Neurosis
Neurosis
Of the concepts which modern psychology has introduced into current vocabulary and thinking, “neurosis” and its adjectival form “neurotic” are among the most significant. Applied to individual behavior the terms have been used so loosely and so widely that they have become at times synonymous with morbid, perverse, inexplicable, abnormal, compulsive, and uncontrollable. Since neurosis is so common and neurotic behavior patterns are so varied, there is some justification for the overly generalized, although inexact, use of these terms.
The more precise word for the conditions subsumed under neurosis is “psychoneurosis,” a term which is closer in its etymology to the way we presently understand the nature of these conditions. Currently, psychoneurosis (or neurosis) designates any of a number of psychic or mental disorders which are accompanied by no demonstrable structural or organic change but which result in disorganization of personality and mental function. This disorganization, however, must not be so severe as to impair reality testing and the use of language or to lead to extensive primitivization of behavior. These three limiting conditions serve in a rough way to distinguish neurosis from psychosis. Because quantitative assessment of mental functioning is involved, this distinction is not always easy to make. This is particularly true in the so-called “borderline” conditions. [For further discussion of this aspect of the problem, seePsychosis.]
There is a certain irony of history that in both popular and technical usage the shortened form of the word—neurosis—has come to replace the more accurate form—psychoneurosis. Actually, neurosis is the earlier term. It was coined by William Cullen in the late eighteenth century, in keeping with his concepts of pathology. Earlier theories of psychopathology were based on the assumption that disorders of mental functioning were related to disturbances of the circulation of the blood or to noxious elements carried by the blood stream to various parts of the body. Cullen, a pioneer neuropathologist, advanced the idea that a disturbance of the function of the nerves is the basis for neurosis. To this day, however, it has not been possible to substantiate this hypothesis.
A completely different approach to the concept of neurosis was initiated, however unwittingly, by Cullen’s contemporary, the controversial hypnotist Anton Mesmer. Although the supernatural aspects of Mesmer’s animal magnetism were soon dismissed by the scientific community, hypnotism as a method for investigating the mind continued to hold the interest of many physicians. This trend was culminated by the work of Charcot, who used hypnotism to demonstrate that hysterical symptoms were genuine, not simulated. According to Charcot and his pupil Janet, the essential difficulty in neurotic conditions was neurophysiological. For various reasons usually determined by heredity, the nervous energy of the brain was not strong enough to integrate its many functions. Some functions became dissociated and pursued an independent, autonomous course. When these dissociated elements superseded the normal mental organization, they became the symptoms of hysteria. [SeeHypnosis; Hysteria; the biographies ofCharcot; Janet; Mesmer.]
Freud also used neurophysiology as his frame of reference in his early studies of neuroses, which he too pursued by means of hypnosis. Later, he discarded hypnosis and substituted for it the technique of studying the free associations of his subjects under the standard conditions of the psychoanalytic situation. From the data obtained by this method, Freud concluded that neuroses resulted from disturbances of the physiology of the sexual drive, specifically from inadequate or abnormal discharge of sexual energy, which he designated libido.
Classification
Neuroses, Freud wrote, could be grouped into two major categories according to the origins of inadequate discharge of libido. In one group this could be traced to unfavorable sexual practices. This group of neuroses he called the actual neuroses. Excessive masturbation, for example, dissipates the libido, causing listlessness, apathy, weakness, etc.—the clinical picture of psychasthenia. Abstinence and coitus interruptus, on the other hand, lead to an accumulation of libido, to a pentup state. The libido is ultimately discharged abnormally along subcortical pathways, giving rise to apprehensiveness, irritability, tachycardia, perspiration, and breathlessness—the clinical picture of anxiety neurosis. [SeeAnxiety.]
In the second group of neuroses, libidinal discharge is blocked not by physical causes but by psychological ones. Accordingly, Freud called this group the psychoneuroses. In the psychoneuroses, the symptoms represent not somatic but psychological derivatives of the sexual impulse. Because of their primitive and disturbing nature, such impulses are denied access to consciousness and their energy is barred from discharge by a process which is called repression. Under certain conditions, to be discussed below, the energy of the repressed sexual drive partially overcomes the barrier of repression and achieves disguised and distorted expression in the form of symptoms. In contradistinction to the symptoms of actual neuroses, the symptoms of psychoneuroses have a mental content which, like dreams, can be translated into ordinary verbal language once they are properly understood. What determines the nature of a particular psychoneurotic symptom is what happens to the libido. In obsessions, it is displaced from its proper context onto some ordinarily insignificant thought; in phobias, it is projected onto some substitute object, which is then avoided; in hysteria, the sexual energy is converted into abnormal innervations, causing paralyses and sensory disturbances. [SeeObsessive-CompulsiveDisorders; Phobias.]
