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April 15, 1958. STRUCTURAL DETERMINANTS OF PHOBIA. Martin Wangh, M.D.
This study utilizes the structural and genetic concepts of psychic functioning as a means of opening the way to more rfined research into the problem of choice of neurosis. It makes use of clinical material from a female patient suffering from nightmares with somnambulism and a wide range of phobic reactions. The clinical neurosis was triggered by a major operation which evoked sado-masochistic impulses. Dr. Wangh postulates for this particular patient a specific type of ego defect, a superego defect, and certain experiences in the development of the patient which led both to the structural disturbance and to the phobic symptoms. Frequent cathartics and enemas in childhood resulted in instinctualization of sphincter control and further impairment of drive control. The ego defect was the disturbance of control of instinctual drives which carried with it a tendency to impulsivity and acting out. The defect in the superego was caused partly by seductive behavior on the part of the patient's father and of her nurse which made her identifications transitory and lacking in internalized controls. Her mother withdrew from her at the least provocation and turned her over to her nurse. This is a kind of primary object relationship which creates a situation favorable to the displaceability of objects found in the psychology of phobias. The patient had a sufficient sense of reality and sufficiently good defense against her sado-masochistic strivings to protect her from extreme acting out, but developed phobic avoidance of situations of temptation which otherwise might have endangered her marriage.
DISCUSSION: Dr. Paul Friedman questioned the diagnosis and suggested that this patient's symptoms might also be found in anxiety neurosis, or in character