NEUROSIS

INRODUCTION:

The term neurosis encompasses a variety of very common mental health disorders that were
once classified as a neurosis are now more accurately categorized as neurotic disorders. The
term “Neurosis” was coined by the Scottish doctor William Cullen in 1769 to refer to
"disorders of sense and motion”. It derives from the Greek word neuron (nerve) with the
suffix -osis (diseased or abnormal condition). In ICD-10 the neurotic disorders are classified
under, ‘neurotic, stress related and somatoform disorders’ from F40-F48.

DEFINITION:

 Neurosis is defined as a mild to moderately severe illness of the personality, in which

the ego function of reality testing is not gravely affected and maladjustment to life is
limited.
 Neurosis is a functional mental disorder characterised by high level of anxiety and
other distressing emotional symptoms such as fears, obsessive thoughts, compulsive
acts, somatic reactions, dissociative states and depressive reactions. The symptoms do
not involve gross personality disorganisation, total lack of insight or loss of contact
with reality. –Longman Dictionary of Psychology and Psychiatry.
 The term neurosis is defined as:
 The presence of a symptom or group of symptoms which cause subjective
distress to the patient.
 The symptom is recognised as undesirable (i.e. insight is present).
 The personality and behaviour are relatively preserved and not grossly
disturbed.
 The contact with reality is preserved.
 There is an absence of organic causative factors.

CAUSES OR ETIOLOGY OF NEUROSIS:

1. Biological Factors:
Inherited predisposition has a little role to play. But biological and psychological
factors together may precipitate neurosis. For example, a hypersensitive person with
family background in which attention is given to very small things will have anxiety in
everyday life. So an anxious environment at home by parents or other family members
may contribute to neurosis.
2. Psychological Factors:
In neurosis maladaptive learning, use of anxiety defences, blocked personal growth,
pathogenic inter-personal relationship, stress and decompensation play an important
role.
 Maladaptive learning- This is when an individual is not able to learn the correct or
proper adaptive technique to solve the problem of life. For eg., a person who has not
 prepared well for examination avoids it by telling her parents that she is feeling very
sick or having abdominal pain. Such an individual is not able to achieve a level of
maturity and fails to learn competencies.
 Anxiety defence: This is introduced as a causative factor by Freud. He described that
threatening inner desires and impulses produce anxiety in a person, to overcome them
the person uses ego defence mechanisms such as denial, repression and undoing ect.
He may use them repeatedly and lead to neurosis.
 Blocked personal growth: personal growth may be blocked due to various factors. It
may be that a person does not get needed opportunities. For example environmental
factors such as values of society may not let the girl, go out and work. Then there is
faulty socialisation where the thinking is towards factors of satisfying the basic needs.
This gives a feeling of inadequacy to a person when he/she is exposed to an
environment which is demanding.
 Pathogenic interpersonal patterns: Pathogenic interpersonal patterns in the family
develops a feeling of inadequacy and despair in an individual.
 Stress and decompensation: Various types of stressors cause a lot of pressure on an
individual, especially where the chance of compensating is less.
3. Sociocultural factors:
Sociocultural factors also play an important role in development of neurotic disorders.
Conversion hysteria is common in low socio-economic status people with less
education, while anxiety and obsessive compulsive neurosis are common in upper
socio-economic status people.

CLASSIFICATION OF NEUROSIS

NEUROSIS
NEUROSIS

Anxiety Phobias Obsessive Neurotic Neuras- Deperso- Hypochon- PTSD

Compulsive Depression thenia nalisation driasis
Hysteria Neurosis (OCN)

Conversion Dissociative
Reaction reaction

Dissociative amnesia Multiple personality Dissociative Somnambulism

Fugue

NEUROTIC DISORDERS:
 1. ANXIETY DISORDER:
Anxiety is the commonest psychiatric symptom in clinical practice and anxiety
disorders are one of the commonest psychiatric disorders in general population.
Freud first introduced the term anxiety neurosis in 1895. Anxiety is a normal
phenomenon which is characterised by a state of apprehension or unease arising out of
anticipation of danger. Anxiety is often differentiated from fear, as fear is an
apprehension in response to an external danger while in anxiety the danger is largely
unknown.

DEFINITION:

 An emotional response (e.g., apprehension, tension, uneasiness) to anticipation of

danger, the source of which is largely unknown or unrecognised. Anxiety may be
regarded as pathological when it interferes with effectiveness in living, achievement of
desired goals or satisfaction, or emotional comfort. (Shahrokh & Hales,2003).

 Ross has defined it, as a series of symptoms, which arise from faulty adaptation to the
stresses and strain of life. It is caused by over action in an attempt to meet these
difficulties.

