Neuroses

Neuroses. The term N. was first introduced into medicine in 1776 by the Scotsman Cullen, who applied it to most neuropathological symptoms, including diseases of organic character, for the understanding of which at that time there were still neither anatomical nor pathophysiological knowledge. The introduction by Cullen of the concept of 'neurosis' was a significant step forward compared to medicine of the 17th and 18th centuries, when, repeating Hippocrates, most nervous diseases were called 'vapors' (affections vapo-reuses) and connected with the influence of vapors of the body's basic fluids—blood, bile, semen, phlegm, etc.—on the psyche. Cullen was the first to definitely attribute these diseases to the nervous system. But the vast majority of these N. were not localized to any particular part of the nervous system. In the first half of the 19th century, the main cause of N. or nervousness was considered to be irritation of the spinal cord (irritatiospinalis), caused either by its anemia or hyperemia or generally by still unknown changes in the spinal cord. Griffin in 1834 even precisely localized in the spinal cord both headaches and ringing in the ears (cervical part), and pains in the extremities and internal organs (thoracic part), and sexual N. (lumbar part). Throughout the first half of the 19th century, the group of N. continued to remain as it were a sack into which all cases that did not yield to a definite explanation were thrown. Moritz Romberg (M. Romberg; 1840-46) called for example N. all diseases of the peripheral nerves, Sandras in 1851 in his manual among N. lists vomiting, diplopia, amaurosis, deafness, convulsions, contractures, hysteria, eclampsia, tetanus, hydrophobia, somnambulism, lethargy, catalepsy, some fevers, chorea, and even some general paralysis resembling paralysis of Bell but without delirium. In the second half of the 19th century, in the era of cellular pathology, numerous attempts were made to establish a precise basis for nervous diseases: successes in the anatomical study of the nervous system at that time allowed gradually to isolate a number of nervous diseases with a definite anatomical substrate, however cases where this basis remained unknown were still quite numerous and all of them were referred to the group of N. In this era the term 'functional' appeared in the sense of 'with unknown patho-anatomical basis'. For N. gradually such a definition was worked out (Hack-Tuke; 1892): 'neuroses are functional disorders of the nervous system, which, as far as we know at the present time, are not connected with any permanent organic changes'. The given definition lasted for a long time, and even in 1907 Raymond defined N. as follows: 'the name N. was agreed upon to designate certain sufferings of the nervous system without organic lesions discoverable by modern methods of research'. 'These are diseases rather with unknown changes than without any changes'—Raymond hastens to add at this point. It was quite natural that with such an understanding of N. their number constantly changed depending on the successes of pathoanatomy: part of the diseases fell out of the group of N., because their anatomical basis was discovered, and at the same time newly discovered but not yet understood in their etiology diseases were included in the group of neuroses: Brochin for example in 1878 added to the neuroses Parkinson's paralysis, Grasset in 1894—Basedow's disease, and tetanus for example was excluded in view of the discovery of the Nicolaier bacillus, angina pectoris in most of its cases turned into a disease of the coronary arteries, etc. As early as 1874 in Ziemssen's manual, where the department of nervous diseases was written by Erb, 520 pages are devoted solely to neuroses of the peripheral nerves and only 33 pages to anatomically localized nervous diseases. We find a particularly vivid criticism of the concept of N. as nervous diseases without anatomical basis in Axenfeld and Huchard (1883). These authors pointed out that the relation of the disease to the nervous system and the absence of known anatomical lesions are extremely indefinite signs: 'The nervous system intervenes in all functions, both visceral and motor and sensory, and when one says that there is a nervous suffering, but does not specify exactly which one, then nothing is expressed thereby. As for the absence of organic changes, this sign would have meaning if one could consider it absolute and final. But in reality everyone admitted that organic changes in N. exist, but they are still unknown. To establish the unity of a group based only on ignorance of