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Ritvo has described with clarity and precision a case which confirms the well-known clinical observation that obsessional neurosis follows more or less closely on phobic neurosis. The phobic defence gives way to an obsessional defence system. We hardly ever find, however, a case of phobic neurosis without some obsessional colouring, and still less do we find cases of obsessional neurosis without phobic elements, the link between them being, as we see, extremely close.
They differ, however, in a number of ways, particularly in the fact that the obsessional defence mechanisms appear to be taken over by an ego whose functions are more evolved than in the phobic patient. The obsessional defends himself fundamentally by thought processes expressed in the obsessions. Protection from fear is, for instance, assured by obsessional doubt which dominates the mental processes. In the obsessional, as with the phobic patient, the factor which activates these reactions is always the same, the fear as much of libidinal as of aggressive drives.
The defence most favoured by the phobic patient, on the other hand, is one of inhibition. He expresses his fears openly: 'I am afraid of killing someone with my car, ' he may say; or, 'I am afraid of killing if I touch a knife.' Similarly, the woman who refuses to walk down the street alone will say that she is afraid of being accosted. This shows that the method used by phobic patients to protect themselves from their various fears lies very close to the sources of the fears; the fear is expressed directly in the inhibition: the man who is afraid of running someone over will never drive as long as he remains phobic, and the woman who fears (and no doubt unconsciously desires) a sexual assault, will refuse to go out alone.
The defensive stronghold in which the obsessional patient takes refuge is often so solidly constructed that it appears to be without cracks and impregnable, particularly against frontal attack. His obsessional defen