HOW MUCH IS TOO MUCH?

Anxiety is usually considered a normal reaction to a realistic danger or threat to
biological integrity or self-concept. Anxiety can be considered abnormal or pathological
if:
 It is out of the proportion to the situation that is creating it.
 The anxiety interferes with social, occupational, or other important areas of
functioning.

ETIOLOGY:
i. Psychodynamic theory: Anxiety is basically due to a conflict, a conflict between ID
and Superego where ego is not able to meditate effectively. Failure to this anxiety
occurs. For various reasons like unsatisfactory parent-child relationship causes
delayed ego development. Overuse or ineffective use of ego defence mechanisms
results in maladaptive Reponses to anxiety.
ii. Emotional conflict: According to McDougall and Gardon, the anxiety neurosis can
arise as a result of conflicts between two emotions.
iii. Repression of the self-assertive tendency: According to Adler, man's most important
and most intense impulse is to assert himself. If the persons ego does not develop
properly and he instead develops a sense of inferiority then his self-assertive is
repressed, and this leads to development of an anxiety neurosis.
iv. Biological theory:
  Genetic evidence- About 15-20% of first degree relatives of the patients with anxiety
disorder exhibit anxiety disorders themselves.
 Chemically induced anxiety states- Infusion of chemicals like sodium lactate,
isoproterenol and caffeine and inhalation of 5% CO2 can produce panic episodes in
predisposed individuals.
 GABA-benzodiazepine receptors- This is one of the most recent advances in search
for the aetiology of anxiety disorders. GABA(gamma amino butyric acid) is the most
prevalent inhibitory neurotransmitter in the CNS. It has been suggested that an
alteration in GABA levels may lead to production of clinical anxiety.
 Other neurotransmitters- Norepinephrine, dopamine and neuroendocrine have also
been implicated in the causation of anxiety disorder.
 Neuroanatomical basis: Modern theory on the physiology of emotional states places
the key in the lower brain centres including thalamus, hypothalamus, and the reticular
formation.
 Medical conditions: the following medical conditions have been associated to a
greater degree with individuals who suffer anxiety disorder than in general
population:
 Abnormalities in the hypothalamic-pituitary-adrenal axis.
 Coronary artery disease, MI
 Pheochromocytomas
 Substance intoxication and withdrawal
 Hypoglycaemia
 Caffeine intoxication

SYMPTOMS OF ANXIETY:
1. PHYSICAL SYMPTOMS
a) Motoric symptoms:
 Tremors, restlessness, muscle twitches, fearful facial expression
b) Autonomic and visceral symptoms:
 Palpitations, tachycardia, sweating flushes, dysponea, hyperventilation, dry
mouth, dizziness, diarrhoea ,pupil dilation, frequency of micturation.
2. PSYCHOLOGICAL SYMPTOMS
a) Cognitive symptoms:-Poor concentration, distractibility, hyper arousal, negative
automatic thoughts.
b) Perceptual symptoms:-Derealisation, depersonalisation.
c) Affective symptoms:- Diffuse, unpleasant and vague sense of apprehension,
fearfulness, inability to relax, irritability, fear of losing control and dying.
d) Other symptoms: Insomnia, increased sensitivity to noise, exaggerated startle
response.
TYPES OF ANXIETY DISODER:

1. GENERALIZED ANXIETY DISODER-

Generalized anxiety disorder is characterised by chronic, insidious onset with
unrealistic and excessive anxiety and worry which may or may not be punctuated by
repeated panic attacks. The symptoms of anxiety should last for at least a period of
6months or long and should not be associated with organic factors for a diagnosis to
be made.
2. PANIC ANXIETY DISORDER-
This is characterised by discrete episodes of acute anxiety. The episode is usually
sudden in onset, lasts for a few minutes and is characterised by severe anxiety.
Classically the symptoms begin unexpectedly or ‘out of the blue’. Usually there are no
apparent precipitating factors, though some patients report exposure to phobic stimuli
as a precipitant.

