Like the preceding ones, these assume very varied forms.
One of the most frequent is "doubting mania." Its characteristic feature is the inability on the part of the patient to affirm a fact or to make a decision.
Many normal persons experience this phenomenon in a slight degree. At the borderland of doubting mania we find individuals who hesitate before mailing a letter, in spite of having already several times verified the contents, the address, the sealing of the envelope, adherence of the stamp, etc.
Doubt is likely to assume the form of scruples, so frequent in religious persons: a fear of profaning sacred objects, of not being in a holy state of mind, etc.
Closely related to doubting mania are the phobias, which are usually groundless and sometimes ridiculous; their absurdity is recognized by the subject himself.
Some patients do not dare to touch any object, constantly wear gloves, wash their hands a hundred times daily, etc. This phobia, which includes also the fear of contracting an infectious disease through contact with contaminated articles (nosophobia), constitutes "delire du toucher."
Others have a fear of being unable to stand up or to accomplish certain movements, such as walking. "In a deserted place, in a very wide street, upon a bridge, in a church, or in a theatre the patient is suddenly seized with the idea that he will be unable to cross the wide space before him, that he is going to die, or that he is going to be sick." 1
This morbid phenomenon, known as agoraphobia, induces a veritable functional paralysis, and the patient may fall if he is not supported. The slightest support is sufficient to calm and reassure him; the origin of the attack is, therefore, purely psychic.
Claustrophobia is the opposite of agoraphobia; it consists of an inability on the part of the patient to remain in a closed space.
Erythrophobia, first described by Pitres and Regis, consists in a fear of blushing. These patients do not dare to attract anybody's attention to themselves, being sure to blush most distressingly. This phobia is closely related to ordinary timidity, of which it is occasionally a complication.
The following case shows a state of panophobia or diffuse anxiety combined with very pronounced doubting mania, manifesting itself by constant uncertainty and by moral and religious scruples. To use the very expressive terminology of Freud, the patient is in a state of permanent anxious anticipation which, at the occasion of the most immaterial and trifling occurrences, develops into an attack of anxiety.
1 Regis. Manuel pratique de Medecine meniale, p. 279.
Miss Margaret F., forty-three years of age, private teacher. Family history: father alcoholic. The patient is of normal intelligence. Disposition melancholy, but gentle and affectionate. The patient lived for twelve years with the same family, where she had inspired a true attachment for herself. She has had no serious illnesses, save frequent attacks of migraine.
The onset of the illness dates back to the fall of 1903. The young lady whom she had been teaching finished her education, and Miss F. had to take another position. This grieved her very much. She gradually grew sad, depressed, and became disgusted with everything. In November, 1903 (seven months after her change of position), she began to have all kinds of doubts: Has she said her prayers properly? Has she not made a mistake in asking the druggist for medicine? Feeling herself to be really ill she left her new position and went home to her parents. Her morbid preoccupations, however, persisted. Her general health was not very good. She lost considerable flesh in a short time. She was taken to a sanatorium on January 4, 1904.
An examination made on that day showed the following: Stature slightly below the medium. Constitution normal. No evident organic disease except a slight degree of emaciation. Lucidity perfect. Patient had a very clear realization of her own condition. She showed uneasiness with continuous agitation: walked up and down the room, shifted from one'foot to the other, rubbed her hands in a nervous manner, looked around with a sort of apprehension, doing all this, she said, in spite of herself and without any definite idea. A few moments after her arrival doubts and fears made their appearance. She noticed a bottle of syrup on a table in her room. Immediately she began to wonder if she had not, without knowing it, poured something into the bottle, perhaps poison, or ink, or perfume. Later on the same day, also on the days which followed, new fears developed and the doubts increased. The following is a transcript of some of the case notes from the records of this patient.
January 15. Patient, on receiving her mail, could not make up her mind to open it. The nurse opened it for her. The patient is afraid to sort her own linen or clothing. She begs the nurse to examine minutely every piece and to take her oath that no injurious powder has been found on the fabrics or on the bed linen. She knew that she had on her arrival at the sanatorium 121 fr. 75 cms. in her pocket-book, in fact she had written the amount down in her note book, yet she was in doubt. She had the nurse count the money over and finally, still doubting, decided to write to her mother asking whether this was the correct amount. In the evening she said her prayers, kneeling at the bedside, but insisted on a nurse being present all the time in order that she might have proof later that she said her prayers properly.
January 17. Patient went to mass and had prepared three 10-centime pieces for the collection. But, contrary to her expectation, the collection tray went around only twice; there remained, therefore, one 10-centime piece. She passed the entire day in most painful anxiety, not knowing what to do with the ten centimes, asking herself whether they were really hers, or whether she had inadvertently taken them from the collection tray, or picked them up from a neighboring seat.
January 23. Patient fears she was disrespectful in her remarks to the physician. This is probably due to her being neglected, because no attention is paid to her complaints. But it is also her own fault that she is left to herself: perhaps she has not followed the doctor's advice, as she should have done. If one could only return the past! It may be, too, that she has not always done her duty toward her relatives; in that case her sufferings are but the punishment of heaven. On close inquiry it is found that the patient has no true self-accusations; the patient herself says that there is no real foundation for these ideas, but that they just force themselves upon her mind.
January 29. The patient was seized with fear at the idea of going up to her room alone to find a handkerchief. A nurse had to accompany her.
February 9. Patient decided to go out for a walk in the park; all the time she insisted on holding the nurse's hand, and still had to come back after a few minutes because, she said, she was very much afraid. "Afraid of what?" the nurse asked her. "I don't know. . . . Was there not an accident or a crime in the park several days ago?" In spite of all assurance on the part of the nurse that nothing unusual had happened the patient could not be calmed, but kept asking the physician, his assistant, and the nurse the same question over and over again.
February 15. At the table the nurse emptied a package of vichy salt into a glass of water. The patient was seized with great terror. "What was that white powder?" Vichy salt, they told her. "But has there not been some mistake? Is it not some kind of poison? Have not some particles of it fallen on my plate?'" Everybody present assured her that she had no reason to be alarmed, that no mistake was possible, that at any rate her plate was too far for any particles from the package to have fallen on it, but all to no purpose; the entire luncheon hour and the rest of the afternoon was passed by the patient in the same state of anxiety.
February 25. Patient wanted to have all the salt cellars on the table emptied as they might contain something injurious.
February 26. Somebody, in relating a piece of news from the paper, made use of the word "accident." The patient uttered a cry. That was horrible, she declared, such words ought not to be uttered in her presence, they cause her such fear. Later it appeared that there was a whole list of words that she ought never to hear: crime, poison, death, thief, sanatorium, asylum, etc.
March 2. Patient was visited by a friend. She seemed to derive no pleasure from the visit, cried a great deal, and took no interest in the news her friend told her. At the supper table she suddenly remembered that it was a fast day and refused to eat any meat. She was offered some eggs, but hesitated a good half hour before accepting them. For her salvation she ought to be content with some peas. On the other hand, the doctor told her to eat meat, which, in fact, would be better for her health. Further, by taking the eggs would she not be depriving someone? Finally she decided, or rather it was decided for her, to have two boiled eggs. But she did not cease worrying and during the entire evening kept asking herself what she ought best to have done.
March 21. The patient was informed that her relatives had decided to take her home, which she had several times begged them to do. Instead of being pleased she became despondent. This may not be prudent, she is not yet cured, who will take care of her at home?
On the following day she was discharged from the sanatorium, unimproved.