Comment on Dr Ritvo's Paper1

We are very fortunate to have such valuable material as a starting point for our discussion on obsessional neuroses. Freud's (1909) paper on The Rat Man is an admirable beginning, but as Zetzel has pointed out, the publication of his actual notes gives us a rare opportunity to see deeper into Freud's theoretical and technical thinking. Zetzel has done an outstanding job in bringing up to date some of the ideas which are already hinted at in Freud's material. The (1949) publication of the case of Frankie is a classic in the literature of child psycho-analysis. Rarely has such a carefully documented case report been presented by so eminent a clinician. Ritvo's paper about the same Frankie some 15 years later offers us another rare opportunity to study certain aspects of psychopathology. He has carefully and skilfully demonstrated that every conflict and symptom that was present in the boy Frankie was still represented in the adult case.

Most of my remarks shall be directed to the case of Frankie since we possess so much more clinical information about him.

My first question concerns the diagnosis. Does the clinical material presented by Frankie's analysts indicate a change from a 'phobic neurosis' to an obsessional neurosis? I do not believe that phobic symptoms imply hysteria nor obsessional symptoms an obsessional neurosis. While it is true that symptoms are among our most reliable indicators of underlying pathology, more recent work has demonstrated that they are not nearly as fixed to the typical clinical syndromes as we used to believe. Although it is true that Frankie had phobias when he came for treatment, he also manifested other symptomatology which indicated deeper and more regressive pathology. He would repeatedly be swept by waves of wild, uncontrolled behaviour, in which he would attack people and scream incomprehensibly: 'Don't grab me, I surrender'. I suspect this kind of disorganized conduct speaks for more serious pathology.

Towards the end