces] while miserliness is determined by both interests equally" (16).

"The main reaction formation applied to the tendency to retain is the heightened sense of order [...] an extension of cleanliness, in accordance with the saying that states that 'dirt is things in the wrong place'" (16).

"We turn now to the character traits that derive from the interest in the product itself of excretion [...] All of them represent positive reactions (sublimation) or negative ones (reaction formation)" (16).

"[...] something must be said of the unconscious copro-symbols [...] food [...] any dirty material [...] street refuse (including, of course, manure), dirty sheets, coal dust, household or garden waste [...] money and children" (16).

"[...] in one of the varieties the person's aim is to throw the product at another object, living or non-living [...] the impulse to stain statues with ink, or the perverse impulse to dirty women or their clothing by throwing ink, acid or chemical substances at them [...] the erotic passion for children…" (16).

"Many children consider it an injustice that what they have produced with such interest is suddenly taken away from them, and this leads to a reinforcement of resentment toward any interference with the individual, which results in an intense feeling against any form of injustice…

[...] They are particularly troubled by the idea that something might be taken from them against their will, especially if it is something that symbolizes feces in the unconscious, as is the case with money…" (16).

"[...] the importance that early educational interference in anal-erotic activities plays in the genesis of hatred" (16).

"The interest in the act of defecation often leads to an interest in the setting of defecation, that is, in the anal canal [...] a tendency to concern oneself with the hidden side of various things and situations. This can manifest itself in very different ways: in curiosity about the back or hidden side of objects and places (such as the desire to live on the opposite side of a hill because it turns its back on a particular place), in a disposition to make numerous errors when distinguishing right from left, East from West, in reversing words and letters while writing, and so on [...] fascination with underground passages, canals, tunnels, etc." (16).

"[...] the psychological derivations of the flatus complex, of the child's interest in the production of intestinal gas [...] aversion to already-breathed air, with a fanaticism for fresh air, a passionate interest in the control of breathing…" (16).

A distinction must be drawn between those adult behaviors that are integrated into the anal-erotic character and those others which, while maintaining a genetic relationship with infantile anal eroticism, manifest themselves in an isolated manner, and not necessarily associated with the remaining components of the aforementioned personality. This is what may occur with those reflected in the two preceding quotations.

Another type of behavior that the author also links to anal eroticism is of too universal a nature and, consequently, it makes no sense to integrate them into a particular character pattern.

"The anal-erotic complex is genetically related to two of the most fundamental and far-reaching instincts: the instinct to possess and the instinct to create or produce, respectively" (16).

"The desire to further manipulate the product and to create from it leads to various sublimations, beginning with the usual fondness of children for molding and manipulating plastic material or putty. The most common sublimation in this direction is cooking, which may later be replaced by an aversion to cooking or may continue as a passion. It finds wide application in two other spheres of life: the industrial and the artistic. Examples of the former are metal molding, construction, carpentry, engraving, etc., while examples of the latter are sculpture, architecture, woodcraft, photography, etc." (16).

After this brief digression into such a curious facet of psychoanalytic thought, it is time to return to the matter at hand: the description of the obsessive personality (then called anal). We already know that Jones elaborated somewhat further on the traits briefly introduced by Freud some years earlier.

Tenacity is the third element of the Freudian triad. It entails, first of all, a way of throwing oneself into a task with the greatest possible effort and intensity, "as if one's life depended on it," to use a common expression. Jones spoke of "feverish concentration." Tenacity also implies the determination not to stop until the task is completed, to the detriment of rest, sleep, pleasures, and even other obligations, which are temporarily set aside.

Anal-erotic personality. Ernest Jones.

"And then they plunge into the work with a desperate and often almost ferocious energy that nothing can throw off course; any interference causes intense annoyance. Characteristic of these people is the excessive reaction to interference, especially when combined with a marked concentration disproportionate to the importance of the task. A related trait is the intense persistence in a task once it has been begun. They allow nothing to distract them, even if subsequent considerations may bring a different perspective regarding the desirability or value of the task" (16).

In any case, tenacity does not apply solely to the task that at any given moment is placed above everything else, but tends to generalize to all aspects of the individual's life. This persistent attitude ultimately leads to exhaustion.

Anal-erotic personality. Ernest Jones.

"[...] they take everything too seriously, and their life is an endless struggle for things to be right…" (16).

It is obvious that, despite the often high costs, tenacity also brings rewards.

Anal-erotic personality. Ernest Jones.

"[...] it has its reward in the quality of the results. These people often show an extraordinary capacity for making their way through difficulties and, with their persistence, getting things done in spite of apparently insuperable obstacles" (16).

Jones identified three types of actions to which the anal character applies its morbid determination above all: those associated with morality and the sense of duty, those that are intrinsically unpleasant, and those related to cleanliness.

Anal-erotic personality. Ernest Jones.

"There are three classes of actions that are particularly prone to being affected in this way [by anal erotism]. Firstly, tasks that carry a special sense of duty or of what is right; consequently, especially moral tasks" (16).

Anal-erotic personality. Ernest Jones.

"[…] Secondly, tasks that are intrinsically unpleasant or tedious, toward which there is an initial resistance […] such as tidying cupboards, cleaning the pantry, completing a diary, or writing a daily report" (16).

Anal-erotic personality. Ernest Jones.

"[…] third class, in which the task is related to objects that are unconscious symbols of the products of excretion […] any form of dust or dirt, anything related to paper, any kind of waste product, and money" (16).

The first trait of Freud's anal character was rigorousness, expressed in "scrupulousness in the fulfilment of habitual duties." Jones, on the other hand, spoke of perfectionism, a concept closely related to the former and one that would, in time, become fully incorporated into the obsessive personality.

Anal-erotic personality. Ernest Jones.

"[…] the desire for perfection is manifest. Nothing can be done by halves" (16).

Anal-erotic personality. Ernest Jones.

"When they finally manage to apply themselves to the task [of responding to accumulated letters] they do so conscientiously, applying all their energy and interest, thereby surprising long-forgotten relatives with an excellently written and detailed update; they dispatch epistles rather than write letters in the ordinary sense.

[…] they often take great care in the fineness and beauty of their handwriting" (16).

Anal-erotic personality. Ernest Jones.

"[…] he cannot write a letter, to give an example, until every object on the desk is placed in its exact position, until the pen or pencil are arranged in a precise order […] an attitude that certainly has an anal-erotic origin" (16).

"Vindictive inclinations" were, according to Freud, an additional element of the anal character. Ernest Jones reiterated them, though without further elaboration.

Anal-erotic personality. Ernest Jones.

"[...] vindicative desire for revenge when harmed or frustrated, which in many individuals of this type develops to the highest degree" (16).

Freud's second additional element, the "tendency toward anger," is likewise not absent from Ernest Jones's description.

Anal-erotic personality. Ernest Jones.

"It may be suspected that infantile anal eroticism has been inadequately handled in anyone who is a victim of chronic irritability or bad temper" (16).

Ernest Jones expanded Freud's brief and precise description with new elements.

One trait to which the Welshman attached great importance and on which he elaborated at length is the delay in the start of activities. Over time, procrastination would fall into oblivion. It was a mistake.

Anal-erotic personality. Ernest Jones.

"They delay and postpone what they have to do until the eleventh or even twelfth hour" (16).

Anal-erotic personality. Ernest Jones.

"First there is a silent, thoughtful period, during which the plan is worked out little by little and, often, half unconsciously. At this moment they must not be hurried, which would result in nothing but flustered irritation. They go on postponing the preliminary steps as long as possible, until the rest of the participants despair of the possibility of completing the task, at least on time. There then comes a bout of concentrated and feverish activity" (16).

The following list completes the behaviors that Ernest Jones associated with anal eroticism and which would manifest, with greater or lesser frequency, in individuals with an anal personality pattern:

The defense of Nature against the advance of urbanization.

A verbose discursive style that attempts to be exhaustive in the presentation of data and argument. It tends to be tedious for the interlocutor.

Not allowing interruptions while he is the one speaking.

Following his own path and resisting doing so at the pace set by others.

Inability to delegate.

A very positive self-evaluation, with a tendency to consider oneself perfect.

A cognitive style marked by a scarce predisposition to consider alternatives to one's own vision of things.

Periods of elevated mood.

Possibility of being unusually submissive.

Great susceptibility to any injustice or harm of which they may be victims.

Low tolerance for the imperfections they may encounter in various situations.

Ascetic exercises.

Attraction to everything that may be hidden.

Attitudes of great tenderness that can overlap with abnormally tyrannical and authoritarian behaviors.

Effort to achieve intellectual coherence in argumentation.

Exercises for purification of one's own body.

Insistent proselytism of one's own ideas.

dsm

Some decades later, the first edition of the DSM included a "compulsive personality" that clearly constituted an extension of Sigmund Freud's anal personality. The choice of a different term ("compulsive" instead of "anal") to designate it made it possible to set aside the Freudian etiological hypotheses. It is not entirely clear to what extent the choice of the expression compulsive was intended to relate the disorder to the neurosis ("obsessive-compulsive") or whether it was used in a broader and more unspecific sense (as in "compulsive buyers").

Compulsive personality. DSM-I (1952).

"These individuals are characterized by a chronic, excessive or obsessive adherence to moral or conformity demands. They may be very reserved, meticulous people and may have an inordinate capacity for work. They tend to be rigid and lacking a normal capacity to relax. Although their chronic tension may lead them to neurotic illness, this is not a constant consequence. The reaction may develop through the persistence of an adolescent behavioral pattern, or as a regression from more mature functioning as a result of stress" (1).

In 1968, the second edition of the manual (2) establishes in a clear manner the relationship with obsessive neurosis. The new designation, "obsessive compulsive (anankastic) personality" leaves no room for doubt. Furthermore, it is stated that the disorder may precede obsessive compulsive neurosis. The clinical description contains no changes with respect to the previous one, with the exception of the addition of the concept over-dutiful, which we can translate as "very diligent."

Twelve years later (in 1980), the new DSM-III introduced significant innovations: the diagnostic entities were not presented through a brief vignette, but through an extensive description that necessarily included more elements than the previous version. Of no lesser importance would be the inclusion of a synthesis in the form of operational criteria whose purpose was to serve research rather than clinical practice.

The subsequent editions of the DSM limited themselves to introducing small differences in nuance and adding somewhat more detail and specificity to the general clinical picture.

Westen's obsessive personality

Drew Westen is a multifaceted author who in the year 99 published an interesting work (25) on personality disorders. The application of multivariate analysis to the responses obtained in the Shedler-Westen Assessment Procedure-200 (SWAP-200) produced several personality dimensions, one of which could be identified, without a doubt, with the obsessive personality of the DSM. However, the overlap is not complete: Westen's obsessive factor includes items not previously described. Furthermore, many of those characteristics in which there is agreement contain relatively original nuances.

Obsessive personality by aggregation

In order to obtain the broadest possible view of the obsessive personality, we have proceeded as follows:

Reading and analysis of the texts of Freud and Ernst Jones, the DSM I, II, III and 5, as well as the items on Westen's compulsive scale.

Isolation and enumeration of the constituent elements of each description. This is a necessarily arbitrary process. The transformation of a linear descriptive text into a list of items will produce different results depending on who carries it out. We have attempted to break each text down into reasonable conceptual units, neither excessively narrow and concrete, nor too vague.

By comparing the items thus obtained, we have looked for which ones recur and in which authors or texts. Here it is worth making another caveat. Each text uses its own vocabulary and the descriptions contain nuances that vary. We have attempted to group together those that reflect the same reality, accepting that the descriptions are not perfect copies of one another.

Let us begin, then, with the "aggregate obsessive personality."

At the beginning of this chapter we introduced several clinical cases through vignettes. All, or nearly all, shared one trait: excessive self-demand and the application of superhuman effort toward the achievement of what was self-demanded.

Self-demand means doing what needs to be done, of course, but it also implies doing it well, without errors, which lengthens the process. The obsessive applies himself to it with energy, perseverance, and meticulousness, paying attention to every detail.

Perhaps it is this need to repeatedly check one's own mistakes that can make them appear to be indecisive people.

Obsessive self-demand has a less visible face, but one that is no less important. It is not only a matter of applying extreme zeal to doing well what needs to be done. It is also a matter of not doing, under any circumstances, that which must not be done. This second battle is fought in a far less visible space: that of the conscience. The result also goes unnoticed, insofar as it takes no tangible form.

Self-demand is closely related to that trait considered nuclear in the obsessive personality: perfectionism. The obsessive insists that the things they do be perfect, flawless, unsurpassable.

Anal-erotic personality. Ernest Jones.

"[…] the desire for perfection is manifest. Nothing can be done by halves" (16).

Anal-erotic personality. Ernest Jones.

"[…] they take everything too seriously, and their life is an endless struggle forthings to be done properly…" (16).

In any case, perfection, for the obsessive, is a necessary but insufficient condition. He aspires to something more. For the obsessive, perfection has little value if it is within anyone's reach. He needs challenges, arduous, unique, difficult objectives that require sustained effort.

Absolute perfection is always unattainable. And, for some authors, the force that drives the obsessive is not so much the trophy of perfection achieved as rivalry. From this perspective, perfectionism would be a relational fact. The ultimate goal of the obsessive would not only be to do it perfectly well, but rather to do it better than others. Or to be, simply, much better, the best.

What ultimately drives him is, perhaps, greatness and recognition.

Self-demand, first of all, applies to those tasks that one may consider as one's unavoidable obligations.

By default, we tend to assume that the duties we are referring to are work-related ones. The obsessive sacrifices everything for his work.

Self-demand is also directed toward cleanliness and the care of one's external appearance.

Obsessiveness would lead, according to Jones, to the need to extend cleanliness to the interior of one's own body.

Self-demand affects the orderly arrangement of things. The obsessive feels an aversion to chaos, and objects must be placed in space according to criteria of geometric or conceptual rationality.

Anal-erotic personality. Ernest Jones.

"[...] he cannot write a letter, to give an example, until every object on the desk is placed in its exact position, until the pen or pencil are in a precise order [...] an attitude that certainly has an erotic-anal origin" (16).

The natural tendency of the obsessive is to extend his self-demanding attitude —and the competitive one— even to leisure and recreational activities.

Obsessive perfectionism applies not only to what the person does, but to how they do it: in an orderly and rational manner; it is the opposite of improvising on the basis of intuitions and momentary impulses.

Excessively high goals and rigidity in the self-imposed means to achieve them can produce the opposite effect: inoperance.

However, it is no less true that other obsessives achieve great accomplishments in their field of action (typically professional performance)

It is well known that a good part of the most successful (professionally) executives and professionals display radically obsessive work habits. Lists, diagrams, and schedules do not always hinder work; rather, depending on how they are used, they can increase productivity.

A trait described solely by Jones is procrastination. For the author, the obsessive often postpones the start of tasks; beforehand, he sinks into a period of sullen self-absorption and perhaps planning. When he springs into action, he does so late, but deploying astonishing energy and tirelessness. Although later texts do not reiterate this interesting characteristic, I personally know someone who fits this pattern to a tee. It would be a very striking pattern, though not universal among obsessives.

An example, provided by E. Jones.

Anal-erotic personality. Ernest Jones.

"When they finally manage to apply themselves to the task [of responding to accumulated letters] they do so conscientiously, applying all their energy and interest, thereby surprising long-forgotten relatives with an excellently written and detailed update; they dispatch epistles rather than write letters in the ordinary sense.

[...] they often take great care in the neatness and beauty of their handwriting" (16).

Perfectionism is not solely a self-imposed demand; it also constitutes a demand directed at others, which will necessarily complicate one's relationship with the rest of the world. Jones asserts that one of the reasons for obsessive irritability is that the individual cannot tolerate things being done poorly; the obsessive would be a highly demanding person not only with themselves, but also with their surroundings. They want everything to be perfect. The most defenseless victims of perfectionist hetero-demanding are, without doubt, one's children.

Anal-erotic personality. Ernest Jones.

"[...] inability to enjoy any pleasurable situation unless all the concurrent circumstances are sufficiently perfect. People with this trait are highly sensitive to any disruptive or discordant element. Their well-being is affected by the most trivial of influences" (16).

Perfectionism interferes with the ability to work as a team; the obsessive do not trust that others can meet their high standards and prefer to act alone. They think they will do it better.

After perfectionism, the field in which we find the most references in the clinical descriptions of the obsessive personality is that of interpersonal relationships. The difficulties are of all kinds.

Obsessive individuals would be irritable and domineering people.

At the same time, they can act in exactly the opposite way.

It should not surprise us, then, that the obsessive is particularly attentive to the hierarchical position of those people with whom he relates, in order to behave in a manner consistent with his relative position (either of dominance or submission).

According to the DSMs, obsessive individuals are also distinguished by a serious, formal, and constricted attitude, to the detriment of spontaneity and empathy.

The DSM-III mentioned some traits that suggest a certain overlap with psychopathy.

Other descriptions include traits that refer us to paranoidism.

On the other hand, some positive, desirable elements associated with success can be derived from Westen's study. Not everything would be detrimental.

The following quotes speak to us about the cognitive style and discourse of the obsessive. They are very clear and require no additional commentary.

Westen, on the other hand, reaches far more benevolent conclusions, almost antithetical ones.

Obsessive individuals experience a kind of blockage that prevents them from relaxing and experiencing or expressing emotions.

Miserliness constitutes one of the three essential traits of Freud's anal personality, who conceived it as a prolongation, in adulthood, of the impulse to retain (feces). The DSMs have maintained this trait, though not so the Westen study, in which it is not added to the remaining items of the obsessive personality.

The accumulation of objects (with the consequent saturation of the dwelling) is recognized by the DSM-5 as an intrinsic trait of the obsessive personality. However, hoarding (or Diogenes syndrome) usually constitutes an independent diagnosis included —that is— among obsessive-compulsive spectrum disorders.

Jones's description, undoubtedly the most prolix of all, contains elements that only he was able to perceive and that are undoubtedly intriguing.

Finally, let us mention two diffuse concepts that permeate everything the obsessive does.

Closed-mindedness, for example, prevents reaching compromise solutions with other individuals. The obsessive accepts only one alternative: the correct one, their own.

The traits of the "aggregated" obsessive personality can be arranged in the manner of the layers of an onion. On one hand, the most nuclear elements — those on which most or all descriptions agree — are found in the central part, in the core. On the periphery of the onion would be placed those elements included by only a few or just one of the descriptions. These traits are far less relevant in clinical practice. Nevertheless, we have endeavored not to omit any of them, since, for our purposes, their interest is no lesser.

Adjunct obsessive personalities: the simple obsessive, Type A, workaholics, and karoshi

The simple obsessive personality

We often overlook an interesting fact: the mental process by which clinicians arrive at our diagnoses does not coincide either with the operational criteria of the official classifications or with the more extensive descriptions in the manuals. Inadvertently, we tend to give priority to some of the symptoms and to forget the others — those whose objectification is more laborious or uncomfortable. This bias is particularly common in the case of personality disorders, whose diagnosis requires more time than is usually available. Since our primary interest is the illness rather than the personality, we tend toward a diagnosis of the latter that is quick, superficial, and unreflective.

Well then, colloquially, one can be an obsessive about something in particular (such as cleanliness, running, stamps, or diet) or one can simply be an obsessive, about nothing in particular. This second group of patients is the one we typically identify as affected by a personality disorder; they are assumed to apply their (obsessive) way of operating to everything they do throughout the day. However, in practice, the tasks that truly matter are those that constitute the fundamental obligations society sets for us: study, paid work, and/or the care of the domestic environment (the home, possessions, children, the sick and the elderly…).

There thus emerges a simple obsessive personality (in contrast to the aggregated one, which is quite complex), in which what is essential is an absolutely energetic, persistent, exclusive, and all-consuming personal dedication to the task. Whether that dedication stems from a pursuit of perfection, from a desire to become wealthy, from a wish to surpass rivals, from addiction, from conviction, or from an effort to appease an internalized stern father figure is not what is essential. What concerns us here is the manner of devoting oneself to the activity, not the reason why.

For this quick, everyday diagnosis of the "simple" obsessive personality, a simple four-more rule would serve the purpose. The way in which the (simple) obsessive applies himself to his activity is distinguished by:

MORE TIME: he devotes more hours per day, more days per week, and more weeks per year to his activity than is reasonable.

MORE PRODUCTIVITY: the obsessive strives to obtain the maximum benefit from each unit of time devoted to the task, to the detriment of enjoying it.

MORE QUALITY: the obsessive attempts to make the fruit of his work irreproachable, flawless, perfect.

MORE QUANTITY: when the result of the work is measured (also or solely) in units, the obsessive will strive to surpass every benchmark.

Type A

In the 1950s, two American cardiologists (Meyer Friedman and Ray Rosenman) began a study —which took them several years— on the personality pattern of patients with ischemic heart disease. The fruit of their work was the Type A personality, associated with a significant increase in cardiovascular risk. Type A individuals were characterized by the following (12):

An intense and sustained drive directed toward goals set by themselves, yet poorly defined.

A deep inclination and disposition to compete.

A persistent desire for recognition and advancement.

Involvement in multiple tasks, always with time limits for completion.

A propensity to accelerate the execution of both physical and mental tasks.

Extraordinary mental and physical alertness.

This personality pattern would also be associated with higher academic and professional performance. Not always, however: in some tests, poor results were observed. This occurred when the task to be performed was complex and carried out under pressure.

Over the years, the association with coronary pathology would be called into question. Not all publications could confirm the correlation, and those that did were usually precisely the studies funded by the tobacco industry. The interest of cigarette manufacturers, one might assume, was to shift the focus of attention away from themselves.

The overlaps of Type A with the clinical picture of obsessive personality are plain to see. It is worth highlighting the fact that two cardiologists came to identify it on their own. Following a completely independent path, they converged with the psychiatric diagnostic tradition at the same point.

Work addiction

There is a growing body of literature on work addiction or workaholism. Both terms can be used interchangeably, although the second appears more frequently outside the academic sphere, with a more diffuse meaning and even with a positive connotation.

The list of behavioral or "non-chemical" addictions (where we find pathologies such as compulsive shopping, pathological gambling, or internet gaming addiction) is slowly incorporating this new entity. Even so, the majority of articles continue to be published in occupational psychology journals.

The definitions of the disorder are still too numerous, as are the measurement instruments and the classification into subtypes. For example, some authors distinguish between an workaholism that is enthusiastic — that of those who genuinely enjoy their work and devote themselves to it for pleasure — and a workaholism that is harmful and dysphoric — that of those people who dislike the performance of their work. Others question this distinction; after all, heroin is also highly pleasurable.

Even so, some realities seem evident at first glance. The obsessive's morbid tendency to work lends itself naturally to being interpreted through the terminology and concepts associated with addictions: an uncontrollable urge, loss of control, progressive absorption in the activity in question, the disappearance of other interests, psychosocial deterioration stemming from exclusive dedication to the addiction, withdrawal syndrome...

The same patients allow us to make two different diagnoses depending on the lens through which we observe them. The same behaviors can be conceptualized as symptoms of a disease (workaholism) or as traits of a personality disorder (the obsessive one). It is a somewhat paradoxical situation. The interested reader can access the excellent review by Andreassen (4).

Karoshi

This Japanese term has been translated as death from overwork (13). The first death attributed to excessive work occurred in 1969. Over time it would come to be considered a veritable plague.

In the 1970s, the Japanese began studying a phenomenon that also affects non-communist Korea and China. These are sudden deaths, which typically occur at the workplace itself, of cardiovascular etiology, and which occur in individuals who work excessively. The threshold between normality and excess is often set at 60 hours per week (while the average South Korean workweek is 68).

As it turned out, cardiovascular risk did indeed increase in parallel with overwork, and there were also collateral victims: the families. The deterioration of family life is not only due to the absence of the male breadwinner, but also stems from the development of "negative feelings" toward one's own family. The more industriousness, the more animosity toward one's spouse and children.

To the objective hours of work, other risk factors would need to be added:

The stress associated with the work itself (demanding or impossible targets, mistreatment, etc.).

In some cases, malnutrition due to lack of time to eat.

The custom of socializing with people from one's own company or from the "business world" once the working day has ended, which in turn is associated with the inhalation of tobacco smoke and alcohol consumption.

In the Japanese islands, the phenomenon karoshi has been a subject of debate in the media and a motive for political initiatives. In line with the Japanese tradition of consensus, governments have repeatedly urged companies to reduce their employees' working hours. A significant obstacle to the advancement of this policy —one that does not cease to surprise us— has been the lack of cooperation from employees, who insisted on remaining active, while avoiding leaving any record of their activity. A reason frequently put forward by workers —even more surprising— is that this is how they compensate for their own shortcomings in the workplace. "Lack of illness awareness" seems to be the norm, and it is families who most often call the specially enabled telephone helplines.

Having reached this point, a brief recapitulation:

The character that Freud called "anal" has survived to the present day with great robustness, unlike what has happened with the vast majority of diagnostic proposals in the field of personality disorders.

It should be noted that in multivariate analysis studies such as Westen's, in which prior diagnostic categories are largely set aside, a dimension unequivocally identifiable with the obsessive personality also emerges.

In any case, there are differences among the various descriptions. They are not identical, but similar.

Let us return to the question we posed at the beginning of the chapter: this way of being, which we no longer call anal but rather anankastic, compulsive, obsessive, or obsessive-compulsive — is it truly the trait version of obsessive neurosis? Is it the personality disorder parallel to OCD?

The answer to this question must be sought in two orders of evidence. The first is that of statistical association, and the second must revolve around phenomenological resemblance.

Is the obsessive personality the trait-version of obsessive neurosis?

Clinical association

According to the exhaustive review by Diedrich (7), several studies conclude that obsessive personality is more frequent among patients with OCD than in the general population or among patients with other psychiatric diagnoses. The same author cites several articles indicating that, among patients diagnosed with OCD, obsessive personality disorder is more common than any other. It would appear, then, that the link between neurosis and personality truly exists.

However, according to publications cited in the same article, the frequencies of obsessive personality in other psychiatric disorders would also be elevated:

Anxiety disorders, 23%.

Affective disorders, 24%.

Substance abuse, 12-25%.

Alcohol dependence, 31%.

Panic disorder, 17%.

Hypochondriasis, 15-22%.

Eating disorders, 13%.

Unipolar depression, 14%.

Generalized anxiety, 34%.

Social phobia, 33%...

These substantial percentages must be weighed against the prevalence of obsessive personality in the general population (3-5%) and in patients with obsessive neurosis (23-45%). One might say that obsessive personality is a kind of common backdrop to a large part of psychiatric pathology, and that the association with OCD is less specific than might have been expected.

Another group of publications, with results that are difficult to interpret, also introduce nuances. When we consider the symptoms of OCD one by one and the constituent traits of the obsessive personality one by one, not all of them tend to be associated with the other pathology. Patients with a dual diagnosis constitute a subgroup with well-defined symptoms and traits.

Thus, the epidemiological evidences turn out to be confusing and ultimately fail to confirm (or deny) with any decisiveness the close and privileged association that should exist between obsessive neurosis and obsessive personality, were the latter to be the "parallel personality" of the former.

Phenomenological resemblance

The other prism from which the relationship between OCD and its supposed parallel personality can be studied is that of phenomenological similarity. At first glance, the existence of a close kinship would seem to be confirmed.

In OCD, both obsessive thoughts and rituals tend to repeat themselves over and over again, persistently. The obsessive personality, for its part, unceasingly deploys the same effort toward achieving its objectives. And, in most cases, this involves repeating the same activities. The element common to both, one might say, is reiteration.

The anankastic neurotic carries out their compulsions in a stereotyped manner, always the same way. Similarly, the obsessive personality submits to an absolute discipline: their lists, schedules, timetables, and plans. Both share the same rigidity.

All descriptions of the obsessive personality emphasize perfectionism: in the results of their work, in hygiene and dress, in the orderliness of things, etc. The clinical picture of OCD, for its part, often reflects a genuine horror of imperfection, a permanent doubt regarding possible incorrectness (in the placement of things, bodily hygiene, household appliances…). A third common thread between personality and neurosis, then, is that of perfection.

The relationship between obsessive neurosis and obsessive personality seems so evident that it does not merit being examined anew or called into question. And yet...

Is the obsessive personality truly obsessive?

Obsession versus obstination

It is worth recalling that the concept of "obsession" is often used with a certain looseness in a way that encompasses both properly obsessive (anankastic) ideas and the type of fixed (or overvalued) ideas that in the first chapter of this book we included in the group of the obstinate (paranoid, non-anankastic patients). This dichotomy compels us to confront the obsessive personality not with one but with two psychopathological phenomena: OCD and obstination (fixed idea). The question that must be answered is: which one does the obsessive personality truly resemble, if either of them? Does it bear more resemblance to the obsessive-anankastic idea or to obstination?

To answer this question, it is first necessary to tease apart the differences between the two.

First difference: the subject matter

The two are distinguished not only by their formal characteristics, but also by their content.

Without any pretension of being exhaustive, let us recall some of the most common "themes" of obsessions:

Ideas of catastrophe, of something serious happening to the patient themselves or to one of their loved ones; these are often associated with rituals of exactness in the performance of simple daily activities, with the aim of warding off the feared misfortune.

Ideas of having inadvertently caused harm to someone: typically, having run over a pedestrian with one's car. These drivers often feel compelled to return to a particular spot — a junction or a traffic light — to verify that there are no victims. Others repeatedly inspect the underside of their vehicle to make sure there are no bloodstains or human remains.

In impulse phobia, the patient fears losing control and harming themselves (throwing themselves onto the subway tracks, falling from a window) or harming a loved one (typically a baby), usually with knives or scissors. The patient attempts to keep sharp objects out of their sight.

Patients who are tormented by sacrilegious images or impulses — invariably religious individuals — experience their obsessive symptoms with great shame and guilt.

Fear of contagion and contamination is among the most frequent anankastic phenomena. To avoid said contagion, the patient embarks on a series of repetitive activities and avoidances that are always entirely lacking in prophylactic efficacy (one patient does not allow the hems of their trousers to touch the ground, another inspects everything they are about to touch or step on so as not to come into contact with any stain, etc.). Compulsive washing, which can go on for hours and may be carried out with harmful substances such as bleach, is frequent and constitutes, in all likelihood, the most characteristic image of the patient with OCD.

Of great interest are those patients who cannot bypass the compelling need to resolve doubts — for example, orthographic ones — that come into their heads. They tend to turn to those around them to obtain an answer and dispel them, at least momentarily.

Let us now recall, also without any intention of being exhaustive, the most frequent or prototypical obstinations:

Querulous individuals querulants who do not go so far as to suffer from genuine delusional activity. They attempt to redress — almost certainly real — injustice they have suffered through legal channels.

Stalkers. In general they seek to take revenge for harm or an affront suffered, or to obtain at least public compensation or recognition. Two particular cases within this group are hypochondriacal persecutors (who tend to target a specific doctor) and spurned boyfriends or husbands.

The amorous stalkers behave in a manner very similar to patients with an erotomania delusion, although they do not experience delusions.

The reformers are individuals who dedicate their lives entirely to a social or political cause to the detriment of their own well-being. These are generally simplistic and utopian projects.

Numerous subjects with megalomaniacal ideas (wonder-workers, individuals endowed with the power to diagnose illnesses, inventors, representatives of the divinity on this planet, etc.) occupy a murky terrain in which it is not clear whether one can truly speak of delusional activity or whether we must make do with the subordinate diagnosis of obstination.

Finally, we should not fail to mention some classic categories, such as that of the misunderstood artists and writers or the nature fanatics.

The enumeration of obsessive and fixed ideas makes it possible to distinguish one from the other, although there are overlaps, such as hypochondriacal preoccupations. The same preoccupation with illness can be situated in the anankastic or the paranoid field (overvalued ideas and delusion). Consequently, the theme or content does not always allow us to distinguish between the two psychopathological phenomena.

Is there a common thread or some set of formal characteristics with which it would be possible to delineate the obsessive-anankastic idea from obstination? Perhaps so.

Second difference: guilt versus harm/grandiosity

One would say that obsessive ideas, in general, contain the fear of sin, of wrongdoing, of impropriety; whether by action or omission; whether by having done it in the past or being able to do it in the future; whether in deed, word, or thought. Did I run over an unknown passerby? Can I sin with a sacrilegious thought or act? Would I be capable of taking my child's life? Did I become infected through not having been careful enough, through my own fault? I know I checked, but will the house flood because I was not careful enough and did not turn off the tap, or did not turn it off all the way?

In some cases this common thread seems more difficult to apply. Even so, with a little imagination, it can remain valid. For example, in the case of obsessive doubts. "I am supposed to know it and I know that I know it, but what if Barcelona is spelled with a V?" Note that the doubts do not arise in those areas in which the patient may be ignorant, and it is acceptable for them to be so, but rather in matters whose knowledge is taken for granted and which could suggest that they are a boor.

As for the common thread running through the different themes of the fixed idea, we already discussed it in the first chapter of the book. They all revolve around two poles: the persecutory pole (that of harm and injury) and the pole of grandiosity, superiority, and utopia. Just like delusions, which they so closely resemble.

Third difference: doubt versus conviction

The obsessive asks himself: What if…? What if I have run someone over? What if the gas is not turned off? What if something horrible happens because I did not perform the ritual? It is completely absurd, but, what if…? What if I contract AIDS from stepping on blood in the street? What if Barcelona is spelled with a V? The obsessive's doubt is somewhat special: it arises in the field of consciousness as a question that resists disappearing, but, at the same time, the patient is aware of the senselessness of that question. Even so, he cannot help but be tormented by the doubt.

In the same way, he is fully aware of the absurdity of his repetitive behaviors; he knows perfectly well that they are entirely ineffective and that they lead him nowhere.

Obstination, on the other hand, is a conviction, a categorical assertion. "I know how to build a happy world." "This doctor has ruined my life." "Water cures everything." And so on.

In summary, we could say that obsessive-idea ≈ pseudo-doubt, while fixed-idea ≈ conviction (non-delusional, pre-delusional).

Two qualifications must be added to this simple schema.

The most severely obsessive patients, especially after decades of illness, come to lose their "sense of reality" and the doubts appear to transform into genuine beliefs. The rituals lose their ego-dystonic character and the patients no longer resist performing them.

When the conviction of the obstinate person (or of the delusional one, it makes no difference) is attenuated, when it draws closer to reality and the person begins to seriously entertain the possibility of being wrong, at that moment we can say that the patient doubts. This is in that case a genuine doubt, radically different from the one that repeatedly makes its presence felt in the consciousness of the patient with OCD.

Fourth difference, between the anankastic ritual and the activity of the obstinate person

Let us take as examples anankastic washing, on the one hand, and obstinate querulous individuals, on the other.

The obsessive patient wants to eliminate any germ that might survive on his hands. He does so by washing them over and over again with the same products, often in a ritualized manner, as in religious ceremonies. He opens and closes the tap always with the same hand, applies the antiseptic product in a particular way, rinses, repeats the process an exact number of times, and so on. At the same time, he tends to overlook many other basic hygiene measures. Either he is not being consistent, or it is that, deep down, his horror of contagion is not what it seems. In the end, he would be more of a crank than a genuine hypochondriac.

The activity of the querulous patient, on the other hand, is completely different — we might say more coherent. He neither always repeats the same action, nor does so in a ritualized manner. In his complaints he seeks effectiveness, and he may just as readily spend entire days studying the Civil Code as preparing his written submissions or seeking allies in his crusade through the courts.

OCD tends to deploy a limited number of actions (compulsions), or even to repeat no more than one, always the same one; the obstinate person, for his part, develops a far broader range of activities: all those he believes will lead him to achieve his objective in the swiftest and most complete way possible.

The obsessive carries out his rituals knowing full well they are useless; the activity of the obstinate person, quite to the contrary, is in keeping with his objectives.

The obsessive's ritual is perfectly defined in its components and makes him feel momentarily calm, relieved — until the unease returns. It is a circular process that never ends. The obstinate person, by contrast, follows a linear process that, even as it advances, likewise never ends. Like the sailor who tries to reach the horizon, he never gets a moment's respite such as the anankastic enjoys. The obstinate person never gets to claim victory; success eludes him.

Fifth: qualitative differences in thematic overlaps

We were saying that theanankastic contents and those of fixed ideas are distinct; this disparity facilitates differential diagnosis. Nevertheless, there are several overlaps in which one and the samethememay present itself, interchangeably, as an obsession or as an overvalued idea. This is the case with hypochondria, with hoarding, and with aggression.

In all three cases we must pay close attention to the details.

Hypochondria

Anankastic hypochondriacal ideas revolve primarily around contamination by germs. They are associated with washing compulsions (of the hands, the body, food, clothing…) and various avoidances (not touching a particular object, not approaching a particular place, not ingesting certain things, etc.). The compulsions and avoidances are entirely disproportionate, absurd, and even harmful. Even so, for the anankastic, what matters most is the carrying out of the rituals and the fulfillment of his avoidances. He does not fear the bacterium itself but rather himself — he fears not having done what was appropriate and doubts whether he has acted correctly (aware that his compulsions are, in reality, absurd and useless).

On the other hand, the overvalued hypochondriac is genuinely concerned about actually having contracted or being able to contract the disease. He acts in a manner consistent with his fear: he tries to get doctors to confirm or rule out the illness with absolute certainty, he studies it, searches the literature for a treatment and applies it, just in case, whenever possible, etc. The feared diseases are infectious ones and cancer, above all. Both adapt very well to the paranoid rhetoric of war. Like other types of enemies, the hypochondriac attack can come equally from outside (invading germs) as from within (treacherous, malignant cells). Both invade, weaken and ultimately kill the patient. Treatment tends to be expressed in warlike terms, as a great battle.

Accumulation

The accumulation of objects has classically been considered an obsessive symptom. More recently (3) it has become an independent diagnosis, albeit included within the obsessive "spectrum."

But the truth is that there are two ways of accumulating:

The anankastic patient piles up useless objects (magazines, old clothes...) just in case, in case they might ever be needed one day. He knows they will be of no use to him, but he is unable to part with said objects. "What if I need that information someday, what if it comes back into fashion someday...?"

The "obstinate accumulation," or paranoid accumulation, derives from a clear will to hoard rather than from an inability to get rid of objects. It is related to persecution or to megalomania: weapons, gold, cars, etc. A megalomaniac patient —with mystical experiences— accumulated enormous quantities of supposedly recyclable scrap and waste because it made him "feel in solidarity with all the poor and needy."

c) Aggression

Anankastic and obstinate aggressive ideas or impulses are also radically different:

The obsessive is terrified by the guilty idea of having been able to harm an innocent and even beloved person, or of being able to do so in the future. He does not want to, but he is assailed by the doubt of whether he might at some point lose control of himself.

The obstinate harasser fears being himself the one attacked, the victim of his enemy. He wants to attack him and often does so, since he considers it his right. When he holds back, it is out of prudence or cowardice, but not out of lack of desire.

The obsessive personality as the trait-version of obstination

What is common to all the patients presented in the first section of this chapter is the fervor with which they throw themselves into work (in a broad sense, including study and domestic tasks) and into their goals. They have their motives, their objectives, and their ambitions; these are not always formulated in a clear and articulated way, but they have them. The obsessive's arguments for sacrificing everything for work may seem flimsy to us; even so, the obsessive adheres firmly to his reasons. No anankastic doubts whatsoever. He displays the conviction and coherence of the querulant, the inventor, or the obsessive hypochondriac. He acts like someone obstinate in pursuit of success, not like a neurotic who hesitates and is paralyzed by insecurity and scruples.

The force driving him is not the guilty doubt of the anankastic, nor any fear that even he might find absurd. The obsessive does not ward off any improbable catastrophe, nor does he atone (at least consciously) for any sin he has not committed. What drives him is the aspiration, conscious and fully embraced, to do something great and valuable, something that can be respected and admired. If he is convinced of anything, it is that this is his duty. However, although he does not act in order to alleviate any guilt, he may feel guilty for notacting and fulfilling his obligation. It is a different kind of guilt, one that is not found at the starting point but at the finishing one; it presents itself to us as a consequence of inaction, not as a cause of action.

His is an ego-syntonic idea, that is, in full harmony with the rest of his person. If any parasitic thought comes to his mind, it will in any case be that of straying from his path or of giving up in his endeavor. The obsessive lives in consonance with his aspirations; they are his, a part of him.

We do not know whether he seeks perfection or success, to do things well or to be the best. Whatever the case, he organizes his activities and his efforts, the pauses and the bursts of speed, according to his ultimate goal. That goal may prove elusive and unattainable to him, but, in any case, he does not cease to advance in the right direction. In this respect the obsessive seems more like the trait-version of obstination than of OCD obsession. His behavior —like that of the obstinate person— follows a linear course, heading toward a fixed point on the horizon. It does not trace the circles that bring the anankastic patient back to the starting point, again and again.

If we confine our analysis to obsessive behaviors in the workplace, we might think, at first, that the obsessive's excessive activity is the fruit of calculation. He works in order to enjoy prosperity. At least, that is what he himself often claims. And yet, if we observe him carefully, things may happen in a different way.

The work of the obsessive has a strange quality that likens him to the cloistered monk. He often does not seem to care too much about prosperity, for he lives an austere lifestyle, with hardly any needs, difficult to understand. He continues to work tirelessly when he no longer needs to. He has amassed more than enough, yet he resists retiring when age or illness would counsel it. In his "free" time, he prefers to plan or brood over his work rather than abandon himself to the enjoyment of its fruits. The strenuous life of monks has a meaning: ad majorem gloriam Dei. But the obsessive (with some exception) does not adduce spiritual motives but rather worldly justifications:

Recognition and power.

The happiness of the family.

The progress of society.

Duty.

First motivation: recognition and power. Although they resist openly acknowledging it, many obsessive patients seek recognition and status. Through professional or business success they aspire to occupy a prominent position, to be known and respected. Precisely for this reason it is common for them to combine an austere lifestyle in their private lives with a ready willingness to spend on representation and image. Others seem more interested in the recognition of their family circle. The obsessive often seeks the approval of his parents (or one of them), even after they have already passed away. "Something he could be proud of" is a phrase I have heard on more than a few occasions.

Second motivation: the happiness of the family. Another recurring argument is that of building a legacy (financial, real estate, business-related, etc.) that guarantees the future of the children and the children's children. That they remain sheltered, at the very least, from poverty or, better yet, that they be the ones to afford themselves what the obsessive himself, despite being able to, has not allowed himself. The obsessive would not renounce the "good life" (a term that is never, in any way, used to refer to his own lifestyle) because it is harmful or deserving of rejection — it is simply that he prefers to offer it to his descendants.

Third motivation: the progress of society. A third group of arguments alludes to social advancement. The emphasis on ceaselessly improving, innovating, and perfecting procedures or the results of one's work is justified because it entails contributing to the material well-being of society as a whole (which was not the case either in Prehistory or before the Industrial Revolution). In a world like ours, where industriousness has replaced piety as the supreme virtue, doing things well, improving, and even innovating, means doing the right thing — that which will result in a better world.

Fourth motivation: duty. In other cases where ambition weighs less and rigidity weighs more, the obsessive simply acts believing that they are fulfilling their obligation. Regardless of the results, they do what must be done. The motivation is moral.

Do the obsessive's way of acting and their lines of argument not refer us back to the conduct and arguments of the obstinate?

Let us take, as an example, a prominent group of obstinate individuals: the reformers. Their goal is to build a perfect political order. For that dream they are willing to sacrifice everything. They seek to establish a society free of conflict that guarantees universal happiness. They deploy an ingenuous blend of extreme altruism (they renounce any other personal interest) and vanity, for they are not only the intellectual architects of the new social and political order, but also dream of being the leaders who will impose it and the rulers who will govern it.

In what ways do the obsessive and the reformer resemble each other? Both struggle tirelessly for a better future (for society, for their own family, or for themselves). Both tend to overestimate their own abilities, as well as the impact and importance of their work. Both share the same austere attitude and, although it may not seem so, an antimaterialist one. Both sacrifice the enjoyment of life, their appetites, and in large part their loved ones for the sake of an ideal that, in all likelihood, they will not see fully realized at the end of their lives. Persevering effort and narrow-mindedness lead the reformer to poverty and even destitution. The same does not happen to the obsessive, but they may end up losing their family, their health, and even their life, like the Karoshi who collapses exhausted over the keyboard.

As for the arguments with which the reformer explains their unbridled activism, they run parallel to those of the obsessive: duty, progress, a legacy for future generations (which now are no longer limited to biological descendants), or the glory that they deserve and that is their destiny.

Well then:

If there are numerous arguments for ruling out that the obsessive personality is the trait-version of the obsessive idea of OCD (as the very name suggests),

if the obsessive personality seems rather like the trait version of the overvalued idea or obstination,

and if obstination is nothing but a variant of paranoid behavior,

then,

one might expect that the universal constants of paranoid behavior would unfold in the obsessive personality.

To evaluate this hypothesis, we will place face to face (a) our "aggregate obsessive personality" with (b) the constituent elements of paranoid behavior that have emerged from the study of paranoid contagion groups. Do they overlap and coincide? That is what we must find out.

The obsessive personality as a paranoid variant

Pride, distrust, rigidity and more

First element of the paranoid tripod: pride, self-overestimation, superiority or grandiosity

The paranoiac sees himself as endowed with greater intelligence, or greater strength, or greater courage, or more positive attributes than most. His superiority allows him to look upon others with contempt, whether he acknowledges it or not.

Is self-overestimation present in the obsessive personality?

Somewhat attenuated, pride was detected by E. Jones among his obsessive patients.

The same author, however, admits that this "good opinion" may go somewhat further.

Anal-erotic personality. Ernest Jones.

"[...] the exalted belief in personal perfection…" (16).

Four traits attributed to the aggregated obsessive personality bring us back to the superiority complex: effort, inability to delegate, purity, and curative omnipotence.

a) Effort

The paranoid contagion groups taught us that superiority is not merely a self-evaluation, a good mark that the militant gives to himself, to his things and to his activities, nor a comforting sensation that comes for free, simply by virtue of having enlisted in a given group. Frequently, superiority is also a mandate: one must strive and earn it. The life of the sectarian, like that of the authentic fanatic, is distinguished by absolute devotion to the cause, without sparing any effort. He feels aversion to sleep and to rest, and feels the obligation to make a permanent effort in favor of the objectives determined by the leadership. Resting is not acceptable: the sectarian cannot afford it because he must work toward goals too importantto neglect. Being a co-participant in something so great makes the militant feel, himself, someone important.

The obsessive also strives to the utmost, wants to progress, to improve, to surpass others and to surpass himself… he will strive as much as necessary to become superior.

b) Delegation

The same dynamic of superiority underlies a trait attributed to the anal personality: the inability to delegate. This was how E. Jones saw it.

Anal-erotic personality. Ernest Jones.

"[...] the conviction that nobody can perform the task in question equally well as himself, and that he cannot trust anyone to do it correctly [...] they refuse to delegate any part of the work, however urgent, to a substitute or assistant" (16).

Anal-erotic personality. Ernest Jones.

"The relationship is clear between the last trait discussed [the inability to delegate] and narcissism and the exalted belief in personal perfection…" (16).

If he has no alternative but to relinquish responsibility, the obsessive will not cease to monitor that things are done correctly, that is, his way. Not the way of others.

In the clinic, hypochondriac or querulous delusional patients behave in a similar way. They treat their doctors and lawyers as if they were their employees, and closely supervise each of their steps or decisions. They want them to act exactly their way.

c) Purity

Sometimes paranoid superiority refers to the body itself and is expressed in terms of purity. It is a metaphor inspired by water or diamonds. It is common in religious cult groups and also occurs in paranoid patients. The absence of impurity implies, in a certain sense, a state of perfection, of clarity, in which negative or harmful elements have been completely eliminated.

In some cases, one's own purity is taken for granted: it derives from the simple act of belonging to the cult. Most of the time, however, it requires an activity aimed at eliminating that which prevents the ideal from being attained. Compulsive washing, diets (often vegetarian) or the intake of large quantities of water serve that purpose.

Jones, for his part, relates purification behaviors to the anal personality.

Anal-erotic personality. Ernest Jones.

"I have found that the anal-erotic reaction often extends to the interior of the body, with the conviction that everything inside is inherently dirty. I have known people who even refuse to put a finger in their mouth, and who have the habit of drinking large quantities of water daily with the idea of purifying the filth inside their body" (16).

d) Anti-hypochondriasis

We already discussed at the time the megalomaniacal ideas of paranoid individuals and groups in relation to health: ideas concerning immunity from disease, ideas regarding the possession of extraordinary healing powers, prodigious techniques, etc.

Jones described something similar in his anal patients.

Anal-erotic personality. Ernest Jones.

"[...] and the conviction that breathing exercises provide a panacea for physical and mental ailments" (16).

Second element of the paranoid tripod: enemies and enmity

Paranoiac character.

"[...] the essential traits of the paranoiac character are the following:

- overestimation of oneself;

- distrust;

- falsity of judgment…" (18).

As the reader will recall, we prefer to speak of enemies, on the one hand, and of hostile behavior, on the other. In turn, we broke down the latter into several elements, for analytical purposes:

The motivations of hostile behavior: distrust, resentment, and honor.

Hyperalertness.

The emotions: fear and hatred.

The behaviors: attack and flight.

In this scheme, distrust is no more than one of the components of hostile behavior.

Regarding the identity of enemies, we develop the idea that they are not always human beings. They can be animals, pathogens, incorporeal spiritual beings, etc. We also speak of the possibility that hostile behavior may be directed toward real, flesh-and-blood adversaries. Paranoid individuals or groups do not always face merely imagined enemies; when they truly have them, they have no need to invent them.

So then. If the obsessive personality is a variant of paranoid behavior: Who is the enemy?

a) The enemy of the obsessive personality

The obsessive personality is competitive, always wanting to win, to surpass others and, when all is said and done, to defeat them. To this end they apply all their ingenuity and all their effort. Although it may sound strange to us, the competitive mindset of the obsessive is not so far removed from the mindset of war. War, after all, is nothing but a competition fought to the death. The rivals of the obsessive are those with whom they compete in the professional, sporting, or any other sphere. In a broader perspective, anyone who might come to overshadow them in prestige or social recognition is an enemy.

But there is more. What, ultimately, drives the obsessive to persevere in their self-demand is the gaze of the other, the need for approval, the what will people say.

"Extraordinary sensitivity…"; it is society as a whole that has acquired, in the eyes of the obsessive, that threatening tonality which the paranoid person, frequently, focuses on a much more reduced number of individuals. The paranoid person fears the gazes, the laughter, or the whispers of others, because he thinks they refer to him and are directed against him, and he cannot bear it. Mutatis mutandis, one might say that the obsessive's impulse to be impeccable and to allow himself not the slightest failure responds to the need to avoid the contempt, the mockery, or the hostility of people.

Therein would lie the persecutory background of the obsessive's self-demand (which must be added to the other background, the narcissistic one). Being at heart a paranoid person, he feels the weight of others' gazes converging upon his person, and it is that weight which leads him to avoid any error. He does what is correct in order to obtain approval, and he needs approval because in this way he avoids rejection. Or so he believes, because, contrary to what might be expected, his competitiveness, and especially his success, can indeed awaken the animosity and envy of those around him.

Although it does not carry much scientific value and relying solely on clinical experience, I would venture to affirm that self-referential interpretations are particularly frequent among individuals with an obsessive personality. Not universal, of course, but considerably more common than in other patients. One need only ask.

In short, every paranoid person needs enemies and, in the case of the obsessive, this place is occupied by a diffuse entity that we can identify as "people" or "society." It acquires somewhat more concreteness when it takes the form of rivals or competitors with names and surnames.

b) Enmity in the obsessive personality

Some of the clinical descriptions of the obsessive personality include elements that in chapter 10 we identified as constituents of enmity behavior.

Rancor is the tendency to cling in a disproportionate manner to the memory of suffered affronts and to act (or to dream of acting) accordingly. This trait was associated with the anal personality.

The refined sense of paranoid honor compels one to respond both to inadequate treatment from others and to injustices. The person of honor tolerates neither slights nor iniquity. Neither do anal personalities:

Anal-erotic personality. Ernest Jones.

"[...] which results in an intense feeling against any form of injustice…" (16).

Anal-erotic personality. Ernest Jones.

"In adulthood they are particularly sensitive in matters concerning justice, to the point of pedantry…" (16).

The two emotional experiences typically associated with paranoid enmity are fear and hatred (or anger). E. Jones attributed to his patients with anal personality an excessive tendency toward anger:

Anal-erotic personality. Ernest Jones.

"It may be suspected that infantile anal eroticism has been inadequately handled in anyone who is the victim of chronic irritability or of a bad temper" (16).

Third element of the paranoid tripod: rigidity

Paranoid character.

"[...] the essential traits of the paranoid character are the following:

- overestimation of oneself;

- distrust;

falseness of judgment…" (18).

Other classic authors used the term psychorigidity to refer to the paranoid cognitive style. It alludes to inflexibility, to the great resistance if not impossibility of change. With regard to obsessives:

Anal-erotic personality. Ernest Jones.

"[...] the matter has only one side and is not open to any kind of discussion" (16).

We studied in chapter 16 how paranoid groups isolate themselves and close off contact or exchanges with their environment. The closed attitude is also characteristic of IPs in general. This closure prevents, of course, the exchange of opinions or ideas.

Obsessive individuals would not be inclined to let themselves be influenced by the opinions of others either.

The paranoid cognitive style is characterized not only by its fixation on an idea and resistance to modifying it, but by a tenacious and passionate defense of that idea. Feeling himself to be in possession of the truth, the paranoiac has no need to seek it. He applies all his logic and argumentative capacity to defending that truth which he is certain he holds in his hands. He neither listens nor engages in dialogue; he monologues and attempts to persuade.

Something similar has been attributed to obsessives.

Their combative attitude, their need to convince, leads the paranoid to develop a cognitive style that attempts to be self-demanding in logical rigor, in precision, in order, in the appearance of coherence. Their ideal is that of irrefutability absolute. As for the obsessive:

Anal-erotic personality. Ernest Jones.

"[...] passion for clarity of thought; they delight in clarifying things, prone to classifying…" (16).

Argumentative tenacity leads the paranoid to develop a particular form of listening that always seeks out the weak points of the opponent, those that will allow them to disarm him. This listening, however, goes hand in hand with an absolutely closed attitude that does not contemplate the possibility of accepting the other's reasoning. It is a mere confrontational strategy. One of the items of Westen's obsessive personality perhaps relates to this facet.

"Capacity to recognize" does not mean capacity to admit.

A notable characteristic of paranoid discourse is the omission of references to specific people, dates, or places. Instead, abstract and impersonal content is preferred. As for obsessive individuals:

Let us recap. We have established that the three classic constitutive elements of paranoid behavior are integrated into the obsessive personality. Indeed, the latter appears to be driven by both grandiosity and hostility. In turn, the cognitive style of the obsessive would be characterized by the same inflexibility as that of the paranoid.

In the following section we will proceed in the inverse direction: starting from the traits attributed to the anal-obsessive personality, we will investigate their presence or absence in paranoid behavior.

Perfectionism

The aspiration to perfection permeates the obsessive's life, it defines it. Does it also define that of the IPP? The truth is that in our description of paranoid behavior we did not include any chapter specifically dedicated to perfectionism. Nevertheless, the imperative of perfection peeks through in other manifestations of paranoid behavior such as messianism, superiority, or hyperhierarchization. In turn, these three manifestations are also present in the obsessive personality.

a) Messianism

The majority of sectarian groups — including the minuscule ones — are convinced of their capacity to significantly improve the world, save it, or bring about some form of complete happiness. Peace or the absence of conflict, equality, immunity from illness (or from bullets), or absolute prosperity stand out among the messianic fantasies. When all is said and done, their promise is that of a perfect world, a world whose achievement always merits a significant effort.

If the obsessive attaches such great importance to the results of their work, it is because they magnify their relevance and impact. They tend to detach from reality and to feel that their professional, academic, or business activity is something more than a drop in the ocean. They experience a diminutive, yet equally comforting, version of messianism. They will not save the world, but they make it much better, and to that end they dedicate all their energies.

b) Superiority

Anal-erotic personality. Ernest Jones.

"[...] the exalted belief in personal perfection…" (16).

The obsessive personality and the IPP share that self-perception which makes them feel superior to others: they are superior for being who they are, for being the way they are, for being what they are, or for what they have. They are also superior for what they do, which must be something great and perfect, something greater and better than what others do. This compels them to make titanic efforts.

In this way, cult groups embark on ambitious projects (proselytizing, architectural, or of any other kind) completely disproportionate to their real capabilities. Exhaustion always accompanies the militant of the most extreme groups, just as it accompanies the obsessive.

The self-demand of the cult member is at its maximum, and it is a demand that, as in obsessives, extends to order and cleanliness (of the premises), to the care of outward appearance, and to the structuring of time. For what one does and achieves, and the appearance with which one presents oneself to others, must be in keeping with one's superiority. They cannot contradict it.

Necessarily, one's own perfection is determined in relation to the imperfection of others. Unfaultless execution casts doubt on the superiority of the one who carries it out. A perfect execution, on the contrary, sustains the superiority complex: that of the cult member and that of the obsessive.

c) Hyperhierarchization

The cult member renounces rest, leisure, and their own interests for the sake of the group's objectives and the directives that, on the go, emanate from the leadership. Their exhausting effort is yet another expression of submission to the authority of the group and its leaders.

It is not so evident that the obsessive's effort is related to submission to anyone, given that it appears to be the obsessive themselves who charts their own course. However, viewed another way, the obsessive is the one who most fanatically complies with the ideals and values of modern society, and the one who most meekly bows to the scrutiny of what people will say. And all of this is without even mentioning their absolute devotion to the company they are part of. The obsessive employee often behaves like a cult member within an organization that is not necessarily one.

Greed

Anal-erotic personality. Ernest Jones.

"The anal-erotic complex is genetically related to two of the most fundamental and far-reaching instincts: the instinct to possess and that of creating or producing respectively" (16).

The propensity to accumulate money is a trait that has been associated with the obsessive personality since its origins. It is also associated with paranoid behavior, as we set out in the chapter on expansionism.

If we delve somewhat deeper into paranoid/obsessive greed, an apparent connection with other facets of paranoid behavior becomes evident.

a) Catastrophism

It is claimed that the obsessive accumulates money "as protection against future misfortunes." The distrust of circumstances, that bias toward thinking things will go wrong, is the cause of greed.

b) Interpersonal distrust

There is a second connection between greed and (paranoid) distrust:

Anal-erotic personality. Ernest Jones.

"[...] They are particularly troubled by the idea that something might be taken from them against their will, especially if it is something that symbolizes feces in the unconscious, as is the case with money" (16).

The obsessive miser fears being dispossessed of what he holds so dear by anyone who approaches him. That basic distrust comes between him and the world around him and causes him not only to accumulate money, but also to conceal it.

c) Narcissism

Accumulating money, perhaps more in our society than in others, transforms the subject into a privileged individual (superiority), someone who can do and have things that are denied to others. The accumulator may choose not to do or have those things, but it is their decision, not an imposition they are forced into by poverty. The accumulation of wealth allows the obsessive to feel the same "overestimation of oneself" that has been attributed to paranoid contagion groups. The key is not only to have a lot, but to have more than, or better yet, much more than, others.

Isolation

Let us recall that the hyperactivity of the obsessive personality limits and deteriorates their social network: personal relationships require time, time that they do not have.

Exactly the same thing happens to the members of paranoid contagion groups, completely absorbed by the imperatives of the group, as well as to numerous delusional patients with the demands of their delusions. Such is the dedication to "their thing" that the remaining facets of their life necessarily suffer.

Isolation, however, is not merely the consequence of monothematic hyperactivity. It is something more than a side effect: it derives directly from paranoid activation, from the inability to trust others or from the contempt that others inspire. Paranoidization, in and of itself, entails a propensity to distance oneself from others. If the obsessive is, ultimately, a paranoiac, it is likely that they not only isolate themselves as a consequence of their work, but also use work as a means of isolating themselves (even if they are unaware of it).

The corollary of the impulse toward isolation, toward living on the margins of others even when they are nearby, consists in neither listening nor allowing oneself to be influenced.

In this way, the obsessive personality does things as it wants and when it wants:

Anal-erotic personality. Ernest Jones.

"It is equally hard to push them into a definite course of action as to stop them once they have started" (16).

Anal-erotic personality. Ernest Jones.

"[...] persons of this type are particularly sensitive to having their time taken from them against their will, and insist in a thousand ways on being the masters of their own time." (16).

The paranoiac tends to exhibit that same independence. So does the cult member, who accepts no influence other than that of their group and disregards all others.

Differentiation

Anal-erotic personality. Ernest Jones.

"[...] they have a strongly marked individuality" (16).

Both paranoiacs and members of cult groups have a marked tendency to differentiate themselves from their surroundings. In Chapter 17 we review the various facets in which the tendency toward originality and difference becomes apparent.

Proselytism

E. Jones attributed to anal-erotic personalities a great passion for persuasion.

Anal-erotic personality. Ernest Jones.

"A passion for the propagandism of ideas…" (16).

Anal-erotic personality. Ernest Jones.

"They are notoriously tedious [...] once they have set their mind on a matter they do not stop until they have gone over it in full length and breadth and said what they wanted to say…" (16).

Anal-erotic personality. Ernest Jones.

"[...] and in the meantime no one is permitted to interrupt or put in a word on the matter. Those who try are simply ignored or provoke great anger" (16).

When they do not conceal them, delusional patients almost always attempt to convince others of their ideas. They seek allies among those who may prove most useful to them, by virtue of their knowledge, their standing, or their influence. Sectarian groups devote an enormous effort to convincing and recruiting new followers. On many occasions, and in parallel, they seek the recognition, the dissemination, and the social acceptance of their convictions, without this necessarily entailing incorporation into the group.

Moralism

This general attitude should be reflected in concrete behaviors in which the high ethical standard is made manifest. For example, according to Freud, obsessives do not lie.

And the thing is…

Anal-erotic personality. Ernest Jones.

"There are three classes of actions that are particularly prone to being affected in this way [by anal eroticism]. First, tasks that carry a special sense of duty or of what is right; consequently, especially moral tasks" (16).

Of course, rigorism has also been identified as one of the manifestations of paranoia.

Paranoia.

"[...] in the clinical picture of paranoia. Among the objective characteristics are included [...] rectitude..." (8).

In the corresponding chapter we assert that one manifestation of the hyperhierarchization of the paranoid contagion group is the punctilious and uncritical compliance with norms on the part of the group's members, especially those occupying the lower positions in the hierarchy; furthermore, the cult member also endeavors to monitor and enforce compliance among the remaining members of the group.

Even so, the moralism of the obsessive and that of the cult member are not identical. The behavioral norms in the paranoid contagion group tend toward originality and toward differentiation from those of broader society, which is not the case for the obsessive. The latter submits to generally accepted ethical standards. Furthermore, the member of the paranoid contagion group is willing to modify their principles whenever the group so determines, something that can hardly be applied to the obsessive.

Regulation-ism

Cults and totalitarian societies tend toward regulatory excess, toward reducing the margin for individual spontaneity, and toward having everything determined from the top down. This regulation-ism reflects the hyperhierarchization of the paranoid contagion group. Promulgating norms upon norms is an act of authority; accepting and complying with them, an act of submission.

Obsessives, for their part, do something similar. They impose upon themselves and upon others more norms than other people do, by taking seriously that enormous chapter of minor prescriptions that the majority overlooks. The obsessive is incapable of "turning a blind eye" to anything. Like the cult member, or like the paranoiac, their life is regulated by a host of obligations that they simply must fulfill.

Finally, it must be remembered that scrupulousness applies not only to what is done, but to the way in which it is done. It affects the what and also the how.

A concern entirely transferable to sectarian groups and the most totalitarian societies.

Independence, dominance and submission

Anal-erotic personality. Ernest Jones.

"They rebel against authority and insist on going their own way" (16).

Anal-erotic personality. Ernest Jones.

"As children they are extraordinarily disobedient [...] they may later develop a reaction formation leading to an unusual docility" (16).

It seems complicated that such contradictory traits could coexist in the same profile of individuals. Can one be both submissive and authoritarian? Obedient and bossy? Is that not the opposite? Is it coherent that if our obsessives are so individualistic they are, at the same time, so attentive to matters of hierarchy? Why should they care? It is something that ought to leave them indifferent: an independent person neither allows themselves to be subjected nor wants to subject anyone else.

The study of paranoid contagion groups, and of cults in particular, can shed some light on this

It all depends on who is in front of them. The adept shows indifference —if not hostility— toward people outside their group and toward the surrounding environment; they follow their path solely according to what the paranoid contagion group they belong to dictates. By contrast, with the rest of the group's members they establish an always asymmetrical relationship in which they are obliged to distinguish whether the person in front of them is below or above in hierarchical status, and to act accordingly.

There are two concrete manifestations of obsessive personality by aggregation which, interpreted from the point of view of paranoid behavior, seem to reflect the impulse toward submission.

a) Suffering

Obsessives compel themselves to do what they do not feel like doing.

Anal-erotic personality. Ernest Jones.

"There are three classes of actions that are particularly prone to being affected in this way [by anal eroticism]. Secondly, tasks that are intrinsically unpleasant or tedious toward which, from the outset, a rejection occurs [...] such as tidying wardrobes, cleaning the pantry, completing a diary or writing a daily report" (16).

One step further, and we can speak of genuine ascetic practices. Obsessives impose upon themselves various degrees of austerity, frugality, pain or discomfort.

Anal-erotic personality. Ernest Jones.

"There are people who are never satisfied with their capacity for self-control, and who continually experiment on themselves in order to increase it [...] drinking tea without sugar, giving up smoking for a time, getting their legs out of bed on a cold night and allowing all kinds of ascetic practices to confirm to themselves their power of self-control [...] lasting influence of the childhood ambition to achieve control of one's own sphincters" (16).

Undoubtedly, some of these practices are striking.

Anal-erotic personality. Ernest Jones.

"[...] the tendency not to change one's underwear more than is absolutely necessary" (16).

In paranoid contagion groups, the deprivation of pleasures, or the active self-infliction of suffering, constitutes a manifestation of submission. The adepts willingly comply with painful demands to which they would never submit in any other context; they do so whenever they are ordered to. Among obsessives, however, the one who gives the orders and the one who follows them is the same person.

b) Repetition

Paranoid contagion groups tend to insist on the performance of frequent ceremonial acts. Rituals serve to underscore integration and submission to the group and, very often, to induce states of collective enthusiasm. They are typically repeated in a frequent and regular manner. Everyday behaviors also tend to be repeated; with times and activities being hyperregulated, the cult member's life becomes particularly monotonous and repetitive. With regard to obsessives:

Control

The obsessive person is said to be attentive to what happens around them, to what and who is there, to where each thing is, to what decisions are made and why, etc.

The paranoid hypervigilance, which seeks to detect risks in time, entails that same need to keep everything "under control".

Also relevant is the control of information that occurs in cult groups, with their demand for absolute sincerity from members, mutual surveillance among group members, violations of privacy, and the systematic reporting to authority figures of any suspicious behavior or attitude. The control of information, in this case by the leaders, is absolute.

Obsessive bond

The descriptions of the obsessive personality in the various DSMs make reference to some alterations in the way of relating to others. These alterations coincide, to a large extent, with what was described in Chapter 21.

Some of the characteristics that we attributed to IPPs turn out to also be characteristics of obsessive individuals. Thus:

Coldness.

Formalism.

For that same formalism, the obsessive will prefer those situations in which the objective is to do something to those others in which, what it is about, is being with.

Secretiveness.

Cruelty.

In the paranoid universe, passions related to great abstract or impersonal matters tend to occupy the place of genuine human interaction. Perhaps something similar occurs in the obsessive personality. For example:

E. Jones would even perceive in his obsessives that same mixture of passionate love, absorption, and hierarchical asymmetry so characteristic of cult groups.

Anal-erotic personality. Ernest Jones.

"[...] the exquisite tenderness of which some persons of this type are capable, especially with children [...] A curious accompaniment of this tenderness is a curious tendency toward the loved (and possessed) object; these persons are frequently dictatorial and even tyrannical, and are extremely intolerant of any display of independence on the part of the loved object" (16).

Exaltation

The manic-like states of enthusiasm that occur in paranoid contagion groups and that are also associated with megalomaniac delusions have their small reflection in the obsessive personality.

Anal-erotic personality. Ernest Jones.

"Periods of activity are normally followed by a marked sense of elation and self-satisfaction…" (16).

Ineffectiveness

The DSMs state on more than one occasion that the obsessive personality may be ineffective in its performance, despite the great efforts it deploys.

This loss of effectiveness would be reached for different reasons. E. Jones spoke of procrastination, the tendency to postpone the start of tasks.

In some patients with paranoid traits and in the biographies of some totalitarian leaders, I have been able to verify that same alternation between periods of withdrawal and inactivity and other periods of feverish activity and combativeness. One might say that the phases in which the attitude of flight from the world predominates alternate with those of attack.

For their part, the DSMs suggest a somewhat more subtle variant of procrastination. Obsessive individuals would tend to leave the most important elements of the task until the end. As it is usual to lack time for the full completion of the work, they run the risk that the only parts that are actually completed are the least necessary ones.

The inefficacy of the obsessive, as the DSM would have it, would also depend on two other traits likewise associated with paranoid behavior: rule-boundedness and perfectionism.

Challenges, objectives or ambitions

According to Westen, the obsessive pursues a goal that is not immediate and that, consequently, will require sustained effort over time.

One of the manifestations of the high cohesion of paranoid contagion groups is their capacity to mobilize collectively, as a single body, in pursuit of collective goals that may be very long-term. They do so with the same tenacity as delusional patients and obsessive individuals in their respective fields of interest.

Non-paranoid traits

To be fair, we cannot overlook some of Westen's observations whose fit within the paranoid model proves complicated.

These observations suggest that obsessive personality disorder (if it is indeed a disorder) may entail a deviation from the mean for the better. In this regard, we cannot offer a simple and plausible explanation, although perhaps we should return to concepts such as hypersociability and paranoid leadership.

Some other observations from the DSMs, for their part, offer a tone that is perhaps more anankastic than paranoid.

Cluster A

The DSMs distribute personality disorders into three large groups (cluster) based on similarity and co-occurrence.

If the obsessive personality is not the trait-version of OCD but of the overvalued idea, first cousin of delusion, quintessence of paranoia… and if the overlaps between the aggregated obsessive personality and paranoid behavior are truly as extensive and manifest as they appear… then it is reasonable to expect that the obsessive personality would be associated, above all, with the paranoid personality and perhaps, by extension, with those most closely related to it: the schizoid and the schizotypal. In other words, it should migrate from cluster C to cluster A. Does this happen? Some studies — though not all — support the idea.

Year 2000. Rossi and his collaborators (22) studied personality disorders (DSM-III-R) in a sample of 400 consecutive patients admitted to a psychiatric ward. The semi-structured interviews were conducted once the clinical picture had notably remitted, in the days prior to discharge, with the aim of reducing as much as possible any potential distortion arising from acute psychiatric pathology. As in other studies, multiple diagnoses were common. The authors calculated the odds ratio of obsessive-compulsive personality against each of the remaining pathological personalities. For each personality disorder, this is the figure obtained by dividing the frequency with which that disorder presents among patients with an obsessive personality (numerator) by the frequency with which that disorder is present in the overall study population (denominator). As it turned out, by some margin, the disorder most associated with obsessive personality was the paranoid (OR: 5.9), followed by the schizoid (OR: 4.5) and the schizotypal (OR: 4.1).

Two years earlier, in 1998, Stuart and several co-authors (24) had published a multicentre study with 1,116 patients focused primarily on determining whether co-diagnoses confirm the classification of the eleven disorders into three clusters distinct clusters. In the specific case of obsessive personality, the primary association was indeed with avoidant personality (OR: 4.72), which also belongs to cluster C. However, the subsequent associations, in order of importance, were with: paranoid personality (OR: 4.46), schizoid personality (OR: 4.21), and schizotypal personality (OR: 3.05).

Based on data obtained from the "National Epidemiologic Survey on Alcohol and Related Conditions", Grant et al. published a paper in 1912 (10) concerning obsessive-compulsive personality. Among other things, they analyzed the association of obsessive-compulsive personality with other personality disorders. After controlling for the effect of sociodemographic variables, the disorder most associated with it was paranoid (OD 4.1), followed by schizoid (OD 3.7) and histrionic (OD 3.1).

Year 2008. Hummelen et al. (11) studied the personality disorders of more than 2,000 patients referred to twelve psychiatric day hospitals in Norway. To this end, they used the LEAD method, characterized by bringing together information from different sources, with the semi-structured interview being one of them. One of their conclusions is as follows: "[...] obsessive-compulsive personality disorder was more closely associated with paranoid personality disorder than with any other personality disorder. Although it was not [statistically] significant, a close association was also found between obsessive-compulsive personality disorder and schizoid and narcissistic disorders" (the latter being a result compatible with the overestimation of themselves that classical authors attributed to the paranoid constitution).

1988. Not all studies, by any means, confirm the proximity of obsessive personality to paranoid personality, or to cluster A. Hyler and Lyons applied the factor analysis technique to the assessments of 552 patients carried out by 287 psychiatrists (14). They obtained four independent dimensions. Three of them coincided with the traditional clusters of the DSM, while compulsive personality alone formed an independent dimension. Even so, the personality disorders most closely associated with obsessive personality, in this order, were avoidant, paranoid, and narcissistic; only the first in a statistically significant manner.

Hyler's work replicated both the method and the result of a study published in 1985 by Kass (17), which also yielded four dimensions. The difference is that, in this case, the main association of the obsessive personality was with the narcissistic one.

In 1997, Blais and his collaborators (5) used a completely different format with which they obtained three independent factors into which the personality disorders were grouped. Their three dimensions did not coincide with the traditional DSM clusters. Indeed, the first of these factors included the following personalities: schizotypal, schizoid, avoidant, obsessive, and paranoid.

Conclusion

The analysis of each of the traits that make up the obsessive (aggregated) personality reveals that these find a natural accommodation in the description of paranoid behavior.

Association studies with other personality disorders point in the same direction.

The relationship could be formulated in the following terms: the obsessive personality is a concrete form of expression of paranoid activation. It emerges when the third leg of the classic tripod —rigidity— is what comes to the foreground, the most evident and, usually, the only thing perceived at first glance.

Bringing the other two legs to light requires a more thorough and less hurried assessment than clinical practice usually allows.

Consequently, the obsessive personality (or compulsive, or obsessive-compulsive, or anankastic) should migrate from the anankastic field to the paranoid one. And to signal the change of location, it would be advisable to adopt a new designation: obstinate personality. We cannot think of any better one. We thus connect with the first of the variants of the paranoid personality that Millon (20) postulated at the time.