TREATMENT
The treatment of anxiety disorder is usually multi modal.
1. Psychotherapy: Psychoanalytical therapy is not usually indicated, unless personality
problem coexist. Usually supportive psychotherapy is used either alone, when anxiety
is mild, or in combination with drug therapy. The establishment of a good therapist-
patient relationship is often first step in psychotherapy. Recently, there has been
increasing use of CBT in the management of anxiety disorders. It works to restructure
your thinking patterns and behaviours which trigger your attacks.
2. Relaxation techniques: In patients with mild to moderate anxiety relaxation
technique is very useful. These techniques are used by the patients himself as a routine
exercise every day and also whenever anxiety provoking situation is at hand. The
techniques include- yoga, pranayama , self hypnosis and meditation.
3. Exposure Therapy - This type of therapy is used to expose patients to the physical
sensations of panic in a safe environment. It forces you to feel the feelings of anxiety
and panic and works to teach your healthier ways of coping with these feelings.
4. Drug treatment: The drugs of choice for generalised anxiety disorder are
benzodiazepines, and for panic disorder antidepressants. Benzodiazepines (like
alprazolam and clonazepam) are useful in the treatment of anxiety disorders.
 OBSESSIVE COMPULSIVE DISORDER

Obsessive-Compulsive Disorder (OCD) is an anxiety disorder where a person has recurrent

and unwanted ideas or impulses (called obsessions) and an urge or compulsion to do
something to relieve the discomfort caused by the obsession. The obsessive thoughts range
from the idea of losing control, to themes surrounding religion or keeping things or parts of
one's body clean all the time. Compulsions are behaviours that help reduce the anxiety
surrounding the obsessions. Most people (90%) who have OCD have both obsessions and
compulsions. The thoughts and behaviours of a person with OCD are senseless, repetitive,
distressing, and sometimes harmful, but they are also difficult to overcome.

DEFINITION-
An obsession is defined as:
 An idea, impulse or image which intrudes into the conscious awareness repeatedly.
 It is recognised as one’s own idea, impulse but is perceived as egoalien ( foreign to
one’s personality.
 It is recognised as irrational and absurd i.e insight is present.
 Patient tries to resist against it but is unable to.
 Failure to resist, leads to marked distress.
 An obsession is usually associated with compulsion.
A compulsion is defined as:
 A form of behaviour which usually follows obsessions.
 It is aimed at either preventing or neutralizing the distress or fear arising out of
obsession.
 The behaviour is not realistic and is either irrational or excessive.
 Insight is present, so the patient realizes the irrationality of compulsion.
 The behaviour is performed with a sense of subjective compulsion. Compulsion
temporarily diminishes the anxiety associated with obsessions.

ETIOLOGY
i. Psychoanalytical theory: psychoanalytical theorists propose that individual with
OCD have weak, underdeveloped egos for variety of reasons: unsatisfactory parent-
child relationship,conditional love. The psychoanalytical concept views clients with
OCD as having regressed to earlier developmental stages. Regression to the earlier
stages combined with use of specific ego defence mechanism like isolation, undoing,
displacement, reaction formation produces the clinical symptoms of OCD.

ii. Biological Theories:There is an increased genetic predisposition in first degree

relatives (5-7%) and greater concordance between monozygotic as compared to
dizygotic twins. However the types of obsessive and compulsive are not always the
same in different affected family members. There is also genetic association between
 Tourette’s syndrome, chronic motor tic disorder and OCD. Indeed, up to 20 percent of
individuals with OCD may have tics, which in turn are suggestive of basal ganglia
disorder.
 There is also an increased incidence of OCD in those who have suffered brain
injury, for example due to head injuries, encephalitis or syphilis. Evidence for a
neurobiological basis has been accrued from positron emission tomography (PET)
and magnetic resonance imaging (MRI) techniques, in which orbitofrontal and
cingulated cortices and basal ganglia abnormalities have been found, as have
reductions bilaterally in the size of the caudate nuclei and retrocallosal white
matter. These findings all suggest structural abnormalities in the brain in at least
some cases of OCD.
 There is also evidence for abnormalities in serotonin (5-HT) transmission in the

central nervous system. Some children and adolescents develop OCD after β-
haemolytic streptococcal infections, suggesting an autoimmune etiology. However,
at present moment, there is no conclusive evidence for OCD having clearly proven
organic etiology.
iii. Behavioral Theory:-The behavioural theory explains obsession as condition stimuli
to anxiety that is similar to phobias. While compulsions have been described as
learned behavior which decrease the anxiety associated with obsessions. This decrease
in anxiety positively reinforces the compulsive acts and they become ‘stable’ learned
behaviors.

Clinical Syndrome

ICD-10 classifies OCD into three clinical subtypes which are :

1. Predominantly obsessive thought or ruminations,

2. Predominantly compulsive acts (compulsive rituals), and
3. Mixed obsessional thoughts and acts

Depression is very commonly associated with OCD. It is estimated at least half the
patient of OCD have major depressive episodes while many other have mild depression.
There are several clinical syndromes have been described in literature, although admixtures
are commoner than pure syndromes. Those major clinical syndromes are:
 i. Washers (contamination)--This is the most common type. Here the obsession is of
contamination with dirt, germs, body excretions and the like. The compulsion is
washing of hands or the whole body, repeatedly many times a day. It usually spreads
onto washing of clothes, bathroom, bedroom, door knobs and personal articles,
gradually. The person tries to avoid contamination but unable to, so washing becomes
a ritual.
ii. Checkers (doubt)--In this type the person has multiple doubts, for example the door
has not been locked, kitchen gas has been left open, counting of money was not exact
and etc. the compulsion, of course, is checking repeatedly to remove the doubt. Any
attempts to stop the checking leads to mounting anxiety before one doubt has been
cleared, other doubts may creep in.
iii. Pure obsession (intrusive thought)--This syndrome is characterized by repetitive
intrusive thoughts, impulses or images which are not associated with compulsive acts.
The content is usually sexual or aggressive in nature. The distress associated with
these obsessions is dealt usually by counter-thought for example praying, “undoing”
actions, asking for reassurance and counting but not with rituals.
iv. Primary obsessive slowness (symmetry)--It is characterized by several obsessive
ideas and or extensive compulsive rituals, in the relative absence of manifested
anxiety. This leads to marked slowness in daily activity. Usually the person demand
on being need for symmetry and precise arranging so in order to neutralize it they will
continue Ordering, arranging, balancing, straightening until "just right" or perfect in
their eyes.
v. Hoarders: Hoarders collect insignificant items and have difficulty throwing away
things most people would consider to be of no value. Hoarders often have chaotic
living environments as a result of their extensive collections.

SYMPTOMS AND SIGNS OF OCD

 Aggressive obsessions
 Contamination obsessions
 Sexual obsessions
 Hoarding/saving obsessions
 Religious obsessions
  Obsessions with need for symmetry or exactness
 Miscellaneous obsessions
 Cleaning/washing compulsions
 Checking compulsions
 Repeating rituals, counting compulsions.
 Ordering/arranging compulsions
 Collecting compulsion
 Miscellaneous compulsions.

Treatment

1. Psychotherapy

There are two types of psychotherapy that can be done to OCD patient. The first one is
the psychoanalytic psychotherapy. This type of psychotherapy is used in certain patients who
are psychologically oriented especially those with anankastic personality. Secondly, is the
supportive psychotherapy which is an important adjunct to other modes of treatment.
Supportive psychotherapy is also needed by the family members.

2. Behavior and Cognitive Behavioral Therapy:-Behavior modification is an effective

mode of therapy with a success rate as high as 80% especially for the compulsive acts.
It is customary these days to combine the cognitive behavioral therapy with behavior
therapy. This involves graded self exposure and self imposed response prevention of
‘undoing’ of obsession through compulsions, and / or cognitive therapy. The techniques
that often used are thought stopping, response prevention, systematic desensitization
and modeling.

3. Drug Treatments

i. Benzodiazepines

For example alprazolam and clonazepam, but they have limited role in controlling anxiety as
adjuncts and should be used very sparingly.

ii. Antidepressant
Some patients may improve dramatically with specific serotonin reuptake inhibitors (SSRi)

 Clomipramine (75-300mg/day), non specific serotonin reuptake inhibitors (SRI),

was the first drug used effectively in the treatment of OCD. The response is better in
the presence of depressive symptoms, but many patients with pure OCD also
improve substantially.

 Fluoxetine (20-80mg/day), is a good alternative to clomipramine and often

preferred these days for its better side effects profile.

 Fluvoxamine (50-200mg/day), marketed as specific anti-obsessional SSRI drug,

while paroxetine (20-40mg/day), and setraline (50-200mg/day) are also effective in
some patients.

iii. Antipsychotics

These are occasionally used in low doses in the treatment of severe, disabling anxiety. Some
example are haloperidol, risperidone, olanzepine, aripiprazole and pimazole.

iv. Buspirone

Has also been used beneficially as adjuncts for augmentation of SSRI, in some patient.

4. Electroconvulsive Therapy (ECT)

In the presence of severe depression with OCD, ECT may be needed. ECT is
particularly indicated when there is a risk of suicide and/or when there is a poor response to
the other modes of treatment. However ECT is not the treatment of first choice in OCD.

5. Psychosurgery

In severe, intractable, chronic and incapacitating cases, where all other treatments have
failed, streotactic site specific brain surgery has been reported to be successful. This has
included the used of radioactive yttrium implants and more recently, non invasive proton,
electron and X-ray techniques. Anterior cigulotomy, capsulotomy and limbic leucotomy
have also been found to be effective in 25-30 percent of such cases. All involve the
separation of the frontal cortex from deep limbic structures. Sadly, psychosurgery only
available as a treatment choice at a very few centers’ throughout the world.
