Neurosis are functional disorders of higher nervous activity of psychogenic origin. The neurosis clinic is very diverse and may include somatic neurotic disorders, vegetative disorders, various phobias, dysthymia, obsessions, compulsions, emotional and mnestic problems. The diagnosis of “neurosis” can be established only after the exclusion of psychiatric, neurological and somatic diseases similar to it in the clinic. Treatment has 2 main components: psychotherapeutic (psychocorrection, training, art therapy) and medication (antidepressants, tranquilizers, neuroleptics, general restoratives).
General information
Neurosis as a term was introduced in 1776 in Scotland by a doctor named Kuplen. This was done in contrast to the earlier statement of J. Morgani says that at the heart of each disease is a morphological substrate. The author of the term “neurosis” meant by it functional disorders of health that do not have an organic lesion of any organ.
In ICD-10, instead of the term “neurosis”, the term “neurotic disorder” is used. However, today the concept of “neurosis” is widely used in relation to psychogenic disorders of higher nervous activity, i.e. caused by the action of chronic or acute stress. If the same disorders are associated with the influence of other etiological factors (for example, toxic effects, trauma, a previous illness), then they are referred to as so-called neurosis-like syndromes.
In the modern world, neurosis is a fairly common disorder. In developed countries, from 10% to 20% of the population, including children, suffer from various forms of neurotic disorders. In the structure of mental disorders, neuroses account for about 20-25%. Since the symptoms of neurosis are often not only psychological, but also somatic in nature, this problem is relevant both for clinical psychology and neurology, as well as for a number of other disciplines.
Causes
Despite various studies in this area, the true cause of neurosis and the pathogenesis of its development are not known for certain. For a long time, neurosis was considered an information disease associated with intellectual overload and a high pace of life. In this regard, the lower incidence of neurosis among rural residents was explained by a more relaxed lifestyle. However, studies conducted among air traffic controllers have refuted these assumptions. It turned out that, despite the hard work that requires constant attention, rapid analysis and response, dispatchers suffer from neuroses no more often than people of other specialties. Among the causes of their morbidity, mainly family troubles and conflicts with superiors were indicated, and not overwork in the process of work.
Other studies, as well as the results of psychological testing of patients with neuroses, have shown that the determining factor is not the quantitative parameters of the traumatic factor (multiplicity, strength), but its subjective significance for a particular individual. Thus, external trigger situations provoking neurosis are very individual and depend on the patient’s value system. Under certain conditions, any, even everyday, situation can form the basis for the development of neurosis. At the same time, many experts come to the conclusion that it is not the stressful situation itself that matters, but the wrong attitude towards it, as destroying a personal prosperous present or threatening a personal future.
A certain role in the development of neurosis belongs to the psychophysiological characteristics of a person. It is noted that people with increased suspiciousness, demonstrativeness, emotionality, rigidity, and subdepressiveness are more likely to get sick with this disorder. Perhaps the greater emotional lability of women is one of the factors leading to the fact that the development of neurosis in them is observed 2 times more often than in men. Hereditary predisposition to neurosis is realized precisely through the inheritance of certain personal characteristics. In addition, there is an increased risk of developing neurosis during periods of hormonal changes (puberty, menopause) and in persons who had neurotic reactions in childhood (enuresis, logoneurosis, etc.).
Pathogenesis
The modern understanding of the pathogenesis of neurosis assigns a major role in its development to functional disorders of the limbic-reticular complex, primarily the hypothalamic part of the intermediate brain. These brain structures are responsible for providing internal connections and interaction between the autonomic, emotional, endocrine and visceral spheres. Under the influence of an acute or chronic stressful situation, there is a violation of integrative processes in the brain with the development of maladaptation. At the same time, there are no morphological changes in the brain tissues. Since the processes of disintegration cover the visceral sphere and the autonomic nervous system, somatic symptoms and signs of vegetative-vascular dystonia are observed in the neurosis clinic along with mental manifestations.
Disorders of the limbic-reticular complex in neurosis are combined with neurotransmitter dysfunction. So, the study of the mechanism of anxiety revealed the insufficiency of the noradrenergic systems of the brain. There is an assumption that pathological anxiety is associated with an anomaly of benzodiazepine and GABAergic receptors or a decrease in the number of neurotransmitters acting on them. The effectiveness of anxiety therapy with benzodiazepine tranquilizers is a confirmation of this hypothesis. The positive effect of antidepressants affecting the functioning of the serotonergic system of the brain indicates a pathogenetic relationship of neurosis with disorders of serotonin metabolism in cerebral structures.
Classification
Personality traits, the psychophysiological state of the body and the specifics of the dysfunction of various neurotransmitter systems determine the variety of clinical forms of neuroses. In American neurology, the main 3 types of neurotic disorders are distinguished: neurasthenia, hysterical neurosis (conversion disorder) and obsessive-compulsive disorder. All of them are discussed in detail in the relevant reviews.
Depressive neurosis, hypochondriac neurosis, phobic neurosis are also distinguished as independent nosological units. The latter is partially included in the structure of obsessive-compulsive disorder, since obsessions (obsessions) rarely have an isolated character and are usually accompanied by obsessive phobias. On the other hand, in the ICD-10, anxiety-phobic neurosis is presented in a separate position with the name “anxiety disorders”. According to the peculiarities of clinical manifestations, it is classified as panic attacks (paroxysmal vegetative crises), generalized anxiety disorder, social phobias, agarophobia, nosophobia, claustrophobia, logophobia, aichmophobia, etc.
Neurosis also includes somatoform (psychosomatic) and post-stress disorders. With somatoform neurosis, the patient’s complaints fully correspond to the clinic of a somatic disease (for example, angina pectoris, pancreatitis, peptic ulcer, gastritis, colitis), however, during a detailed examination with laboratory tests, ECG, gastroscopy, ultrasound, irrigoscopy, colonoscopy, etc., this pathology is not detected. There is a history of a psychotraumatic situation. Post-stress neuroses are observed in people who have survived natural disasters, man-made accidents, military operations, terrorist acts, and other mass tragedies. They are divided into acute and chronic. The former are transient and manifest themselves during or immediately after tragic events, usually in the form of a hysterical fit. The latter gradually lead to a change in personality and social maladaptation (for example, the neurosis of an Afghan).
Stages
Neurotic disorders go through 3 stages in their development. At the first two stages, due to external circumstances, internal reasons or under the influence of ongoing treatment, neurosis may cease to exist without a trace. In cases of prolonged exposure to a traumatic trigger (chronic stress), in the absence of professional psychotherapeutic and / or medical support for the patient, the 3rd stage occurs – the disease passes into the stage of chronic neurosis. There are persistent changes in the structure of the personality, which persist in it even under the condition of effective therapy.
The first stage in the dynamics of neurosis is considered a neurotic reaction — a short-term neurotic disorder lasting no more than 1 month, resulting from acute psychotrauma. Typical for children. As an isolated case, it can be observed in people who are completely mentally healthy.
A longer course of a neurotic disorder, a change in behavioral reactions and the appearance of an assessment of one’s disease indicate the development of a neurotic state, i.e., neurosis itself. An untreated neurotic state for 6 months — 2 years leads to the formation of neurotic personality development. The patient’s relatives and he himself talk about a significant change in his character and behavior, often reflecting the situation with the phrase “he/she was replaced.”
Symptoms
Vegetative disorders are polysystemic in nature, can be both permanent and paroxysmal (panic attacks). Disorders of the nervous system function are manifested by tension headache, hyperesthesia, dizziness and a feeling of instability when walking, tremor, paresthesia, muscle twitching. Sleep disorders are observed in 40% of patients with neuroses. They are usually represented by insomnia and daytime hypersomnia.
Neurotic dysfunction of the cardiovascular system includes: cardialgia and discomfort in the cardiac region, arterial hypertension or hypotension, rhythm disturbances (extrasystole, tachycardia), pseudocoronary insufficiency syndrome, Raynaud’s syndrome. Respiratory disorders observed in neurosis are characterized by a feeling of lack of air, a lump in the throat or suffocation, neurotic hiccups and yawning, fear of suffocation, an imaginary loss of respiratory automatism.
On the part of the digestive organs, dry mouth, nausea, decreased appetite, vomiting, heartburn, flatulence, unclear abdominalgia, diarrhea, constipation may occur. Neurotic disorders of the genitourinary system cause cystalgia, pollakiuria, itching or pain in the genital area, enuresis, frigidity, decreased libido, premature ejaculation in men. Thermoregulation disorder leads to periodic chills, hyperhidrosis, subfebrility. With neurosis, dermatological problems may occur — rashes of the type of urticaria, psoriasis, atopic dermatitis.
A typical symptom of many neuroses is asthenia — increased fatigue both in the mental sphere and of a physical nature. There is often an anxiety syndrome — a constant expectation of upcoming unpleasant events or danger. Phobias are possible — fears of an obsessive type. In neurosis, they are usually specific, related to a specific subject or event. In some cases, neurosis is accompanied by compulsions — stereotypical obsessive motor acts, which may be rituals corresponding to certain obsessions. Obsessions are painful obsessive memories, thoughts, images, drives. As a rule, they are combined with compulsions and phobias. In some patients, neurosis is accompanied by dysthymia — a low mood with a sense of grief, longing, loss, despondency, sadness.
The mnestic disorders that often accompany neurosis include forgetfulness, impaired memorization, greater distractibility, inattention, inability to concentrate, affective type of thinking and some narrowing of consciousness.
Diagnostics
The leading role in the diagnosis of neurosis is played by the identification of a psychotraumatic trigger in the anamnesis, data from psychological testing of the patient, studies of personality structure and pathopsychological examination.
In the neurological status of patients with neurosis, no focal symptoms are detected. There may be a general revival of reflexes, hyperhidrosis of the palms, tremor of the fingertips when stretching the arms forward. The exclusion of cerebral pathology of organic or vascular genesis is carried out by a neurologist using EEG, MRI of the brain, REG, ultrasound of the vessels of the head. With pronounced sleep disorders, it is possible to consult a somnologist and conduct polysomnography.
Differential diagnosis of neurosis with psychiatric (schizophrenia, psychopathy, bipolar disorder) and somatic (angina pectoris, cardiomyopathy, chronic gastritis, enteritis, glomerulonephritis) diseases is necessary in the clinic. A patient with neurosis differs significantly from psychiatric patients in that he is well aware of his illness, accurately describes the symptoms that bother him and wants to get rid of them. In difficult cases, a psychiatric consultation is included in the examination plan. To exclude the pathology of internal organs, depending on the leading symptoms of neurosis, the following is prescribed: consultation of a cardiologist, gastroenterologist, urologist, etc. specialists; ECG, ultrasound of the abdominal cavity, FGDS, ultrasound of the bladder, CT of the kidneys, etc. studies.
Treatment
The basis of neurosis therapy is the elimination of the effects of a psychotraumatic trigger. This is possible either with the resolution of a traumatic situation (which is extremely rare), or with such a change in the patient’s attitude to the current situation, when it ceases to be a traumatic factor for him. In this regard, psychotherapy is the leading treatment.
Traditionally, complex treatment combining psychotherapeutic methods and pharmacotherapy is mainly applied to neuroses. In mild cases, only psychotherapeutic treatment may be sufficient. It is aimed at revising the attitude to the situation and resolving the internal conflict of a neurotic patient. Among the methods of psychotherapy, it is possible to use psychocorrection, cognitive training, art therapy, psychoanalytic and cognitive behavioral psychotherapy. Additionally, relaxation techniques are taught; in some cases, hypnotherapy. Therapy is carried out by a psychotherapist or a medical psychologist.
Drug treatment of neurosis is based on neurotransmitter aspects of its pathogenesis. It has an auxiliary role: it facilitates the work on oneself during psychotherapeutic treatment and consolidates its results. In asthenia, depression, phobias, anxiety, panic attacks, the leading antidepressants are: imipramine, clomipramine, amitriptyline, St. John’s wort herb extract; more modern — sertraline, fluoxetine, fluvoxamine, citalopram, paroxetine. In the therapy of anxiety disorders and phobias, additional drugs of anxiolytic action are used. For neuroses with mild manifestations, herbal soothing fees and short courses of mild tranquilizers (mebikar) are indicated. With extensive violations, preference is given to benzodiazepine-type tranquilizers (alprazolam, clonazepam). With hysterical and hypochondriac manifestations, it is possible to prescribe small doses of neuroleptics (tiaprid, sulpiride, thioridazine).
Multivitamins, adaptogens, glycine, reflexotherapy and physiotherapy (electroson, darsonvalization, massage, hydrotherapy) are used as supportive and restorative therapy of neurosis.
Prognosis and prevention
The prognosis of neurosis depends on its type, stage of development and duration of course, timeliness and adequacy of psychological and medical care provided. In most cases, the therapy started on time leads, if not to a cure, then to a significant improvement in the patient’s condition. The long-term existence of neurosis is dangerous with irreversible personality changes and the risk of suicide.
A good prevention of neuroses is to prevent the occurrence of traumatic situations, especially in childhood. But the best way can be to cultivate the right attitude to the coming events and people, to develop an adequate system of life priorities, to get rid of misconceptions. Sufficient sleep, kindness and a mobile lifestyle, healthy nutrition, and hardening also contribute to strengthening the psyche.