The Types of Psychiatric illness
The Psychoneuroses Anxiety and the Anxiety State
Some forms of psychological defences were described. These serve to prevent various mental conflicts from resulting in the unpleasant state of tension technically termed ‘anxiety’. `Anxiety' covers all degrees of fear from mild apprehension to uncontrolled panic. Its sources are, frequently, unconscious. Paradoxically, this is still true even in the so-called phobias, which will be discussed below under the heading of Anxiety Hysteria.
Most people have experienced anxiety in some degree, though not everyone is equally prone to it. It is not known for certain why this is so. Genetic factors may have a bearing, and it seems fairly wellestablished that certain events in childhood play a significant part. It is possible that these two factors are complementary. Whatever its more distant origins, anxiety is often precipitated by some form of current stress. In some cases, the stress will be self-evident, as in loss of one's home through fire or flood, serious physical illness, financial catastrophe, difficulties in marriage, threatened or actual loss of employment and indeed in all circumstances where the individual feels threatened or insecure. In other cases the stress will be less obvious, and the significance of unconscious factors altogether greater.
Anxiety may be acute (may begin suddenly) or chronic (prolonged). It may also start gradually. Often it is very short-lived, though it can and does recur. It may produce certain secondary effects, although these are not pronounced in the milder forms. Restlessness is an example, and varies considerably. The same is true of impaired concentration and disturbed sleep.
Physical changes, when they occur, are temporary and reversible. Thus, the pulserate may rise and is sometimes experienced as palpitations. The blood pressure may increase. Occasionally, there is a tendency to diarrhoea or to the frequent passing of urine. Other bodily changes are often present, but clinically they are not of any great importance.
Short-lived anxiety, unless severe, rarely calls for treatment. But longstanding anxiety often brings a patient to his doctor. The doctor may prescribe a sedative or a tranquilliser, or may discuss with the patient whatever difficulties may seem to underlie the condition. Sometimes he may refer the patient to a specialist for more detailed psychotherapy.
Simple uncomplicated anxiety of any considerable duration, however, is not often seen by the psychiatrist. It is almost always complicated by further symptoms, usually of an hysterical or obsessional kind.
There are two main clinical kinds of hysteria: anxiety hysteria, in which the patient develops phobias; and conversion hysteria, in which the patient develops bodily symptoms. In addition, there are certain striking disturbances of consciousness which are more difficult to classify. They are described under the heading of ‘dissociation hysteria’.
In this condition the anxiety relates to an external situation, object or person. But unlike the anxiety present in the face of a very real danger, the fear in anxiety hysteria seems irrational. Thus there may be fear of open spaces, streets, lifts, tube-trains, water, spiders, or children, to name only a few examples. Such irrational fears are termed ‘phobias’.
The apparently irrational nature of these fears springs from the fact that the sources of the anxiety remain unconscious, while the fear is displaced from the original object or objects on to a relatively harmless substitute. But the choice of object or situation is itself significant since it represents, in a symbolic form, the original dangerous object or person.
A man afraid of a crowded tubetrain may be unable to face his fear of a tangled domestic situation from which he can see no escape. A modest girl of strict upbringing may be unable to allow herself to recognise the temptations which strangers represent for her, and thus be confined to her home by an apparently irrational fear of streets. These are simplified examples; as a rule, the determinants of the phobia are rather more complicated.
A dangerous internal impulse is sometimes symbolised by a phobia. A man who is afraid of knives may, in this way, be expressing his alarm at his own destructive feelings.
But whatever the phobia symbolically represents, its success as a defence rests in the opportunity it gives the patient to avoid the apparently threatening situation and so maintain some peace of mind. But the price the patient pays may be heavy. For while a patient with a fear of tube-trains may manage perfectly well as long as he travels by bus, a patient with a severe street phobia may be seriously incapacitated.
Just as in anxiety hysteria inadmissible unconscious factors are symbolised by a phobia, so, in conversion hysteria, they are symbolised by bodily symptoms. The anxiety is now said to be `converted', that is, its sources are represented by the bodily change. Usually, this form of hysteria is a more successful defence against anxiety than the phobia; indeed, in some cases of conversion obvious anxiety may be entirely absent.
The forms which conversion may take are as limitless as the varieties of phobia. Very striking disabilities such as blindness, deafness or paralysis are less common than they were fifty years ago, but they still occur from time to time. On the other hand, hysterical loss of voice, muscle weakness, pains of all kinds, headaches and disturbances of sensation such as numbness still occur with the greatest frequency. An inevitable result of this is that some patients are referred to general hospitals for specialist medical and surgical advice, where investigations fail to reveal a physical basis for the disorder.
It used to be thought that hysteria of this kind occurred almost entirely in women. This idea originated from the notion of the ancient Greeks that the symptoms of hysteria were due to a wandering of the womb or ‘hysteros’. Nowadays it is recognised that hysteria is common in men.
A hypothetical example may help to demonstrate some of the symbolism to be found in conversion hysteria.
An attractive young woman whose mother had recently died had to cope unaided with a tyrannical and bedridden father. Her sense of duty allows her no protest in spite of an intense longing for a young man whom she often meets during the course of her daily shopping. One morning she wakes to find both legs paralysed. The unconscious conflict between desire and hostility has been converted into a bodily symptom which has three immediate results. First, she can no longer meet the young man she admires. Secondly, she can no longer care for her father since she is now unable to climb the stairs. Thirdly, her sexual conflict is symbolised by the paralysis.
This case is oversimplified, but it may serve to illustrate not only the process of symbolisation but also the gain from the illness which results from the productionof symptoms. This so-called 'secondary gain' explains why conversion hysteria is not always easy to cure.
This group of conditions is closely allied to conversion hysteria. The main difference is that, in dissociation, the disturbance is one of consciousness while in conversion the disturbance is bodily.
To this category belong certain ‘dream states', somnabulism or sleep-walking, massive loss of memory, wandering from one town to another with no recollection (fugues) of the journey, and the very rare cases of ‘multiple personality'. In these remarkable, rare cases a man may live part of his life in an apparently ordered way, without any knowledge on his part that he lives the rest of his life in an entirely different way, perhaps in a different place and under a different name. In fiction the best-known example is Stevenson's ‘Dr. Jekyll and Mr. Hyde', but there are a number of startling though authentic cases on record.
In all forms of dissociation a whole area of the patient's mental life which he does not wish to recognise is excluded from consciousness.
The Hysterical Personality
A large number of people, who cannot necessarily be regarded as psychiatrically ill and who may never develop hysterical symptoms, show certain personality traits which together constitute what is known as the ‘hysterical personality’.
These people are often said to be emotionally shallow, able to form impulsive and fickle relationships but rarely ones of a lasting or deeply felt kind. They are often sexually capricious or frigid. They are said to be fond of the limelight and tend to dramatise their actions and relationships. Where these traits are sufficiently pronounced to interfere seriously with the patient's life, treatment may be called for.
The Obsessional Neurosis
Unlike hysteria, the major disturbance in obsessional neurosis is of thought, word or deed, so that the patient feels compelled repeatedly to think certain thoughts or perform certain actions. In each case the symptom is determined by unconscious factors, and often seems perverse, alien or absurd to the conscious mind.
The obsessional symptom is characteristically recurrent, occurs against the patient's conscious wishes, and cannot be dismissed by an act of will. These features distinguish the obsession from all other forms of pre-occupation.
There are countless varieties of obsessional thoughts. There may be disturbing ruminations of killing a loved one, or of spreading infection or poisoning people. Such thoughts occasion a great deal of guilt. Elaborate defences may be involved in a constant fight to prevent any such thought from being translated into action. But sometimes the thoughts concerned seem trivial or even meaningless. In such cases the trivial thoughts may sometimes occupy the patient more and more until, occasionally, more important thoughts are virtually excluded. In some cases the thoughts take the form of unwanted philosophical speculations, such as ‘Why am I?’ or ‘What is God?’ Sometimes thoughts appear in flagrant contradiction of the patient's conscious attitudes. A religious man, for example, may feel plagued by blasphemous ideas, and a woman who prides herself on her purity may find herself preoccupied with obscene thoughts.
Sometimes the thoughts refer to recent actions. The patient may find himself constantly wondering whether or not he has turned off a gas tap, locked a door or switched off a light, even when he knows perfectly well that he has done so. In other cases the thought of doing some definite and purposeful act may be followed immediately by the thought of doing its opposite. Such a condition may be characterised by extreme indecision.
Some people are obsessed by words rather than by thoughts. A man may find himself compelled to mutter an obscene, trivial or frightening word, and then feel very embarrassed in case he has been overheard. More rarely, he may shout. As with all obsessions, a conscious fight against these activities results in anxiety which may be very considerable.
When we consider compulsive actions, we find them equally varied. The patient may feel compelled to remember every single event of the day and to record it in a diary, even when he feels the task overwhelmingly beyond him and stays up half the night in a vain endeavour to complete his notes. Or he may find himself compelled to write on lavatory walls, to his continued astonishment, guilt and disapproval.
Sometimes he has to touch a series of objects, often in a carefully organised manner and order. Such activities may become so involved and elaborate that his life is seriously dislocated by them.
Although such compulsive actions may remain isolated they are often built up into complicated rituals. A woman may have to dress in a certain order, have everything `just so', and may take several hours to get the seam of her nylons straight.
Guilt is a striking feature of obsessional neurosis. It explains the constant need to eliminate objectionable thoughts, to check and recheck whether or not one has done any damage. Ambivalence-in this case the coexistence of destructive and reparative tendencies-is more pronounced in this disturbance than in any other neurosis.
Many defences are employed by the obsessional subject to allay his anxiety. A return is often made to earlier levels of development when magical devices, such as crossing one's fingers, touching wood, walking round ladders and stepping between cracks on the pavement, were used for supposed self-protection (as in young children). Another defence is displacement. In obsessional neuroses, the fight against unconscious forces takes the most devious routes.
The Obsessional Personality
As with the hysterical personality, the obsessional personality shows a number of traits which are shared by many people who cannot be considered psychiatrically ill, unless these traits are so pronounced that everyday life is seriously interfered with.
They can be considered ‘careful’ or ‘mean’ according to taste and according to the general regard in which they are held. They are punctual and set great store by time. They are sticklers for exact usage of words, custom and social order. They demand a great deal of themselves and set high standards for others. They tend to take strict moral attitudes to the point of being puritanical. They are active, hard-working and scrupulous. They are often excessively tidy and clean. They are the natural enemies of dirt, untidiness and disorder. But faced with a choice between two similar attitudes, or courses of action, they may become utterly indecisive and uncontrollably anxious. Such a situation will, of course, call for treatment.
Often the conditions described under the headings of `hysteria' and `obsessional neurosis', as well as those conditions predominantly characterised by anxiety, are not present in pure form but show features of different types of neurosis. Anxiety with some conversion symptoms, and phobias occurring in obsessional states are common examples of "mixed' neuroses.
It is doubtful if the term `neurotic depression' can be regarded as a diagnosis in its own right. Depression, a subjective feeling of sadness and misery, occurs in its milder forms in normal people but in the neuroses the depression may be of considerable duration and intensity.
Depression can occur in any of the neuroses so far described. It is closely related to feelings of guilt, though the guilt is by no means always conscious. It is often present in hysteria. If often colours an otherwise obsessional picture. When depression is the leading symptom in the neurosis, some doctors prefer to diagnose ‘neurotic depressive reaction’.
Feelings of depression are often precipitated by an external event which may be striking, as in bereavement, or relatively trivial. But it is important to recognise that what determines the quality of the depression is not the magnitude of the external stress, but its unconscious significance for the patient. Indeed, consciously, the precipitating event may be entirely overlooked.
Associated with the depression there may be impaired concentration, loss of appetite, varying feelings of hopelessness, variable degrees of self-reproach, anger and irritability. But, with the possible exception of selfreproach, these features are not specific, and may occur in any form of neurosis even when little depression is evident.
Other Neurotic Illnesses
Other conditions are sometimes referred to as if they were separate neuroses.
In this condition the patient complains that he does not feel real, that his body feels as if it is not his, that he feels a puppet or automaton, or that he feels as if he is acting in a play. In our view this condition is almost always part of another neurosis or psychosis, and constitutes a pecial defence against unpleasant or disturbing feelings.
Some doctors also describe ‘hypochondriasis’, in which there is fairly persistent preoccupation with bodily health or ill health, as a separate entity. We believe that the condition is usually part of another illness such as hysteria or the obsessional neuroses. It is also very common in depression and other psychoses.
The Sexual Perversions
Human sexual behaviour varies so widely that it is not always easy to say what is normal and what is perverse. Indeed, the concept of sexual `normality' is often a social one. Male homosexuality, for example, was entirely accepted in the Greek City State but is not tolerated in most countries today. On the other hand, female homosexuality, which can hardly be regarded as less `perverse', rarely arouses so much condemnation.
It is difficult to give a satisfactory psychological definition of sexual perversion. In general, however, the perverse sexual act tends either to exclude or replace heterosexual genital intercourse, or to relegate it to a subordinate role. Thus the exhibitionist or the peeping Tom gets sexual satisfaction without indulgence in intercourse; the homosexual may never have sexual relations with women or, if he does, he will find relations less satisfying than those with men; and the fetishist finds the excitement he gets from the article of clothing concerned of primary importance, even when intercourse takes place.
Homosexuality in either sex may be active or passive and both forms may be practised at different times by the same person. The partners may be of any age. Some male homosexuals (probably a fairly small percentage) show a preference for children. Some homosexual attachments are very constant and the partners may live together, sometimes in great affection. Other homosexuals are promiscuous.
In fetishism the subject, invariably a male, is excited by some particular article of female clothing such as a stocking, a piece of underwear or a shoe. Not all fetishists require a partner to wear these items to get sexual satisfaction, but when they do the article itself is sexually more important than the person who wears it.
The man or woman concerned gets satisfaction from exposing the body, while in `voyeurism' the voyeur gets his sexual enjoyment from spying on couples making love.
Sadism and Masochism
In sadism the sadist derives sexual pleasure from inflicting pain, while in masochism the reverse is the case.
These are the commonest perversions met with in clinical practice, though only a small proportion of perverts seek treatment.
In some adolescents perversions are merely forms of sexual experiment and have no special significance. In some homosexuals genetic factors seem to be important, especially in men with pronounced feminine physical characteristics and, equally, women of masculine build and appearance. But psychological factors can rarely be excluded.
The growing child passes through important stages where his relationship with parents, brothers and sisters make him aware of the fundamental sex differences. During these stages, attitudes of passivity or assertion, and feelings about masculinity and femininity are encountered and dealt with. Failure to negotiate these stages satisfactorily has important consequences in later sexual development. In perversions, such early difficulties have been pronounced. In addition, problems at these stages are reinforced by pathological attitudes developed even earlier in childhood.
The majority of people with perversions never come to treatment. The fact that the symptom is in itself pleasurable tends to weaken the incentive to seek help. If, in addition, the pervert has a fairly stable and well-adjusted private life he may only wish to be left in peace.
Psychotherapy offers the best, if not the only, hope of resolving the mental conflicts behind the perversion, though its use is limited. Sometimes, especially in fetishism, a form of `deconditioning' has been used. In some male perversions, where the urge to practise the perversion is particularly strong, synthetic hormones have been used to damp down the sexual drives.
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