Neurotic Disorders and Somatisation

Introduction
Neurotic disorders are a collection of psychiatric disorders without psychotic symptoms and lacking the intense psychopathology of, say, hypomania or major depression. Having said this, neurotic disorders are a major source of suffering to individuals, their families and to society. The cost of treating alll neurotic disorders would be substantial, but the cost of non-treatment to society (in terms of lost production and lost efficiency) is probably greater. According to CroftJeffreys & Wilkinson (1989) the estimated cost to the UK of neurotic illness in 1985 was 373,000,000. A decade later the sum must exceed half a billion pounds a year. After all, over a third of sickness certificates are for psychiatric illness, much of this being neurotic, (Jenkins, 1985). The persistent nature of anxiety disorder over time ,with its childhood antecedents and often recurrent prognosis, means that it may dominate sufferer's lives, (Angst & Vollrath, 1991). Only chronic heart disease produces more disability.

 Neurosis (from the Greek ) refers to a class of functional mental disorder involving distress but not delusions nor hallucinations, where behavior is not outside socially acceptable norms.[1] It is also known as psychoneurosis or neurotic disorder, and thus those suffering from it are said to be neurotic. Once a common psychiatric diagnosis, the term is no longer part of mainstream psychiatric terminology in the United States, though it continues to be employed in psychoanalytic theory and practice, and in various other theoretical disciplines.

History and use of the term

Neurosis was coined by the Scottish doctor William Cullen in 1769 to refer to "disorders of sense and motion" caused by a "general affection of the nervous system." For him, it described various nervous disorders and symptoms that could not be explained physiologically. It derives from the Greek word neuron (nerve) with the suffix -osis (diseased or abnormal condition). The term was however most influentially defined by Carl Jung and Sigmund Freud over a century later. It has continued to be used in contemporary theoretical writing in psychology and philosophy.[2] The American Diagnostic and Statistical Manual of Mental Disorders (DSM) has eliminated the category of Neurosis, reflecting a decision by the editors to provide descriptions of behavior as opposed to hidden psychological mechanisms as diagnostic criteria.[3], and, according to The American Heritage Medical Dictionary, it is "no longer used in psychiatric diagnosis."[4] These changes to the DSM have been highly controversial.[5]

Generalised anxiety disorder Panic disorder Phobias - specific and generalised Obsessive compulsive disorder Dissociation disorder Somatisation disorders Adjustment disorders Post-traumatic disorder

Psychoanalytical account of neurosis

As an illness, neurosis represents a variety of mental disorders in which emotional distress or unconscious conflict is expressed through various physical, physiological, and mental disturbances, which may include physical symptoms (e.g., hysteria). The definitive symptom is anxieties. Neurotic tendencies are common and may manifest themselves as depression, acute or chronic anxiety, obsessive-compulsive tendencies, phobias, and even personality disorders, such as borderline personality disorder or obsessive-compulsive personality disorder. It has perhaps been most simply defined as a "poor ability to adapt to one's environment, an inability to change one's life patterns, and the inability to develop a richer, more complex, more satisfying personality."[6] Neurosis should not be mistaken for psychosis, which refers to loss of touch with reality, or neuroticism, a fundamental personality trait according to psychological theory. According to psychoanalytic theory, neuroses may be rooted in ego defense mechanisms, but the two concepts are not synonymous. Defense mechanisms are a normal way of developing and maintaining a consistent sense of self (i.e., an ego), while only those thought and behavior patterns that produce difficulties in living should be termed neuroses.

Jung's theory of neurosis

Main article: Jung's theory of neurosis Jung found his approach particularly fitting for people who are successfully adjusted by normal social standards, but who nevertheless have issues with the meaning of their life. I have frequently seen people become neurotic when they content themselves with inadequate or wrong answers to the questions of life (Jung, [1961] 1989:140). The majority of my patients consisted not of believers but of those who had lost their faith (Jung, [1961] 1989:140). [Contemporary man] is blind to the fact that, with all his rationality and efficiency, he is possessed by "powers" that are beyond his control. His gods and demons have not disappeared at all; they have merely got new names. They keep him on the run with restlessness, vague apprehensions, psychological complications, an insatiable need for pills, alcohol, tobacco, food and, above all, a large array of neuroses. (Jung, 1964:82). Jung found that the unconscious finds expression primarily through an individuals inferior psychological function, whether it is thinking, feeling, sensing, or intuition. The characteristic effects of a neurosis on the dominant and inferior functions are discussed in Psychological Types. Jung saw collective neuroses in politics: "Our world is, so to speak, dissociated like a neurotic

Effects and symptoms

There are many different specific forms of neurosis: pyromania, obsessive-compulsive disorder, anxiety neurosis, hysteria (in which anxiety may be discharged through a physical symptom), and an endless variety of phobias. According to Dr. George Boeree, effects of neurosis can involve: ...anxiety, sadness or depression, anger, irritability, mental confusion, low sense of self-worth, etc., behavioral symptoms such as phobic avoidance, vigilance, impulsive and compulsive acts, lethargy, etc., cognitive problems such as unpleasant or disturbing thoughts, repetition of thoughts and obsession, habitual fantasizing, negativity and cynicism, etc. Interpersonally, neurosis involves dependency, aggressiveness, perfectionism, schizoid isolation, socio-culturally inappropriate behaviors

Generalised Anxiety Disorder (GAD)

GAD may affect up to 5% of the general population. The classical syndrome of generalised anxiety disorder involves both psychological and somatic symptoms (Rapee, 1991). Psychological symptoms include free-floating anxiety (ie anxiety not attached to any particular object or event) and a fearful preoccupation with the future. (Tiller, 1994). Even so, in the quest to alleviate anxiety disorders, doctors should be careful not to rely purely on drugs or psychological treatment. As Tiller comments, 'doctors should avoid stigmatising people with mental illness by implying that everybody should be able to overcome mental distress without the need for drugs'.

 Somatic symptoms include tachycardia, palpitations, essential tremor, muscular tension, hypertension, dizziness, sweating, hyperventilation, and epigastric discomfort. Anxiety is often a presenting symptom of depressive illness, and it is sometimes difficult to disentangle the two.

 Brief counselling and training in problem-solving techniques to help patients with GAD without resorting to anxiolytics and apparently without increasing demands on precious GP time (Catalan et al, 1984 & Andrews, 1991). Self-help programmes for anxiety disorder using anxiety management booklets have been found effective, (Sorby, Reavley, & Huber, 1991). General practitioners welcome clinical psychologists' help in the management of anxiety disorders, and desire an increased availability of clinical psychology services, (Deans and Skinner, 1992). Useful drug treatments for anxiety include short courses of benzodiazepines, and antidepressants such as paroxetine. Efforts have been made to reduce the use of benzodiazepines in general practice, and these have been successful,

 In a study comparing cognitive therapy, analytic psychotherapy and anxiety management training in the treatment of GAD, cognitive therapy appeared to be significantly more effective, (Durham et al 1994). There was no indication that longer courses of therapy were more effective than a basic 8-10 sessions.

Panic disorder
Anxiety is felt in separate recurrent bouts (panic attacks) in which somatic symptoms of palpitations and dizziness may predominate. Sufferers often feel that they are about to die during an attack. Depersonalisation and derealisation may accompany the attack. The sufferer tends to avoid the places where such attacks have occurred in the past. Thus a series of panic attacks may precipitate agoraphobia. Sometimes sufferers overcome their fear by mis-using alcohol or benzodiazepines. Organic causes for anxiety and panic disorders must be excluded. Thyrotoxicosis often presents with anxiety. Mitral valve prolapse and cardiac arrhythmias are also associated. Cognitive therapy has been shown to be of benefit (Beck et al, 1992) in addition to the psychological and drug treatments outlined above for GAD.

Phobias
Defined as an excessive and somewhat irrational fear of some object or situation which is usually so disturbing that it leads to avoidance of that object or situation (avoidance behaviour). Avoiding the feared thing only makes further contact with it even more anxiety-provoking. About 8% of the general public have some kind of phobia. Most people have fears of specific things like a fear of the dark or spiders, but rarely do these fears dominate their lives. When the fears become preoccupying and the individual takes special steps to avoid the feared thing (like a mother asking her son to read through all her magazines first to ensure that there are no pictures of spiders) then a minor fear becomes a specific phobia. Ninety per cent of sufferers are women. Psychological treatment is based on two principles: reducing the anxiety associated with the feared object and practising exposure to the feared object or situation.

Agoraphobia
A fear of the market place, of crowds, of travelling on public transport, and an avoidance of social situations and a marked tendency to stay at home, rarely, if ever, venturing outside. Three quarters of sufferers are women. Behavioural therapy can be very successful, based on exposing the patient to a graded hierarchy of situations ranging say, from a walk of ten yards away from the front door to a day out in town. Often the patient's partner can be enrolled as a co-therapist. Antidepressants, including MAOIs, may be particularly useful. Some patients may reluctant to give up their illness behaviour, because there may be considerable psychological rewards attached to it eg making the partner more attentive.

Social phobias
These involve the fear of meeting people, or the fear of behaving in an out of the ordinary way in company. Whereas the agoraphobic is frightened of people in the mass, the social phobic is also often afraid of one-to-one interactions with others. Alcohol or benzodiazepines are often abused to reduce anxiety ahead of the event. Anticipatory anxiety impairs performance in the feared situation leading to a cycle of reduced confidence and increased anxiety before the next meeting and so on.

Obsessive-compulsive disorder (OCD)

Obsessional ideas are thoughts that come repeatedly into a person's mind, and which have some undesirable quality fas far as that person is concerned. The ideas may be nonsensical, say, or violent or obscene; such as ideas about harming a baby in a new mother or swear words repeatedly coming into the mind of a priest. Obsessional ideas are sometimes called intrusive thoughts. Patients may describe intrusive thoughts as being like a conversation in their head. The key points to distinguish these intrusive thoughts from hallucinatory voices are that they: lack the real quality of a voice are experienced inside the sufferer's head (i.e. not experienced in external space) are recognised as a product of the sufferer's own mind. The intrusive thoughts are not delusional either because although the thoughts are often incorrect the patient may volunteer how absurd the thoughts are. In other words they have insight into the nonsensical nature of the ideas.

Compulsive acts or rituals may be performed to reduce the anxiety associated with obsessional thoughts. For example the person who continually fears contamination may wash and re-wash their hands many times a day, even to the point of breaking the skin down. Compulsive acts and rituals are sometimes perfomed to ward off some undesirable event. Performance of these rituals may interfere with everyday life. A patient who repeatedly spends two hours washing and showering after a toilet break at work may lose their job. As with other neurotic disorders there is an overlap with depressive illness (since depressive illness may have obsessional features). Obsessional personalities are essentially meticulous and perfectionistic workers who, if given a deadline will work to it, but who may expend great effort in getting things just right. Their attention to detail may infuriate those around them. In terms of treatment at least 50% of patients with OCD can be treated using drugs such as fluoxetine and clomipramine. In patients who can accept it behavioural treatment with exposure and response prevention has a high success rate.

Dissociation disorders
Imagine the mind has many layers of awareness. In clear consciousness we are aware of our surroundings and our inner thoughts usually at all levels. A thought which occurs at one level is usually apparent throughout the system. The sensation of hunger at one level is accompanied by fantasies of food and plans of how to get that food at other levels. At other levels of the mind memories of past meals and events might be triggered too. Somehow the thoughts, memories and sensations on all these levels are integrated. In dissociation disorders we might imagine that somehow the layers are not being integrated properly, so that there are discrepancies or dissociations between the thought activity at different levels. Some people speak of a 'splitting of the stream of consciousness'. An example of this dissociation might be that some memories are strikingly unavailable to the conscious individual. Hypnotic or trancelike states, and depersonalisation episodes are other examples of dissociation

 When something extremely unpleasant happens dissociation may be a way of coping. Children who are being abused often feel as if the abuse is not happening to them, but to somebody else. They feel removed from it all. When the abuse is not happening it may be difficult for them to access the memories and feelings they had whilst they were being abused. Sometimes these split-off memories may only be acknowledged by an abused individual years later. The information about the unpleasant event is not lost, but is stored at some relatively inaccessible level to protect the sufferer from hurt. A further example of dissociation is the phenomenon in battle where a soldier running across a battlefield is shot at, but continues running oblivious of the bullet that has entered him. Only when he returns to safety can he begin to feel the pain and acknowledge the wound he has sustained.

 The lack of integration caused by dissociation may produce a number of related disorders. Sigmund Freud described a variety of cases, then diagnosed as hysteria, but which now attract the diagnosis of dissociative conversion disorders. An example might be a young patient who has no physical abnormality, but who is adamant that they are unable to walk. The patient may undergo many diagnostic tests, but no abnormality is found. Other patients may present with atypical pains that defy our knowledge of human anatomy. Catharsis, an emotional return to the original traumatic event, via psychotherapy, hypnosis, or drug abreaction (provoked by intravenous diazepam, say), may release the patient from their symptom. Often the symptoms have some symbolic meaning, so that a child who is frightened to speak out against the abuser may develop an aphonia (an inability to speak), i.e. the trauma is 'converted', hence the term conversion disorder.

Somatisation disorder
Not all patients have the ability to formulate psychological distress in psychological or emotional terms. They may present their inner conflicts an distress as physical symptoms. At a basic level this may be 'a way in' to discussing their problems with their doctor, but at another level the patient may be quite unable to accept a psychological basis for their illness at all. In somatization disorder a patient may take their somatic symptoms from doctor to doctor in a vain attempt to find some test, investigation or cure that has not been offered elsewhere. Many negative investigations and therapies may have been tried by past doctors to no avail. Symptoms may involve any bodily system and may include gastric pain, belching, vomiting, nausea, itching, burning, tingling, numbness and fatigue amidst others.

 The psychological factors in the presentation of somatic symptoms are apparently often underestimated by primary-care doctors (and vice-versa for psychiatrists), but an 8-week teaching package involving a re-attribution model for symptoms, and using small group techniques, role play and video training has been shown to improve recognition and management skills (Kaaya et al, 1992 & Gask et al, 1989 ). The re-attribution model seeks to move away from a dialogue about physical causes for physical symptoms, and whilst acknowledging the reality of the symptoms, looks at the psychological factors that make them better or worse. Four stages have been identified (Goldberg et al, 1994): Provide clear information about negative physical examinations and investigations whilst acknowledging the reality of the physical symptoms State the relevant mood state and associated symptoms and refer to psychosocial factors previously identified Explain the relationship of mood and pain/physical symptoms

Post-traumatic stress disorder

After being involved in or witnessing severe life-threatening accidents or traumas, victims may suffer with a post-traumatic stress disorder, (PTSD). PTSD is common in soldiers and it has been described in various wars. During the first world war it was known as 'shell shock'. Symptoms of PTSD include episodes of re-living the trauma. Re-living may occur in flashback sequences during the daytime or as vivid recurrent dreams during sleep. Other symptoms include hyperarousal, insomnia, social withdrawal, numbness, fear and avoidance of cues that trigger memories of the event. Re-living the trauma may be associated with anxiety, fear and aggression. Depression may co-exist with PTSD. Patients may also self-medicate with alcohol and substance abuse problems are often associated with the disorder. Antidepressant therapy may be helpful. Counselling as a matter of course is often offered to victims of disasters and those who witness them (e.g. stadium fires, crowd disasters). Repeated rehearsal of the trauma in continuing therapy may not be helpful and there is evidence to show that psychological debriefing after traumatic experiences does not prevent subsequent psychiatric morbidity, although such debriefing may initially be valued by the survivor, (Deahl et al, 1994) Prognosis

References

Andrews, G. (1991) The management of anxiety. Australian Prescriber, 14, 17-19. Angst, J, & Vollrath, M. (1991) The natural history of anxiety disorder. Acta Psychiatrica Scandinavica, 84, 446-452. Bass, C. & Benjamin S. (1993) The management of chronic somatisation. British Journal of Psychiatry, 162, 472-180. Beck, A T, Sokol, L, Clark, D A, Berchick, R, Wright F. (1992) A crossover study of focused cognitive therapy for panic disorder. Am. J. Psychiatry, 149, 779-783. Catalan, J, Gath, D, Edmonds, G, Ennis, J. (1984) The effects of non-prescribing of anxiolytics in general practice: 1. Controlled evaluation of psychiatric and social outcome. Br. J. Psychiatry, 144, 593-602. Craig, TK J, Drake, H, Mills, K, Boardman, AP. (1994) The South London somatisation study. II Influence of stressful life events and secondary gain. BJPsych, 165, 248-258. Croft-Jeffreys, C, Wilkinson, G. (1989) Estimated costs of neurotic disorder in UK general practice. Psychological Medicine, 19, 549-558. Deahl, M P, Gillham, AB, Thomas, J, Searle,M M, & Srinivasan, M. (1994) Psychological sequelae following the Gulf War. British Journal of Psychiatry, 165, 6065.

Personality Disorders The DSM-IV defines a personality disorder as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individuals culture, is pervasive, and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment". The manual identifies and describes diagnostic criteria for 10 specific personality disorders. These are listed as below: Paranoid Personality Disorder: characterized by a pervasive pattern of distrust and suspiciousness. Schizoid Personality Disorder: characterized by a pervasive pattern of detachment from social relationship Schizotypal Personality Disorder: characterized by a pervasive pattern of acute discomfort in close relationships, cognitive and perceptual distortions and eccentricities of behavior Antisocial Personality Disorder: characterized by a pervasive pattern of disregard for and violation of the rights of others. Borderline Personality Disorder: characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affects and marked impulsivity.

Histrionic Personality Disorder: characterized by a pervasive pattern of excessive emotionality and attention seeking.
Narcissistic Personality Disorder: characterized by a pervasive pattern of grandiosity, need for admiration and lack of empathy. Avoidant Personality Disorder: characterized by a pervasive pattern of social inhibition, feeling of inadequacy, and hypersensitivity to negative evaluation. Dependent Personality Disorder: characterized by a pervasive pattern of submissive and clingy behavior related to an excessive need to be taken care of. Obsessive Compulsive Personality Disorder: characterized by a pervasive pattern of preoccupation with orderliness, perfectionism, and control.