Using the same nosological principle, that is, the disposition of libido, Freud made a further division of the psychoneuroses, a division which enabled him to incorporate the psychoses into his system of psychopathology. He divided the psychoneuroses into those conditions in which the libido is vested in mental representations of other persons from those in which the libido is vested almost exclusively in representations of the self.
In the first group he observed that the symptoms were substitute expressions of sexual wishes originally directed toward the significant figures of one’s childhood. During treatment of neurotic patients these wishes of childhood are transferred onto the therapist. Accordingly, he called these neuroses transference neuroses. This group includes the more familiar psychoneurotic entities, for example, hysteria, obsessive-compulsive neurosis, and phobia.
The situation is different in case of psychoses. Transferences presumably do not take place, and the libido remains fixed upon the self, as in the very young child. Freud applied the term “narcissism” to all phenomena in which the self is taken as the object of libidinal wishes. He called the psychoses which constitute extreme forms of narcissism narcissistic neuroses.
Further study has indicated that this nosology is not quite satisfactory. The entire concept of the actual neuroses has been challenged. While it is true that there are neurotic conditions which are associated with abnormal sexual practices, it has been difficult to establish that these conditions necessarily result from such practices or that the symptoms are devoid of psychological content. In addition, transferences do take place even in the so-called narcissistic neuroses or psychoses. To be sure, such transferences may be indiscriminate, transient, and volatile, but they often do represent expressions of libidinal wishes toward figures from childhood foisted onto the therapist or other persons. Furthermore, other elements, such as conflicts over aggression, the inadequacy of the ego’s defenses, and a tendency for regressive primitivization of mental functioning, seem to be equally important in the development of psychosis.
Another group of conditions was subsequently added to this nosology, namely, the traumatic neuroses. Here, neurosis occurs when the organism has been exposed to a life-threatening psychological stimulus of such intensity as to overwhelm the mind’s ability to deal with it. As in the case of the actual neuroses, the essential etiological element is the magnitude of the stimulus, and, here too, the symptoms presumably are without significant psychological content.
Although this classification is widely used, it does justice neither to the great variety of clinical forms which the neuroses assume nor to the multiplicity of factors involved in their etiology. Actually it is difficult to classify the neuroses because they are very complex. They are not distinct, circumscribed entities like tuberculosis, diabetes, or other physical diseases. Any attempt to make a close analogy between neurosis and physical disease is bound to break down upon meticulous examination. Neurosis is part of a developmental process. This is true even though many neuroses appear suddenly and acutely. The neurotic process consists of a wide range of responses to the failure of the mind to resolve inner conflicts. These responses may take the form of symptoms, inhibitions, character traits, and repetitive patterns of behavior. All of these may justly be considered neurotic because they have a common etiology and derivation.
In the 1930s Freud revised his theory of the nature and origin of neurosis in keeping with his appreciation of the central position of intrapsychic conflict in mental life. According to this newer theory, conflict is a regular, normal feature of mental life. The mind can be divided into three groups of functions according to the role each group plays in conflict. One group, the id, consists of instinctual drives—sex and aggression and their derivative manifestations. Another group, the superego, is composed of moral demands and selfpunitive tendencies—the products of training and experience. Finally, there is the group of executant functions, the ego, which integrates the conflicting aims of the id and the superego with due regard to the external or “real” world. As the individual develops and learns, his ability to resolve intrapsychic conflict grows. Mental health depends upon the capacity of the ego to effect an acceptable solution of the conflicting claims made upon it.
The genesis of neurosis
Childhood conflicts
In the genesis of neurosis, the vicissitudes of the psychological conflicts of childhood are of critical importance. The most significant conflicts involve the wishes of the Oedipal phase of development (ages 3 to 6). These wishes, uniformly encountered in almost all children in civilized societies, are concretely experienced in the form of fantasies or fantasy-like thinking. These wishes are simple enough: to possess what one desires and to eliminate what stands in the way of gratification. To the immature mind of the child, its wishes in themselves may appear threatening. In addition, the child fears punishment or retaliation for these thoughts. Anxiety, an innate response to an unpleasant state, appears as a warning affect, signaling the threatening emergence into consciousness of some unacceptable wish, together with the danger of retaliation associated with it. If the ego is unable to master anxiety by repressing the emergent drive, an anxiety state of traumatic proportions may follow. To prevent this and to fend off anxiety, other maneuvers have to be instituted. It is at this point in the conflict that the neurotic process of inhibition or symptom formation begins.
The particular form which a neurosis assumes in a child depends upon the specific measures used to ward off anxiety. All children have severe conflicts, and most children develop some kind of childhood neurosis. Usually a childhood neurosis assumes the form of general apprehensiveness, nightmares, phobias, tics, mannerisms, or ritualistic practices. Most of the primary behavior disorders of children represent disguised forms of neurosis from which the element of manifest fear has disappeared. Phobia is probably the most frequent symptom of childhood neurosis. Fears of darkness, burglars, intruders, ghosts, and animals are so common they are often regarded as part of normal development. Tics and ritualistic practices are less common and in general represent somewhat more severe manifestations of childhood neurosis.
The factors which serve to intensify the conflicts of childhood and to diminish the ego’s capacity to resolve them are many. Some of these factors are constitutional or innate, for example, the inherent strength of the drives and, to a considerable extent, the predisposition to anxiety. The contributing etiological factors which to date have been investigated more thoroughly are the developmental and accidental ones. Most prominent among these are overstimulation, seduction, the effects of physical illness, and various traumata. How the child discharges and controls his drive impulses is determined to a very large measure by the behavior of the parents and earliest teachers. Using gratification and frustration—reward and punishment— and serving as models for identification, parents and educators set the patterns for how conflicts may be mastered.
With the passing of the Oedipal phase the intensity of childhood conflicts abates. The conflicts do not, however, disappear altogether, and, invariably, vestiges of the neurotic process may be discerned in the mental life of children during the period of latency (ages 6 to 12). In some instances, elements of the childhood neurosis may persist through the period of latency into adult life. More often, evidence of the persistent effect of the neurotic process may be seen during latency in character traits, work habits, and sublimations. Not all of these are necessarily pathological. [SeePersonality, article onPersonalityDevelopment.]
Adolescence
The conflicts of the childhood period are evoked anew during adolescence as a result both of physiological changes and of the psychological implications of assuming the adult role. Variations of the fantasies which originally served as vehicles to express drive derivatives during childhood become the conscious concomitant of adolescent masturbation. The guilt over masturbation derives less from the physical activity and more from the unconscious wishes which find substitute expression in the masturbation fantasies. During the period of adolescence a second attempt is made to master conflicts arising from childhood wishes. With the successful resolution of these conflicts, the individual finds his adult identity in his sexual role, moral responsibility, and choice of social role and career. Thus, one can see that the transformation of the neurotic process and its failures is an inherent part of the process of civilizing the individual in the broadest sense. [See Adolescence.]
Neurosis in adults
Neurosis develops anew in adults when the balance between the pressure of the drives and the defensive forces of the ego is upset. This balance may be disturbed in many ways. There are three types of situations which account for neurotogenesis in adults:
(1) An individual may be unable to cope with the additional burden which normal development places upon him. The physiological transformation of the drives, the responsibilities of marriage, and the exigent, competitive, and aggressive requirements of maturity may overtax the capacities of the ego, reviving childhood anxieties.
(2) Disappointment, defeat, loss of love, physical illness, and other inevitable consequences of the human condition may lead an individual to turn from current reality to seek gratification in the world of fantasy. In the development of a neurosis the fantasies to which one turns are usually derivatives of the wishes of the Oedipal phase. As these wishes are regressively reactivated, the conflicts and anxieties of childhood are revived and the process of symptom formation is reinstituted.
(3) By a combination of circumstances an individual may find himself in adult life in a situation which corresponds in its essential features to some childhood trauma or some conflict-laden fantasy. Current reality is then misperceived in terms of the childhood conflict, and the individual responds as he did in childhood by forming symptoms.
The central position of childhood conflicts in neurosis is an empirical finding. It demonstrates that fundamentally neurosis is a developmental disturbance. Although the neuroses of adults, without fail, stem from the neurotic conflicts of childhood, the symptoms from which the adult suffers may be entirely different from those which were prominent during his childhood. It is also important to note that the same unconscious conflict may be resolved by the ego in many different ways. Some resolutions represent progressive development, an enrichment in fact of the adult personality. In the same individual, however, pathological transformation of the conflict may give rise to symptoms.
In order to demonstrate the implications of what has just been said the following clinical material, highly condensed and severely simplified, is offered. A woman patient realized during her childhood that she enjoyed being an only child. Observing her playmates, she felt that the presence of a sibling would deprive her of her parents’ love and of food. She wanted no more children to be born to her parents, and in fantasy she imagined destroying potential rivals by devouring them inside her mother’s body. She felt guilty over these wishes and imagined that the unborn siblings would wreak vengeance upon her. She was told that the fetus, developing in the mother’s body, lived like a fish in a special fluid. She developed a fear of going into the ocean and was unable to eat fish of any kind. When she heard that there are worms which live inside people, she became frightened of all worms. This young, unconscious devourer suffered from nightmares in which animals threatened to devour her. During the latency phase she became interested in raising tropical fish and from this activity developed a deep knowledge of ichthyology. When young fish were born she took pains to remove them from the tank to prevent their being devoured by the older fish. She became a teacher who was extremely protective of her pupils, demanding so little of them that one of her supervisors said in criticism that she tended to “feed” the pupils too much. For her part she was aware that she was afraid her students would disapprove of her. As an adult, she still suffered from a fear of worms. In addition, she developed claustrophobia. Whenever she found herself in a confined space she became extremely anxious. Unconsciously, she feared that the occupants of the confined space would turn upon her and destroy her. She avoided marriage because she thought that she would die of some complication of pregnancy. She avoided any kind of food which could serve as a carrier for intestinal parasites.
In this illustration one can observe the transformations of the childhood conflict over wishes to devour and fears of being devoured in retaliation. The fear of worms persisted from childhood into adult life. The childhood animal phobia and fear of the ocean were replaced in the adult neurosis by claustrophobia. The woman had various eating inhibitions throughout life: in childhood an aversion to fish was dominant, and in adult life an inhibition to eating meat was most prominent. The phenomena just cited represent pathological derivatives of the unconscious conflict, namely, neurotic inhibitions and symptoms. However, the woman’s becoming a teacher and her interest in ichthyology, derived from the same conflict, represent subliminations, that is, activities which enriched her life and contributed to adaptation.
It is evident from what has been said that in every individual some remnant of the anxieties of the childhood period will find representation in the mental life of the adult. To a certain extent, therefore, neurotic trends may be found in every person even in the absence of clinically discernible neurosis. Reliable statistics are very hard to come by because the criteria employed for defining the presence of neurosis vary from one observer to another. It has been estimated by different authorities that between 30 and 60 per cent of the complaints which bring patients to the general practitioner are functional, that is, neurotic in nature. Neurosis as a clinical entity becomes significant only when it reaches the point of severity, where it interferes with the individual’s normal functioning and adaptation.
Most symptom neuroses are mixed in nature. They combine into the clinical picture reactions which are typical for several neuroses. A patient does not necessarily have either hysteria or compulsion neurosis. Usually, his illness shows features of both. Furthermore, there are conditions appropriately termed neurosis which are without symptoms. In such persons their “sickness is their soul.” Their history, their very fate, constitutes a record of failure to contain neurotic conflict within the bounds of symptom formation. Repetitive episodes of failure, victimization, self-induced defeat, and bizarre personal liaisons replace symptoms. Very similar are the severely inhibited personalities. By denying themselves many of the usual sources of gratification and success, they appear to be free of anxiety or symptoms.
Neurosis is a commentary on the ubiquity of intrapsychic conflict in civilized life. It is a distortion of the process of development and adaptation that may afflict an individual as he grows up in a community which demands renunciation of primitive antisocial tendencies. Freud felt that the prevalence of neurosis reflects the deep-seated and universal opposition to the need to effect the renunciation which is essential for civilization.
Jacob A. Arlow
[Directly related are the entriesAnxiety; Mental Disorders; Mental Disorders, Treatment Of; Psychosis. Other relevant material may be found inConflict, article onPsychological Aspects; Developmental Psychology; Individual Psychology; Nervous System, article onStructure and Function of the Brain; Psychoanalysis; and in the biographies ofAlexander; Freud; Horney; Klein.]
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