Introduction
Neurosis is a general term used to describe various forms of mental disorders that involve symptoms of anxiety, depression, hysteria, phobia, and obsessive compulsiveness. The Scottish physician and researcher William Cullen first used the term during the eighteenth century. At that time, a whole range of symptoms and diseases were referred to as neurotic and were thought to be organically based, with specific, localized points (for example, digestive neurosis). The Austrian psychiatrist Sigmund Freud
coined the term
psychoneurosis
to denote and describe his discovery that neurotic disorders do not have localized organic origins but are psychological in nature and caused by early emotional trauma, the results of which are psychological and emotional conflict. Based on his research into neurotic disorders with colleague and physician Josef Breuer, Freud created the theory and mental health discipline of psychoanalysis. The psychoanalytic understanding of mental disorders is based on the observation that early life experience, in combination with an individual’s biological givens, affects later emotional development and that many of the sources of one’s psychological symptoms (for example, unhappiness and anxiety) stem from early experiences with parents and other caregivers. These early interpersonal experiences, coupled with one’s early temperament, have emotional consequences that are largely unconscious in nature.
The symptomatology associated with various neurotic disorders, then, stems from emotional conflicts originating in early life. Although the sources of these conflicts are unconscious, the consequences of this unrecognized emotional turmoil lead to various psychological symptoms.
Early Conception of Neurotic Disorders
During the end of the nineteenth century and the early part of the twentieth century, Freud described the two broad types of neuroses: transference neuroses and narcissistic neuroses. He thought that patients with psychotic symptoms or severe depression were incapable of forming a relationship with their treating psychoanalyst; they were narcissistic, autistic-like, and consequently unable to be helped by psychotherapeutic means. He believed that patients with hysterical, phobic, or obsessive-compulsive symptoms, however, were capable of developing an emotional tie to the analyst. He referred to the special nature of the patient-doctor relationship as transference
and referred to patients with hysterical, phobic, or obsessive-compulsive symptoms as suffering from transference neuroses. These patients were amenable to “the talking cure.”
Freud first began to formulate his theory of psychoneurosis, his discovery that symptoms had psychological meaning, after studying in France with the famous French neurologist
Jean-Martin Charcot, who demonstrated that patients’ symptoms under hypnosis
could be displaced or eliminated. For example, a woman with an arm paralysis could be hypnotized and the paralysis transferred from one arm to another. This observation, coupled with his experience of treating sexually repressed upper-middle-class patients in the late nineteenth and early twentieth centuries in Vienna, led Freud to the conclusion that neurotic symptoms stem from early sexual wishes and desires that were unacceptable and therefore rendered unconscious. Psychological defense mechanisms such as repression are used to eliminate unacceptable thoughts or feelings or painful inner emotional conflicts.
Freud believed that around the age of three or four, the child wanted to possess the parent of the opposite sex and get rid of the same-sex parent (the Oedipus complex in boys, the Electra complex in girls). Because of basic physical limitations and fear of retaliation, these desires had to be repressed. Unresolved sexual conflict and less-than-successful repression of these wishes and desires led to the various forms of neurotic symptoms. These symptoms represented repressed sexual conflict that was striving for release and gratification (“the return of the repressed”). The particular symptom both symbolized and disguised the nature of the conflict. The specific fixation point at which the individual’s sexual development was arrested dictated the “choice” of a particular neurotic disorder or symptom. Heightened sexual pleasure was localized at three bodily areas, corresponding to three different stages of development. The three stages of childhood sexuality were labeled oral, anal, and phallic, with the Oedipus complex culminating at the phallic stage of development. Healthy negotiation of these stages and the Oedipus complex dictated normal heterosexual relationships. Fixation or arrest during these stages of development culminated with problems in intimate heterosexual relationships as an adult as well as in the development of neurotic symptomatology.
The symptoms associated with hysterical neurosis have been recognized since antiquity. They include unstable and tense emotional experience, hypochondrias, overreaction to external demands, sexual conflict coupled with heightened flirtatiousness toward the opposite sex, and lack of psychological insight. Hysterical neurosis may lead to a conversion of anxiety into physical symptoms.
Freud also discovered that the hysteric’s predominant mode of defense against conflict and distress is repression. With repression, an individual is unable consciously to remember or experience disturbing feelings, thoughts, or wishes. In hysterical neurosis, unacceptable thoughts and feelings have been eliminated from consciousness via this mechanism of defense. The presence, however, of a neurotic symptom reflects the fact that repression was incomplete. Unacceptable anger at a loved one, for example, will be repressed from consciousness, but one may be left with the symptom of paralysis of the arm. A psychological conflict is converted into a physical symptom.
The obsessive neurotic is seen as utilizing his or her intellect excessively, so as to avoid emotional conflicts or experience. These individuals, therefore, will excessively ruminate, be hyperrational, and avoid their emotions completely. They use the defense mechanism of intellectualization and also of reaction formation, whereby one behaves the opposite of what one truly but unacceptably feels. The obsessive neurotic, therefore, may be overly kind and rational toward someone at whom she or he is enraged but also loves.