anatomical changes means to admit that in reality there is no unity in this grouping, that it is only an amalgam of facts similar to each other only in one respect, namely that their nature is unknown to us. As a result, ignorance is thus elevated to the degree of a nosological unit'. But it should be noted here that to the group of N. were referred diseases not only on the basis of a negative sign, i.e. absence of organic substrate; here were also included states which had positive features as well. This positive feature was that in N. there is always a mixture of somatic and psychic disorders, a mixture which is difficult to separate; from diseases in which psychic phenomena come to the forefront, to N. were attributed hysteria, hypochondria and depression. From the end of the 1860s in connection with the successes of experimental psychology, with the study of hypnotism, as well as with the progress of psychiatry, many researchers began to especially emphasize this purely psychic characteristic of N. The psychic conditioning of N. was first emphasized by Briquet (1859), then these ideas were taken up and widely used in the teaching on hysteria by Charcot and his school, by Möbius (his teaching on ideogenesis), by Westphal and others. Bernheim and his pupils, abusing the term 'suggestion', taught that 'N. are characterized above all by mental disorder and especially by disorder of suggestibility'. Bernheim, like Charcot, emphasizing the internal connection existing between suggestibility and affect, also attributed a large role in the origin of N. and especially of hysteria to affective or emotional shocks. Finally Dubois in 1904 especially sharply emphasized the participation of the psyche in N., pointing out that 'neuroses are characterized by one capital fact: the intervention of the psyche, mental representation, in all their symptoms'. On the basis of this Dubois proposed to replace the term N. by the term 'psychoneuroses'. In this concept the term 'functional' acquired not only a negative meaning (in the sense of absence of anatomical changes) but also a broader positive meaning: in this concept, in opposition to crude morphology, the dynamic understanding of the pathological phenomena observed in neurosis was put forward. The understanding of N. as a violation of the dynamics of the relationship between higher and lower functions of the organism was given by Pierre Janet. 'In each function,' he said, 'there is a part, especially highly standing and consisting in the adaptation of man to the particular circumstance of the given moment (fonction du reel), when we need to use a certain simple function in accordance with the whole aggregate of external and internal conditions into which we are placed at the given moment. E.g. the function of nutrition must be performed in the presence of a large number of persons, with the obligation of conversation, in a certain costume, etc. Usually physiologists and neuropathologists study the simple part of functions and disorders of simple functions: the patient does not walk because he has broken his leg, because his motor nerve fibers are destroyed, does not eat because he has cancer of the stomach, etc. But disease can strike the higher parts of the function, e.g. the patient cannot eat in society. It is precisely the higher part of the function—adaptation to these complex circumstances—which is affected in N.' The understanding of N. developed by Janet is far from sufficient. Remaining within the plane of psychologism, detaching phenomena from their biological base, not connecting them with social historicity, Janet doomed his considerations to abstraction and artificiality. Almost simultaneously with Janet (in 1893) another teaching, which then became very widespread, arose about the psychic origin of N.—the teaching of Freud (S. Freud) (see Psychoanalysis). Freud also attributes great importance in the origin of N. to lower psychic functions—the unconscious ('it'). The teaching of Freud not only gives a general idea of the mechanisms of N., but also seeks to explain the causes of the appearance of these and not other symptoms of N. in a given patient, connecting them with the peculiarities of his experiences, studying the dynamic transformations of one experiences into others ('complex representations'). In our psyche and in the normal state are stored, according to Freud, fragments of experiences we have undergone, not realized by us, especially connected with more or less strong emotions. Every drive, desire, accompanied by emotion, must manifest itself in one or another external reaction, must be 'reacted out'.

If the fulfillment of a desire proves unacceptable from the standpoint of the individual's social and moral orientation ('the superego'), then it is repressed from consciousness ('censorship'), but traces of the affect remain in the subconscious, which, when subsequently associated with some random representation, manifest in the form of symbolic dreams, symbolic actions (see Displacement), and in the case of very strong emotion, in the form of N. Freud's system of views on N. further deepens the errors of Janet, growing from the same common root as the latter. This deepening of errors consists primarily in the fact that psychoanalysis assigns decisive importance to the 'subconscious' and 'unconscious', fundamentally opposing them to the 'conscious.' From this, the appeal to spontaneity, 'oceanism,' which permeates all of Freud's doctrine becomes clear, thereby throwing us far back. From this, the reactionary nature of these concepts is also clear, a reactionary nature consisting in atomizing the psyche, expelling from it the leading principle—the socio-class one. Claparéde, Kraepelin also believe that the sharp manifestation of affectivity in movements in N., which generally, according to Darwin, serve as modified primitive means of defense, is the result of the impossibility of finding a way out of a complex situation through reasoning, i.e., with the help of higher mechanisms. In such cases, phylogenetically more ancient defense mechanisms come into play. Hence in neuroses, for example, vomiting as a manifestation of disgust, hysterical mutism or trembling as a manifestation of fear, etc. In the same way, Kretschmer has recently interpreted hysterical mechanisms. Pavlov's doctrine also approaches this point of view in its understanding of neurotic symptoms as arising from a conflict between inhibition and excitation processes in the cerebral cortex. The imperialist war particularly vividly demonstrated the pathogenic significance of the affect of fear in the origin of N., revealed the ability of these affects to cause purely somatic disorders—vasomotor, trophic—and thus vividly confirmed the outstanding role of psychological factors in the origin of N. The war and the subsequent sharp class shifts with particular persuasiveness also revealed the tendency of certain people, under certain conditions, to create a chronic tendentious or purposeful N. (Tendenzneurose, Zweckneurose) from a short physiological affective episode. In those cases where life became unbearable under the given conditions, under the influence of a sharp affect, manifestations of lower, ancient defense mechanisms (trembling, seizures, clouding of consciousness) arose. Under the influence of 'nosophilia' (Wernhofer, Sokolowsky), the 'desire for illness,' these mechanisms gradually came under the will and appeared each time the patient needed to be ill in order to ensure rest, obtain a pension, etc.; what Kretschmer called 'mastery of hysterical mechanisms' occurred (see Traumatic neuroses). Thus, to N. (mainly to hysteria) were attributed all psychogenic reactions, and the very concept of N., or more correctly psychoneurosis (especially in Freud's conception), extremely expanded. And some, like Adler, Weizsäcker (A. Adler, Weizsäcker), began to define neuroses 'as the biological manifestation of the social inadequacy of the individual' (see below). It became necessary to delimit neuroses, on the one hand, from ordinary psycho-biological reactions, i.e., from those bodily phenomena accompanying psychological experiences that are observed with every emotional movement, and on the other hand, from psychogenic psychoses (see Psychogeny), since it was found that so-called major psychoses (schizophrenia, manic-depressive, paranoia) and associated pathological characters (schizoid, paranoid, etc.) and psychopathies also tend to give psychogenic outbreaks in connection with a difficult life situation, while it is quite inappropriate to call neuroses such psychogenic states as reactive depression, paranoid character developments, etc. Therefore, a number of authors (K. Schneider, K. Blum) began to propose retaining the name psychoneuroses (hysteria) only for those psychogenic reactions that play out in the narrowly bodily sphere and by their far exceed normal psycho-biological reactions. Thus, again, the mixture of mental and bodily phenomena, elements of participation of somatic functions, was put forward as a characteristic feature of N. Reichhardt (Reichardt) proposes to distinguish mental phenomena occurring on the basis of vegetative functions from higher mental ones associated with cortical mechanisms, and to attribute the former to N. (or more precisely (see below) to neuropathies), and the latter to psychopathies. Therefore, it is quite understandable that alongside the successes of psychological theories of the origin of N., searches continued for those bodily symptoms that would characterize N. The success of neurasthenia (see) described by Beard depended largely on the fact that Beard sharply emphasized the somatic point of view: somatic exhaustion of the nervous system. This emphasis on somatic pathological elements in neurasthenia was also the reason why, among the broad mass of patients, few wanted to be hysterics and neurotics in the sense of Janet, Kretschmer, Freud, and all agreed to become neurasthenics. 'In neurasthenia,' as K. Monakow (K. Monakow) correctly defined it, 'the subjective complaints are explained by objective bodily changes, and thus the neurasthenic escaped any moral evaluation; this gave undoubted substantial relief for many patients.' Relief not only for patients, we add, but also for many physicians, since thereby the physician was pulled from the area of complex and unfamiliar to him psychological concepts into his usual naive materialistic explanation. Neurasthenia for a time absorbed almost everything that had previously been understood under the name of functional neuroses: not only almost all neuroses were included in it, but also most mild forms of manic-depressive psychosis, schizophrenia, psychopathies. Hysteria was retained only thanks to its brilliant psychological interpretations by the Charcot school, its too bizarre external, often purely somatic manifestations. But here too hysteroneurasthenia appeared, and in 1902 Nissl put the question sharply: 'If the pathological anatomy of N., although it is finally unknown to us, nevertheless exists, and otherwise, said Nissl, it cannot be, then it is absurd to rack one's brain over the psychological interpretation and of hysteria.' The success of the study of anatomy and physiology of the vegetative nervous system at the end of the 19th and beginning of the 20th centuries, the study of the endocrine system, their connection with the entire lower mental life, the life of emotion, the identification of vagus neuroses by Girard, O. Rosenbach, the study of vagotonic, sympathicotonic symptoms by Langley, Eppinger-Hess, and Cannon's doctrine on the significance of adrenaline in the origin of emotions, the discovery and study of subcortical centers regulating the activity of the vegetative system, metabolism, the study of physicochemical conditions of cell work in normal and pathological states, the doctrine of electrolytes—all this supported the somatic trend in the doctrine of N. (see Vegetative neuroses). A number of neuroses entirely dependent on the peculiarities of the vegetative nervous system were identified—angioneuroses, angiotrophoneuroses (see); finally, in connection with the doctrine of the vegetative nervous system, the question of neuroses of individual organs was widely raised (see Stomach, Intestines, Heart—their neuroses, Vegetative neuroses). However, the somatic trend in the doctrine of N., by establishing a more or less definite morphological basis for them, thereby also led to the negation of the very concept of N. as a functional suffering without an organic basis, connected with psychological experiences. Therefore, the question arose of whether it is necessary to either completely eliminate the concept 'neuroses' or not to attribute vegetative disorders and so-called organ neuroses to them. 'As to how difficult it is to define what organ neuroses are,' says, for example, the Vienna professor Chvostek in 1927, 'testifies to the absence to this day of a unanimous decision even as to whether organ neuroses exist at all. Everyone understands the essence of organ neuroses in their own way, and at different times something different is understood under this name. The main thing here is seen in the disorder of function without anatomical changes, explaining it by physicochemical processes. However, the division of anatomical and non-anatomical does not exhaust the matter, since heavy toxic disorders without an anatomical basis (Redlich) are possible, and a disorder of function can lead to a 'fixed manifestation,' and under neurosis one can understand only something transient, connected with experiences, capable of restoration.'

Advances in clinical medicine also led to a progressive narrowing of the concept of 'organ neuroses,' for example, a mass of dyspeptic disorders in the form of vomitus nervosus, eructatio nervosa, were revealed in the research of Bergmann and his school as hidden cholecystitis; girdling pains in the left hypochondrium with extensive irradiation, previously interpreted as neurotic, turned out in the research of Katseh to be pancreatitis in most cases; a quarter of all cases interpreted as N. of the stomach, according to observations of Bansch, proved to be stomach ulcers or cholecystitis; heart neuroses turn out in many cases to be pendulous heart (cor pendulum Wenkebach'a); the concept of essential hypertension also removed many cardiovascular diseases from the group of neuroses. As for cases of organ neuroses, which are closely connected with disorders of the autonomic nervous system, in view of the fact that here the path.-anat. substrate is either established or can at least be assumed with a high degree of probability, it is more correct in such cases to speak, as Laignel-Lavastine and V. K. Khoroshko propose, of 'sympathoses' or, as Redlich proposes, of 'neuropathies.' 'Even functional disorders caused by lesions of nerve plexuses or ganglionic apparatus lose their specificity as soon as we subsume them under the concept of N.,' says Bergmann. In short, we must strive to find the genesis of nervous shifts and speak not of neuroses, but of their biochemical, allergic, endocrine, autonomic bases, and refrain from attributing strictly localized organ function disorders to neuroses, even if they are of a physico-chemical nature. 'The reason for the uncertainty about organ neuroses,' says Bergmann, 'lies in the one-sidedness of etiological medical thinking. Neuroses are not so much peculiarities of the nervous system as partial manifestations of a special cell structure, a special constitution.' 'There are no organ neuroses,' Khvostek states even more categorically, and Redlich even proposes to abandon the universal term 'neurosis' and to break it down according to genesis (see below). That is why in the end, organ N. are increasingly being applied only to diseases of purely psychogenic origin. Only the psychological pliability of symptoms gives a relative basis for the diagnosis of organ N. Therefore, for example, Krehl directly states: 'When we speak of N. of the heart, we think only of diseases caused solely by "nervousness," moreover transient, non-dangerous; such "nervousness" is identical with the mental.' But if in N. the matter always concerns their psychogenic origin, then it is necessary to take into account the statement of Bumke, in which he, regarding psychogenic path. reactions and psychoneuroses, stated in his report at the Kassel Congress of German neurologists in 1925: 'Psychoneuroses have not existed for a long time. They have merged with psychopathies and reactive psychoses... "Nervous" and hysterical predispositions cannot be treated differently from paranoid or manic-depressive constitutions...' The term 'psychoneurosis' is preserved only because of the fear of the general public of the term "mental illness." 'Meanwhile, psychiatry now, as Reichardt states, is by no means the doctrine of ^insanity" (Irrenheilkunde), but the doctrine of all path. reactions of the human psyche (Seelenheilkunde), and has long since left the towers of insane asylums to enter everyday life.' In this case, all psychogenic diseases, even if they express themselves with somatic symptoms, belong to the field of psychopathies in the broad sense of this word. 'In general, as O. Schwarz says, the former alternative, that a symptom can be either mental or somatic, now finds its dialectical resolution in unity, and the integrity of the personality in that the mental is not the opposite or even parallel to the physical, but a constitutive moment of the higher holistic structure.' One cannot isolate psychopathological phenomena into a special group solely on the grounds that their manifestation occurs in the area of somatic phenomena. And the tendency to attribute all psychogenies, all phenomena closely connected with the reaction to the surrounding environment, to N. is also incorrect, since undoubtedly, as already indicated above, it is possible for psychogenic reactive occurrence of both outbreaks of major psychoses, and on the other hand, the entire content of psychoses always closely depends on social factors and experiences. Psychoanalysis reveals the dynamics of the transformation of experiences in schizophrenia, and the mechanisms of Janet and Freud also operate in psychoses. Such is the state of the doctrine of N. at the present moment. The pendulum of scientific understanding of N., although still oscillating from psychological to anatomical understanding, the amplitude of the concept of N. becomes so wide that for this reason alone the concept itself requires dissection. From adhesions in the abdominal cavity, giving the nearest or distant viscero-visceral reflex, to ideogenesis, which "plays a role in the mechanism of complex repressions"-such is the methodological inadequacy of this category. If the problem of N. is still raised today for revision at congresses, then Redlich is certainly right, who stated at the Kassel Congress of German neurologists and psychiatrists in 1925 (with whom the majority present agreed, including Allers, Bleuler, Jung, Kahn, Kretschmer, Liepmann, Moriakow, