What is Neurosis?
Types of Neuroses
The classification of neuroses into various clinical entities is an artificial imposition of order on a chaotic state of nature. Many patients show a mixture of several neurotic syndromes. The pure syndromes however, appear with sufficient frequency and distinctness to form the nucleus of the diagnostic categories into which they are divided. In the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM II), published by the American Psychiatric Association, nine neurotic syndromes are listed. Six constitute the bulk of neurotic disorders and three (neurasthenic neurosis, depersonalization neurosis, and hygochondriacal neurosis) occur less frequently and are less sharply delineated. In the description that follows, only the six major syndromes are discussed.
Anxiety neurosis is characterized by the central position of the symptoms of anxiety.
Anxiety is a painful inner state of nervousness, tension, and foreboding dread accompanied by a variety of unpleasant bodily sensations and reactions, such as rapid heartbeat, palpitations, sweating, trembling, "butterflies in the stomach," a feeling of being unable to get sufficient air into the lungs, and pain in the chest. Anxiety occurs in either an acute or a chronic form. In the acute form, sudden attacks of violent symptoms seize the patient for minutes at a time, inducing in him a state of panic that sufferers report to be more painful than the most intense physical anguish.
Chronic anxiety, as the term implies, consists of protracted symptoms of lesser intensity. Both forms may be incapacitating and debilitating and lead the patient to seek medical help. Fear has bodily signs and symptoms similar to those of anxiety, but fear is a response to an obvious environmental danger situation, whereas the anxiety of anxiety neurosis occurs without any clear-cut association with external stimuli. Such anxiety is often termed "free-floating anxiety."
The conversion type of hysterical neurosis is more common in women than in men and is marked by a wide variety of somatic symptoms. The symptoms may affect the muscles, producing paralyses, contractures, or abnormal movements; the senses, producing anesthesia, blindness, or deafness; or the vegetative functions, causing loss'- of appetite or vomiting.
The bodily symptoms of hysteria differ from those due to an organic cause; thus in hysteria the disturbance in function does not correspond to nerve pathways but rather to the common concept of a particular body part. A patient with hysterical paralysis and anesthesia of a limb, for example, will have an arm and hand totally paralyzed and anesthetic ("glove anesthesia") from the elbow down. No lesion of the nervous system can possibly be found or made that will produce this distribution of paralysis or sensory disturbance.
Hysterical patients characteristically show no worry or concern over what appears to be very serious and incapacitating disturbances in function-a phenomenon frequently called "la belle indifference."
In the dissociative type of hysterical neurosis, the primary difficulty lies in altered states of consciousness of varying degrees of severity. The simplest and most common is amnesia, in which the patient loses his memory for events in his life that range in time from a few hours to his whole life. Naturally, this condition drastically affects the patient's identity.
Repeated periods of amnesia may alternate with periods of normal memory. In each state the patient is able to remember only those events associated with that phase of consciousness present at any given moment.
In fugue states, the patient not only loses all memory of his past life but characteristically travels far from home. There, for some weeks or months, he takes up a new identity and life until his normal self suddenly returns, and he "awakes" in bewilderment about where he is and what he has been doing.
The double or multiple personality, allegedly common in the 19th century, is, for reasons not clearly understood, now rare. In the double personality form of dissociative hysteria, two separate persons appear to exist in one body. The two persons appear alternately and exhibit personality traits and behavior that often are totally opposite from one another. Characteristically, one personality (the "normal" person) is "good" and well-behaved and knows nothing of the other, while the secondary personality is a creature of the senses, knows all about the "normal" person, despises his righteous behavior, and plays tricks on him to embarrass and distress him.
At the core of the phobic neurosis is an irrational anxiety in the face of an object (a subway, an elevator, a crowd, or a steeple) or a situation (height, being alone, or being in open spaces) in which there is not sufficient real danger to warrant the manifest fear. The patient is able to control his anxiety by avoiding the phobic object or situation. If the phobias are sufficiently extensive or affect a vital activity, the condition can so restrict an individual's life as to cause serious incapacity.
In this type of neurosis, the obsession, or obsessive thought, is the central feature. An obsession commonly is a thought that some kind of harm or damage is going to occur to people or objects in the patient's environment. The thought forces itself on the individual's attention against his will and appears to him to be foreign to his sense of himself. He feels compelled, generally unsuccessfully, to fight against the thought. Although he knows intel1ectually that the thought is irrational and not likely to be realized, he nonetheless reacts emotionally with considerable anxiety.
A compulsive thought is a similar kind of idea in which the patient feels compelled to perform a certain action; for example, he may be compelled to perform an aggressive of blasphemous action, such as shouting obscenities in a church. In the compulsive act, the patient actually carries out an action under inner compulsion. The act is often performed to allay anxiety by counteracting an obsessional thought, as in the patient who every time he turned on a light had the thought "My father will die" and would then have to touch the switch again, saying "I take back that thought" in order to quiet his anxiety.
In depressive neurosis there is a painful feeling of sadness and depressed mood. It occurs usually in response to an environmental loss of a person or a valued object or situation. It may be accompanied by fatigue, difficulty in concentration, loss of appetite, and troubled, restless sleep. In addition, the patient may experience an unpleasant loss of self-esteem and self-confidence and tend to be critical of his own shortcomings.
In contrast to patients with psychotic depressions, patients with neurotic depressions are rarely suicidal.
Causes of Neurosis
Several schemes for explaining the causes of neuroses, including learning theory and biological explanations, have been proposed, but psychoanalytic explanations, based on Freud's theories, still provide the most useful framework.
Psychoanalysis is a conflict psychology that conceives of the mind as having elements opposed to one another in a dynamic equilibrium. Impulses, emotions, and fantasies, especially sexual and aggressive fantasies, arise from the id and have to be controlled by the ego (the "1") at the dictate partly of the superego (the conscience) and partly of the mores and sanctions of society.
A major source of control used by the ego is repression, a mechanism of defense that automatically renders the elements from the id unconscious and unavailable to conscious awareness or voluntary recall. Though unconscious, the elements remain active and may return or threaten to return to consciousness and to discharge their energy in action. The forgetting of a name that one knows exists somewhere but cannot actively remember, only to have it "pop into one's mind" when one has turned one's attention elsewhere, is an example of the force of repression and the existence of the unconscious mind.
Neurotic symptoms occur when certain forbidden, repressed impulses threaten to break through the repression into conscious representation and expression. Then repression is intensified or auxiliary defenses are called into operation, with the specific defense determining the form of neurosis.
Anxiety arises as a result of the ego's reaction of fear to the dangerous impulse as it threatens to escape control. Anxiety is associated with most neurotic conditions, and when found in pure form, constitutes the anxiety neurosis. Dissociative hysteria shows the effects of repression itself. The memory loss of amnesia results from the intensified repression of specific mental elements, the memories, related to the forbidden impulse.
In conversion hysteria the pressure exerted by the repressed impulse is expressed in a disguised form through conversion of the impulse into a somatic symptom that often symbolically expresses the impulse. A hand paralyzed in a contracted fist, for example, may represent a repressed, forbidden aggressive wish to hit an enemy.
In phobic neuroses, the phobic object is an external symbolic representation of the underlying impulse, often derived from an unimportant fragment of memories associated with the impulse or painful events. A patient of Janet's, for example, was phobic of the color red, a phobia derived from a bunch of red flowers on her father's coffin, a scene she had repressed. In a phobia the energy of the impulse is projected from the inner frightening impulse onto an environmental situation related to the impulse and is then displaced from the central important elements of that situation to a trivial, insignificant component of the total constellation of elements.
The patient thus is rendered afraid of objects outside himself rather than of his impulses. He then can control the anxiety by the secondary defense of avoiding the phobic object.
In the obsessive compulsive neurosis the impulse and associated emotion-often aggression and anger-am repressed, or isolated, from the thought representing them-such as killing someone- leaving only the emotionless thought in consciousness.
The thought, then seemingly foreign to the patient, is forced onto his attention by the strength of the underlying, unconscious impulse. Neurotic depression results in part from a sense of sadness at the loss of a valued object.
At the same time, the loss arouses anger at the object thus lost. The anger causes the patient anxiety, and he defends himself against it by the mechanism of turning away from the object arousing the anger and turning it inward on himself.
This leads to self-deprecation, guilt, and even suicide attempts in the more severe, psychotic depressions.
Learning theorists stress the cognitive aspect of mental functioning and explain symptoms as having been learned from previous conditioning: certain actions have been followed by punishment and from then on produce the fear of punishment if that behavior is carried out.
Furthermore, certain modes of behavior, such as the avoidance of external objects associated with a forbidden action, reduce anxiety. A behavior thus reinforced becomes a lasting habit pattern. Learning theory has led to useful treatment methods, especially for phobias, but as an explanatory scheme it does not take into account the complexity of the mind.
Presumably there is a basis in brain function for every psychological experience, but these functions have not been sufficiently elucidated to provide an adequate explanation of behavior. For example, stimulation of the autonomic nervous system and the presence of adrenalin and lactate in the blood are associated with anxiety but are probably secondary to higher processes in the brain experienced as psychological conflicts in conscious awareness.
Reading Material - A few books that can help...
Treatment of Neurosis
The therapy of neuroses is a very complicated matter that cannot be explained in a few words.
Generally the treatment is aimed at the cause or the symptoms of the particular neurosis and may be psychological, behavioral, or physiological in nature.
Psychoanalysis is the most far reaching of the various forms of psychotherapy and is aimed at the causes of neuroses. Developed by Freud from his work with neurotic illness, it is often the treatment of choice for patients with neuroses, especially when changes in character structure as well as in symptoms are aimed for.
In psychoanalytic treatment the patient lies on the couch with the doctor behind him and obeys the "fundamental rule" of analysis-free association. The patient reports aloud everything that comes to his mind, no matter how shameful, disgusting, unpleasant, or painful it may be. True free association is an ideal that is rarely, if ever, achieved, for the same defenses that serve to render forbidden impulses unconscious in the first place likewise prevent significant associations from entering the patient's mind and cause him to show resistance to speaking freely.
In psychoanalytic treatment, the analyst's initial task is, through listening to his patient's associations, to spot the signs of anxiety and resistance that point to underlying unconscious conflicts manifested as neurotic symptoms and undesirable character traits. Once the analyst becomes aware of these signs and conflicts, he confronts the patient with their existence, helps him to clarify their nature, and through interpretation enables the patient to gain insight into the unconscious forces behind the surface manifestations and their roots in pathological childhood events and relationships.
The analyst is aided in his work by the fact that in the course of analysis the patient develops a transference neurosis. He revives neurotic feelings and attitudes derived from early life situations and inappropriately invests his analyst with these, allowing both analyst and patient through the analytic approach to discover the origins of the neuroses. Gradually, as the analysis proceeds, the patient repeatedly reviews his neurotic symptoms and behavior. He works through his neurotic conflicts, becomes aware of his unconscious motivations and defenses, and achieves a healthy alteration of his personality and human relationships with a corresponding disappearance of his neurosis.
The length of analysis (generally three to five years) and the frequency of the analytic sessions (usually four or five times a week) often make analysis impracticable, and it is often unnecessary for many neuroses with uncomplicated symptoms. In these cases, brief, analytically oriented insight psychotherapy may be recommended.
The aim of analytically oriented insight psychotherapy is a more limited exploration of the unconscious factors entering into the production of neurotic symptoms. In this kind of treatment the therapist is more active and focuses on specific areas of conflict without attempting a Complete analysis of all of the patient's pathological character traits or relationships.
There are many forms of symptomatic treatment. In the psychotherapeutic realm, supportive therapy aims at providing the patient a relationship with a professional therapist who, through reassurance, guidance, and skillful manipulations, helps to strengthen the patient's ego defenses against his psychological conflicts and to maintain his functioning in daily life.
Hypnosis, which in the sensitive patient can create an altered state of consciousness similar to that seen in dissociative hysteria, is an intense form of suggestion aimed at the direct suppression and removal of symptoms.
Behavior therapy attempts to relieve anxiety by deconditioning techniques and involves teaching the patient how to achieve relaxation. Behavior therapy may also remove neurotic symptoms by associating them with painful external stimuli in the so-called aversive conditioning. Pharmacological treatment, such as tranquilizers, aims at altering the brain chemistry so that the neurophysiological processes producing bodily symptoms are rendered inoperative.
The results of treatment by any of the methods yet devised are uncertain. The current resurgence of research into therapeutic methods is therefore very timely.