Advanced Psychopathology

Monday, March 06, 2006


OC/Hysterical: Robert's Reaction

Shapiro suggests that aberrant modes of cognitive processing define both obsessive-compulsive and hysterical disorders. According to Shapiro, obsessive/compulsives and hysterics are more or less opposite in their cognitive functioning. McWilliams, while focusing primarily on the defensive operations of obsessively, compulsively, and hysterically organized people, also notes these patients’ cognitive styles.

Obsessive/compulsives are notable for their attentional style, moralistic thinking, indecisiveness, and “loss of reality.” Obsessive/compulsives maintain a hypervigilant and narrowly focused state of attention at all times. Their sharp focus exacts a heavy cost: obsessive/compulsives are so occupied with their primary object of interest that they’re unable to attend to anything outside the beam of their attention; as a result, their perceptual, cognitive and affective range is constricted. Shapiro notes that healthy attentional functioning is defined by oscillating between states of willful concentration and relaxed receptivity – this attentional flexibility is impossible for the obsessive/compulsive. As a result, “surprises” and “hunches” are absent from his experience.

An oppressive sense of moral burden drives the obsessive/compulsive’s relentless activity. Shapiro notes that these patients are hyperaware of duty, propriety, and authority, and search for rules and expectations to guide their actions. Their ceaseless toil, Shapiro suggests, reflects a desire to please a higher power and to forestall criticism and culpability. The obsessive/compulsive patient is most likely to report discomfort (feelings of “losing control” or “going crazy”) in the absence of a goal towards which to extend himself. McWilliams suggests this moralistic drive results from unsatisfactory resolution during the anal period of development and associated feelings of shame. (This shame, McWilliams says, is one of the few emotions an obsessive/compulsive patient will allow himself to feel).

The indecision typical of the obsessive/compulsive patient also reflects an orientation towards external authority and disinterest in his own emotions. Shapiro suggests that normal decision-making hinges on an acceptance of one’s own freedom, and the ability to entertain one’s impulses. The obsessive/compulsive patient abhors personal freedom, has no idea what he wants, and is interested only in what he “should” do; as a result, his decision making process involves an logic-based vacillation between this and that, with no gut feelings to expedite the process.

Shapiro suggests that the obsessive/compulsive patient tends to “lose reality” in a sense. By this, Shapiro doesn’t mean that the patient is delusional, but that in applying himself to his endless directives, he’s lost the Gestalt – he’s lost the forest for the trees. For example, Shapiro notes that obsessive/compulsives have a difficult time stating how they feel, how they perceive the world around them, and how they perceive themselves. McWilliams describes the obsessive/compulsive’s cognitive manipulation of reality differently, suggesting that completion of rituals and internally generated directives give the patient the illusion of magical or omnipotent control. By controlling what he can via ritual or thought, the obsessive/compulsive keeps at bay that which is threatening (e.g. fantasies, emotions).

Hysterical patients’ cognitive style is roughly opposite the obsessive/compulsive’s. The hysterical cognitive mode is impressionistic, lacking in factual detail, labile, and responsive to the most obvious or impressive stimuli present. As a result of this cognitive style, hysterical patients are lacking in factual information about themselves and the world at large, and the memories they articulate in therapy are long on impressions and short on facts. Shapiro suggests that hysterics never fully encode factual information into memory. In contrast to the narrow hypervigilance of the obsessive/compulsive, the hysteric is always struck by things, and always ready to act on a hunch. Interestingly, McWilliams suggest that the hypersensitivity and spontaneity of higher-functioning hysterics is an asset in creative and artistic endeavors.

The hysteric’s poverty of factual information and responsivity to compelling stimuli extends to himself and his feelings. (This lack of self-knowledge is a resemblance between the hysteric and the obsessive-compulsive). The hysteric responds to his own fleeting thoughts with an investment of energy without considering their context or importance, and without considering whether they merit a dramatic response. Even the most violent of his “emotional outbursts” may be experienced as something he doesn’t own or recognize, as though they are mild states of possession. The hysteric’s responses to fleeting stimuli, both internal and external, coupled with the inability to perceive and encode facts leads to a feeling of lacking a stable, factual self. Instead, the hysteric experiences himself as the sum of his reactions and dramatizations. To combat this poverty of coherence and factual information, McWilliams suggests that the hysterical patient’s must reconstruct a “credible,” (if not totally accurate) narrative of himself in therapy.

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