Freud also wrote about phobia
as a neurosis whereby an individual uses the defense mechanism of displacement, transferring a danger that is internal (castration anxiety, for example) onto an external danger that symbolizes the inner anxiety. Castration anxiety due to Oedipal conflict may lead to a displacement of that fear onto an external danger, with the phobic child, for example, manifesting a seemingly irrational fear of being bitten by a horse.
Contemporary Understanding
Modern psychoanalytic understanding of neurotic disorders is broader than the early Freudian classifications of hysteria, obsessive-compulsiveness, and phobia, with less emphasis on sexual conflict as the sole causative feature. Conflicts involving a range of early emotions and impulses are seen as implicated in the development of neurotic disorders. Modern psychoanalysts use scientific approaches to enhance theory and practice. The University of Michigan research psychoanalyst Howard Shevrin, for example, has provided empirical brain-based evidence for the presence of unconscious psychological conflict and has enhanced the understanding of the role of unconscious conflict in the formation of psychological symptoms.
Sexuality and aggression continue to be seen as essential driving forces that shape development and are central factors in the construction of neurotic symptoms. Additionally, the modern psychoanalyst considers factors associated with later points of development, when examining neurotic symptomatology.
The developing child is seen as possessing immature intellectual, emotional, and imaginative capacities. He or she is faced with managing inner fears as well as with negotiating relationships with primary caretakers. Frustration and conflict inevitably emerge, and patterns of emotional experience, fantasy, and behavior develop in response to these early experiences. Modern psychoanalysis emphasizes the position that character, behavior, and the imagination of the child all reflect, in part, solutions to the inevitable conflicts experienced by the child as a result of his or her wishes, urges, and fantasies that are unacceptable to caretakers and also ambivalently felt by the child (hateful feeling toward one’s mother, for example). Emotional conflict, guilt, and self-condemnation inevitably result to some degree or other and necessitate the mobilization of various psychological defense mechanisms, including repression. Fears, wishes, and thoughts that are unacceptable and censored take on a dangerous, forbidding dimension. These unresolved, repressed thoughts and feelings lead to the creation of unconscious fantasies that are in conflict with the more conscious self and may cause seemingly senseless or unreasonable emotional turmoil. For example, a young boy who is frightened, ashamed, and guilt-ridden by his hateful impulses toward his father will repress these urges. As an adult, he may inexplicably feel like a “monster” (an unconscious fantasy of himself when angry) whenever he naturally asserts himself, without consciously understanding why self-expression is so difficult.
Modern psychoanalysis differentiates a range of neurotic disorders within two broad classifications: symptom neurosis and character neurosis. The symptom neuroses are specific and tied to specific symptoms. Hysterical neurosis, obsessive neurosis, depressive neurosis, and anxiety neurosis all reflect underlying emotional conflicts but are manifested through different symptoms. For example, the hysteric converts emotional turmoil into somatic complaints. The obsessive is emotionally cut off from self and others and is ritualistic, while the depressive is sad, with chronic self-esteem problems. The anxiety neurotic ruminates and may have a specific irrational fear (phobia).
With symptom neurosis, the neurotic is distressed and the symptoms are ego-dystonic; that is, the symptoms are felt to be alien, unwanted, and foreign to the self. With character neurosis, however, symptoms are not present and the character neurosis is reflected by maladaptive and enduring personality patterns of behavior and experience that, although neurotic, are accepted features of the individual’s self or identity (ego-syntonic). Others may perceive an obsessive neurotic personality, for example, as unemotional and excessively avoidant of feelings, but he or she will see himself as objective and fastidious. The hysterical neurotic personality will view himself or herself as spontaneous and not excessively emotional, whereas the depressive neurotic personality may realize he or she is always depressed, but believe that it is for good reasons. Because the neurotic pattern of behavior is ego-syntonic, neurotic personalities are more difficult to treat.
Psychoanalytic Treatment
Psychoanalytic
psychotherapy seeks not only to relieve current symptoms but also to deal with root emotional conflicts and causes of the symptoms or behavioral patterns. Because the sources of one’s conflicts, symptoms, and behavior patterns are essentially unconscious, and because defenses have been constructed to help one adapt as effectively as possible, psychoanalytic treatment takes time, is intensive, and lasts from one to three or more years. The therapeutic relationship that develops is intimate and intense. The psychoanalyst and patient collaborate in the exploration of the patient’s symptoms and style of relating. This leads to the patient becoming aware of his or her underlying sources of conflict, not only intellectually but also emotionally. The emotional understanding occurs predominantly through the understanding of feelings, thoughts, and fantasies that arise out of the realistic and unrealistic (transference) dimensions of the therapeutic relationship. It is through the relationship that the patient can reexperience, in the here and now, how his or her inner conflicts and unconscious difficulties have been creating symptoms and dysfunctional repetitive patterns of behavior. The analyst and patient work together to understand how and why certain wishes and desires, feelings, thoughts, and unconscious fantasies have developed and contribute to the patient’s emotional and behavioral difficulties. Over the course of treatment, the patient’s capacity for emotional integration improves, as does his or her capacity to function without self-defeating behaviors, emotions, and thoughts.
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