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Part One
The medical approach to psychological problems
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1
Classification in psychiatry
Systems of classification are useful in the sciences in that they provide a means whereby highly complex material can be rendered more manageable and subjected to experimental inquiry. The fact that an individual structure can be assimilated into a particular category on the basis of one or two variables enables one to make a prediction that it will possess some of the other attributes which are considered to be characteristic of this particular membership class. Thus psychologists and psychiatrists who favour a rigorous scientific approach have naturally expended a great deal of energy on developing taxonomic systems for dealing with the wide range of behavioural disturbances which are presented to them.
A classification system, of course, is only of any real value here if it provides the clinician with some knowledge as to possible causes, course of action and appropriate management of a particular type of disorder. It is therefore not surprising that neither the theologians nor the moral therapists took much interest in developing such a conceptual system. As far as the medieval priests were concerned, all psychological disturbances were seen as having a common cause (possession by the devil) and a common treatment (exorcism). This was administered to everyone who was seen to be afflicted in this way. Thus a list of the various types of disturbance would have contributed little to the understanding or management of the individual case. Pinel and his followers concentrated on creating a stress-free environment where each person could come to terms with his own particular problems, and it is doubtful whether they would have allowed the existence of a system of classification to have much of an influence on the way in which the individual was handled in their institutions. Thus it has really been the medically oriented practitioners who have been concerned to isolate various discrete categories of behaviour, analogous to physical illness.
The psychiatrist who undoubtedly laid the foundations of the currently employed classification system was Emil Kraepelin (1913). He pointed out that certain groups of signs and symptoms occurred together with sufficient regularity to merit the designation of ‘disease’. He then proceeded to describe the diagnostic indications associated with each of the syndromes. In addition he saw the origins of the disorders as being due to hereditary diseases, metabolic disturbances and endocrine abnormalities. He found no place for psychological or sociological factors in the causality of these diseases. Furthermore he took a very deterministic position and stated that patients either naturally recover or inevitably deteriorate, depending on the nature of their disease. Although his overemphasis on organic factors and fatalism regarding outcome are not shared by even the most organic of contemporary psychiatrists, his comprehensive classification system, with some major modifications, is still adhered to by clinicians throughout the world.
There are generally considered to be five major types of psychiatric disorders. These are:
(i) the neuroses
(ii) personality disorders
(iii) functional psychoses
(iv) organic psychoses
(v) mental retardation
In the following pages, some of the most common examoles of each category are defined and described.
Before dealing with these various disorders, it is necessary to make a brief comment regarding the style in which they are presented. Although it is not in keeping with the general theme of this book to talk about people experiencing ‘symptoms’ and demonstrating ‘signs’ of ‘mental illness’, it would be extremely tedious for the reader were these medical expressions to be translated or qualified repeatedly throughout the remainder of this chapter. In the interests of simplicity, therefore, the medical format and language will be adopted.
The neuroses
The individual is considered to be neurotic if he experiences anxiety in situations which do not generally evoke such a reaction. He attempts to cope by avoiding, both in his thoughts and his behaviour, the causes of his distress. Although much of his behaviour may seem to be maladaptive, he does not exhibit the bizarre and violent behaviour which is characteristic of other psychiatric disorders. Instead he appears as an unhappy and guilt-ridden person who is ineffective in both work and social situations.
The neurotic paradox is an expression used to refer to the self-defeating strategies adopted by patients in this category. At first sight it appears puzzling that an individual should cling to thinking and behavioural patterns which ultimately bring distress and unhappiness. The explanation most favoured by psychologists is that these coping mechanisms bring him relief from anxiety in the short term. In addition, it follows that since he is always avoiding, he never allows himself to test out the situation to determine how stressful it actually is. In other words, the seemingly paradoxical behaviour of the neurotic, in making himself more and more upset by irrational or exaggerated fears, can best be understood in terms of his desire for immediate tension release.
Anxiety neurosis
Definition. One of the most lucid descriptions of anxiety neurosis or ‘free-floating anxiety’ as it is sometimes called is that provided by the American Psychiatric Association (1968):
This neurosis is characterized by anxious over concern extending to panic and frequently associated with somatic symptoms. Unlike ‘phobic neurosis’, anxiety may occur under any circumstances and is not restricted to specific situations or objects. This disorder must be distinguished from normal apprehension or fear, which occurs in realistically dangerous situations, (p. 39)
Clinical picture. The patient with anxiety neurosis typically has some or all of the following symptoms:
1 inability to concentrate
2 difficulty in making decisions
3 sleep disturbances
4 overactivity of the autonomic nervous system (see A2), e.g. rapid heart beat, palpitations, excessive sweating, nausea, gastrointestinal distress, severe headaches, excessive muscle tension.
Patients who fit into this category are directly experiencing all the discomfiture generated by their anxiety, unlike other neurotics who have developed some,strategy which prevents them from feeling the psychological and physical pain. Those who suffer from ‘free-floating anxiety’ tend to experience persistent tension which is interrupted from time to time by acute panic attacks. The misuse of alcohol or other drugs by these patients in order to alleviate the immediate stress can sometimes complicate the clinical picture.
Phobias
Definition. A phobia is a persistent fear of a specific object or situation for which there is no rational basis. The patient himself typically recognizes that there is no danger but this awareness in itself does nothing, as a rule, to alleviate his distress. Phobias may involve stimuli which do not normally evoke a fear reaction (e.g. birds), or they may concern situations which make most people a little uneasy (e.g. flying). These are a few of the more common phobic stimuli with their diagnostic labels:
acrophobia – heights
agoraphobia – open space
claustrophobia – closed space
monophobia – being alone
pathophobia – disease
pyrophobia – fire
Clinical Picture. The patient usually has many of the autonomic disturbances which are characteristic of anxiety neuroses, but in this case the symptoms are only experienced when he is faced with certain specific objects or situations. These physical symptoms of anxiety range from mild discomfort to vomiting and fainting.
There has been much discussion in the literature recently as to whether the disorder of agoraphobia should really be considered a bona fide phobia. This problem has arisen largely because clinicians have tended to make use of this diagnosis with people who are terrified to leave their house. A close examination of their complaint would undoubtedly reveal that, in the majority of cases, it is not the ‘open space’ factor which is causing the anxiety but the thought of facing the outside world. Thus the term phobia hardly seems appropriate unless it can be accepted that ‘the world outside my house, constitutes a specific situation. Increasingly, psychiatrists have come to accept the views of clinicians such as Snaith (1968) who suggests that this misleading diagnostic label should be replaced by ‘non-specific insecurity fears’. Thus it would appear that the various problems encompassed by the term agoraphobia are more akin to anxiety neurosis than to phobic states, in the majority of cases. The term should be reserved for that relatively small group of people who really do experience anxiety in wide open spaces.
Obsessive-compulsive neurosis
Definition. The patient with obsessive-compulsive neurosis experiences persistent thought patterns which he tries to prevent (obsessions) and repetitive tendencies to behave in a way which he does not wish to (compulsions).
Clinical picture. Some of the more common obsessions include such diverse topics as exaggerated concern regarding bodily functions, repeated attempts to solve problems, or strong tendencies to commit immoral acts of various sorts. Probably the most frequently occurring -compulsions are those concerned with washing or toilet rituals. Typically the patient feels that he has to count up to certain numbers when washing his hands and his face in order to be free from contamination. If he is interrupted then he experiences an overpowering urge to go back to the beginning and start all over again.
The essential feature of obsessive-compulsive disorders is that the ideas or impulses to action occur with ‘a subjective sense of compulsion overriding an internal resistance’ (Slater and Roth, 1969). This resistance is seen to be the important distinguishing feature between an obsessional thought pattern and a delusional system. Thus if the patient is totally overwhelmed with ideas of contamination, and does not feel them to be irrational, then the diagnosis of obsessive neurosis would not be applied and that of schizophrenia given serious consideration.
Neurotic (reactive) depression
Definition. In the case of reactive depression the individual’s symptoms of extreme dejection are seen to be a response to some stressful event or series of upsets.
Traditionally, psychiatrists have attempted to make a distinction between neurotic and psychotic (endogenous) depression. There are now many who would argue that the dividing line is far from clear (Kendall, 1968) and that depression should be regarded as a unitary disorder. For. present purposes, the two types of depression will be presented with their presumed-to-be distinct clinical features.
Clinical picture. The major symptoms which would enable one to make a diagnosis of ‘neurotic depression’ are as follows :
1 subjective report of unhappiness
2 inability to face the future
3 lack of energy
4 difficulties in concentration
5 pre-occupation with unpleasant thoughts
6 difficulties in getting off to sleep
It should not be assumed that all depressives walk around in a slumped and dejected fashion, with facial expressions telegraphing their feelings of deep despondency. Many depressives manage to take an active part in conversations, smile when appropriate and even recite jokes in order to present a good front to their friends, colleagues, spouse and sometimes even to their family doctor.
Hysterical neurosis (conversion type)
Definition. Traditionally the diagnosis of conversion hysteria is used with those conditions where the symptoms of some physical illness appear in the absence of any organic pathology. According to Freud, the signs of disturbance are merely manifestations of unresolved sexual conflicts. In his view, the anxiety elicited by such matters is converted into a physical form. Although few contemporary clinicians would support such an explanation, the term conversion hysteria is still widely used. As well as providing the individual with release from psychological tension, it is claimed that the symptom benefits the individual in other ways. This ‘secondary gain’, as it is called, refers to the fact that the individual may acquire the attention he craves for, or may avoid an unpleasant situation, by consciously developing his particular symptom. Since it is often difficult to determine any ‘gain’ the individual may be deriving from his symptoms, most psychiatrists regard this aspect as a common but not essential feature of hysteria.
Clinical picture. The physical symptoms of conversion hysterics can usefully be considered under three main headings: sensory, motor and visceral.
1 Sensory symptoms:1 Two of the more common types of reactions involving these senses are anaesthesia (complete loss of sensitivity to pain) and paresthesia (tingling or other unusual sensations). More dramatic disorders of this type which have been reported are hysterical blindness (Parry-Jones etaky 1970) and hysterical deafness (Malmo, 1970).
2 Motor symptoms: The psychoanalytic literature contains many reports of cases of hysterical paralysis, where the patient has lost the use of an arm or leg because of psychological disturbances (e:g. Abse, 1959). Disturbances of speech such as aphonia (inability to talk above a whisper) and mutism (complete inability to talk) are other examples of motor types of hysterical disorders.
3 Visceral symptoms: Pseudo-cases of appendicitis, malaria, tuberculosis, and pregnancy demonstrate the extent to which conversion disorders can simulate organic conditions. Far more common are the-coughing fits, black-outs and severe headaches to distinguish many of these disorders from psychosomatic illnesses such as asthma or migraine which many would argue are partially caused by psychological factors.
There are three features of hysterical conversion disorders which have been variously proposed to assist the clinician in distmguishing them from organic and psychosomatic illnesses. These are:
1 ‘la belle indefferénce’ – lack of concern about symptoms
2 selective nature of the dysfunction – e.g. inability to speak in the presence of certain people
3 inconsistency in symptomatology – e.g. paralysed arm which does not atrophy.
Useful as these guidelines are, the differential diagnosis issue, particularly with those patients who have more than a superficial knowledge of medicine, can prove to be problematic.
Hysterical neurosis (dissociative type)
Definition. The disorders referred to as hysterical dissociative type occur less frequently but are even more theatrical than the conversion type. -As the name might suggest, it is used in those cases where the patient attempts to escape from Stress by cutting himself off in some way or other. As a result, he is able to deny responsibility for his behaviour.
Clinical picture. There are thought to be four basic types of hysterical dissociative disorder: somnambulism, amnesia, fuge and multiple personality.
1 Somnambulism: The sleepwalker typically gets out of bed in order to perform certain acts in connection with his dreams. He returns to bed and continues to sleep as if nothing has happened, as a rule. He has no recollection of his nightly activities when questioned.
2 Amnesia: Hysterical amne...
