Neurotic disorders. Neuroses. The treatment of neuroses

Forms of neurosis

Until now, in psychiatry there was some confusion and inconsistency on the question of various forms of neurosis. For example, the term neurasthenia is used to denote all forms of neurosis, the origin, cause and content of which is not obvious. It must be recognized it is not easy to distinguish between various mental illnesses, and should not be surprising that a disease in which there is no obvious physical changes, is often referred to as “neurasthenia” or “hysteria.” This situation indicates that professionals need to develop a point of view, which will allow them to make reliable statements regarding the psychological neurosis.

Psychoanalysis provides just such a view, mainly because it allows us to see the beginning of the unconscious and instinctual life. Because the instincts and desires belong to the biological and mental health, neurotic disorders can also be expressed in two ways: either through psychiatric representatives of instincts, that are feelings, passions, ideas, or through physical relaxation. One could argue that this is an artificial separation (on the disease, based on the physical conditions and disease based on biological differences), because all the diseases occur in a somatic basis.

Psychoanalysis, in principle, has no objection to the fact that all neuroses occur on an organic basis. Just psychoanalysis recognizes that the role of organic injury is not always the same, some neuroses are a direct result of organic injury, but in other cases, despite your best efforts, you can not prove the presence of this factor. Inevitably it leads to the conclusion that the mental factor plays a crucial role not only in the formation of neuroses, but in certain organic diseases. Keep in mind this is taken into account that the mind affects all organic diseases, and some of them are caused by psychological reasons only. Relying on instinct theory, psychoanalysis, first identified the various forms of neurosis, and then created a scale, which housed all of the disease, ranging from the purely physical and mental ending.

Using a psychological method of research, analysis outran a few biologists, and now, perhaps, they will study in this direction. Although, it is virtually impossible to distinguish physical illness from psychological, Freud still managed to separate the neuroses caused by organic causes, the so-called current neuroses(actual neuruses), from the psychoneuroses, and he held this distinction on the basis of psychological test. He also pointed out where the psychic meets organic. In practice, the analyst rarely has to deal with current neuroses - for patients who suffer from them, rarely come to him - but they are interesting from a theoretical point of view. Because the actual neurosis is present in each disease and, as we learn later, psychoneurotic symptoms result from it. As already mentioned, neurasthenia are called a variety of diseases that are hard to fit under any definition.

Freud first separated from neurasthenia neurosis anxiety. He took the two diseases to the actual neuroses. In the recent nervousness he could not find any reason of mental or psychological mechanisms, and psychoneuroses, as he said, were caused by psychological factors. In this way, he broke with the medical direction of the time and chose a more productive way. Even today you can hear that “as somatic disorders weren’t found, the illness has a psychological nature.”

Freud used exactly the opposite method he considered “not psychogenic” those diseases which cannot be explained from a psychological point of view. The actual neuroses can be influenced by psychological methods but only in a roundabout way that is changing the patient’s lifestyle. Apart from neurasthenia and neurosis anxiety, to current neurosis is often referred hypochondria. Federn believed that depersonalization also belongs to this group.

Neurasthenia

The diagnosis of “neurasthenia” is still often misused. In fact, neurasthenia should be called a definite disease, it occurs mainly in the increased cranial pressure, fatigue, tiredness and painful physical sensations and digestive problems. The reason is very hard work, sorrow etc. However, it is not very convincing, since patients with neurasthenia could hardly tolerate any physical or mental strain.

Ferenczi described the temporary appearance of typical neurasthenic symptoms (headache, hypersensitivity, pain in arms and legs and so on) and called it “one day neurasthenia.” It often occurs after a night of wet dreams, and therefore directly related to sexual life. Even before Freud discovered that excessive masturbation, which lasts a long time and frequent nocturnal emissions lead to neurasthenia. It is not entirely clear why masturbation causes neurasthenic symptoms.

Hypochondria

Hypochondria is closely related to neurasthenia. It is often accompanied by masturbation in adolescence. The fear of punishment associated with feelings of guilt merge with the unpleasant physical sensations associated with masturbation, with neurotic symptoms, and dispose of them mentally. However, hypochondria can be manifested in the later period of life, after many years of adolescence, when sexual activity does not bring satisfaction.

A man of fifty years was suffering from a fear that his heart would stop beating, limbs would fall off and so on. He could not sleep because every few minutes, he woke up to check whether everything was fine. He really felt the pain in the area of ​​the heart, legs and nose. The culmination of all of these complaints was the fear that he would die of “arteriosclerosis”. He had heard that at his age arteriosclerosis can develop and he believed that his internal organs, which he imagined to himself in the form of certain tubes, would lock, and any part of his body would disappear. At the beginning of treatment, without any influence from the doctor, he tied his suffering with his irregular sexual life. For many years he performed coitus interruptus. He felt that it was bad for him, he hurt his head and genitals and had various other unpleasant sensations. Several times he tried to “heal” through extremely aggressive sexual act, but every time he was stopped by the fear of breaking the moral and religious laws. In the end, he was overflowed by the fear that the seed which he held during sexual intercourse will block his penis and cause him irreparable harm. The fact that the average person feels in the genitals during sexual excitement, the patient felt throughout the body  (we call this form of identification and libidinal ego saturation narcissism).

Fear of losing a part of the body corresponds to an unconscious fear of losing the genitals, then there is the fear of castration. Sperm did not find a way out during intercourse and it caused the accumulation of libido, which then spread throughout the body and caused a state of tension, with which the ego could not cope mentally. Emerged from the pain the ego defended itself with the old unconscious fear of castration, and that was reflected in hypochondriacally feelings and fears.

Because schizophrenia is characterized by the transformation of objective libido in an narcisstic one, it is easy to understand why hypochondria is most pronounced in the early stages of schizophrenia, when patients are not yet able to curb the narcissistic libidinal demands in other ways. The difference between hysterical and schizophrenic hypochondriac is that hysterical hypochondriac the objects of the outer world remain objects of libido, but in schizophrenic hypochondriasis the objects of libido become the organs of the subject.

Depersonalization

The hypochondriac, is characterized by an exceptional (thus disturbing) introspection. The same applies to the depersonalization. Depersonalization is the alienation of the outside world from the inside. The patient loses the sense of reality, internal and external perceptions and sensations. The outside world seems to him a strange, unreal, “visionary”, and the thoughts, feelings and a sense of his own body, too, to some extent, for him loses its reality. Many facts prove that the denial of reality, perception, sensations and feelings is the first consequence of attempts to override the libido that is to take him from the object and send it to another location.

This intermediate state, distinguished by intensity and duration, is present in all the neuroses and therefore is itself an actual neurosis. If hypochondria has often psychic superstructure, then the actual-neurotic depersonalization element of redistribution of the libido is always accompanied by psychological factors, such as disturbances in the ego, the perception of a violation. It is amazing how strong is the feeling of helplessness and anxiety in patients suffering from depersonalization and loss of reality experiences. Just as there is a hysterical and schizophrenic hypochondria, there is also a hysterical and a schizophrenic depersonalization.

With hysterical depersonalization, objects are stored, with schizophrenic depersonalization they disappear or are about to disappear.

Neurosis anxiety

In fact, with any actual neurosis there are connected a number of concerns. However, it is the strongest in neurotic anxiety, here the clinical picture is dominated by anxiety. Anxiety manifests itself in different forms: a free-flowing, uncertain, for example, in the form of attack, in the form of anticipatory anxiety, as anxiety about someone, shortness of breath, palpitations, sudden lack of oxygen, shivering, diarrhea, etc.

All of these symptoms do not necessarily occur together. Each of them may indicate anxiety. In this case we’re talking about embryonic anxiety. Some physical symptoms of anxiety are similar to conversion hysteria, such as sudden: difficulty breathing, tremors, and so on. Just as in neurasthenia, hysterical symptoms can be grouped around the actual-neurotic nucleus and anxiety neurosis. A simple neurasthenia does not depend on mental health reasons, and simple neurosis anxiety also did not define the psyche. It is caused by disturbances of sexual arousal, such as coitus interruptus, coitus reservatus, frustrated arousal, prolonged abstinence and so on. When sexual arousal occurs abnormally, then there is no discharge in orgasm and satisfaction does not occur.

Neurasthenia is due to excessive sexual activity, and anxiety neurosis - because of repeated violations of sexual gratification or because of his absence. It is possible that anxiety sometimes occurs because of intoxication, because the known diseases such as Graves’ disease, are based on thyroid dysfunction, due to which there is anxiety. According to Ferenczi’s report, anxiety develops after fixing the vas deferens. A special form of disturbances caused by an abnormal sexual life (anxiety neurosis or neurosis) depends on the type of sexual trauma. In addition, in neurasthenia, the unused psychic sexual energy plays a major role, in neurosis and anxiety the major role plays purely the somatic energy.

Violations of the instinctual life, which includes a psychic or somatic component are present in all actual neuroses. Actual neurosis may last a long time, they can become chronic. In this case, they turn into psychoneurosis, but this is not random, since each actual neurosis corresponds to a certain form of psychoneurosis: neurasthenia corresponds to conversion hysteria, anxiety neurosis – phobias, hypochondria – schizophrenic psychosis. Synthetic ego function subdues pain topical neuroses and processes them in psychoneurosis. This is exemplified by schizophrenic hypochondria. It is a consequence of particularly painful stress in the organs. The ego perceives the altered state of the body not only as something painful, but as something alien. This foreignness is constantly annoying ego and it is necessary whatever it takes to subdue it. Schizophrenic reaction to such bodily sensations is typical. Hypochondriacal ideas are developing, also hallucinations, and their goal is to overcome and subdue these mental disorders that ego perceives as narcissistic injuries.

In the first phase of the disease is as follows: the patient tends to recover with the help of the hypochondriacally ideas of his ideal ego, which, as he thinks, he has lost. Ego absorbs painful organic disorders caused by blocked libido, and mental processes them, on the one hand, it satisfies the need for punishment, on the other hand, this is balanced by the deranged narcissism of the ego. All that is initially perceived as something alien and unpleasant, the ego makes use of synthetic function, and as a result the ego assimilates (in certain circumstances) what it previously rejected.

The assimilative and adhesive force of ego processes a neurotic core, not only in schizophrenic hypochondria, but also for any other neurosis. Similarly, the ego transforms neurasthenic symptoms in conversion hysteria. Mental impulses cause the ego to cling to the physical sensations of neurasthenia, although it has been long it since ceased to exist. They form the so-called true-neurotic core conversion hysteria, just as hypochondriacally sensations form the core of actual-neurotic schizophrenia. It is not difficult to understand how this translates anxiety neurosis in psychoneurosis (in phobia, obsessive neurosis). In this way, it is clear that every neurosis is associated with disturbances in sexual life.

However, this does not mean that any violation of the sexual life in the broadest sense of the word inevitably leads to neurosis. On the question of why not everyone gets sick of actual neurosis if in his sex life occur some violations, the answer is very simple: the reaction of a person depends on his disposition. Some can handle the sexual tension for a long time, while others – for a brief period. It depends on the ability to maintain libido, without causing serious breaches or sublimate it.

The treatment of neuroses

Psychoanalytic interpretation of the neuroses provides an explanation to the common relative ineffectiveness of the symptomatic treatment of neuroses, in particular, exclusively intended for drug therapy (treatment with pills). The impact of pill is aimed at addressing the mental and physical stress and anxiety, which occurs in the neuroses, which creates the following chain of causation: there is no tension – no symptoms – treatment is completed.

Psychotherapeutic practice, that do not take into account the need for a deep study of neurotic disorders (including unconscious conflicts), are also aimed at ridding the transformation of the symptom (“improvement of symptoms”) - or by removing the stress (relaxation techniques), or through self-help skills training to help cope with stress or prevent its occurrence (self-hypnosis; pshychotraining activities; behavioral therapy, psychotherapy, based on the suggestion). These methods are directed to the surface adaptation of the patient to the effects pathogenic factors.

The described approaches to the treatment of neuroses are mainly concentrated in the above cause-effect relationship (stress-symptom - symptomatic treatment) and do not affect the deep structure of the neurotic conflict - the fundamental causes of the disorder. As a result, the patient is temporarily relieved of suffering (neurotic symptoms) just before the next relapse, or doomed to the appearance of new symptoms - if the former is not worked out, but are elementary suppressed by pills. In this way, patients may need repeated treatments, as well as the risk of deterioration of the flowing condition remains.

Psychoanalytic treatment of neurosis, by contrast, focuses primarily on the dynamics of deep neurosis. For the therapist, the neurotic symptom (and getting rid of the symptom) is not a goal but a mean of treatment, the key to understanding the place in the psyche of the patient’s processes. Such an understanding in the healing of neuroses is initially focused on significant changes in the patient’s personality that creates a solid foundation for its return to a full (and not based on a particular system of temporary props) psychological functioning and that only allows talking about true healing.

These considerations make clear the futility and even danger as a passive relationship to neurotic symptoms and attempts of self healing (as of pharmacological so of “psychological” kind). In addition, it is worth to remember the so-called “secondary gain” from neurotic suffering. For example, if a person is suffering from masochistic neurosis “interested”, he is almost interested to remain in a morbid state. The concept of “secondary gain” from the disease, unfortunately, is not an invention of the theorists, but a real curse for both the patient and concerned for his state relatives and friends. Secondary gain from the disease poses additional obstacles in the treatment of neuroses and increases resistance to psychotherapy.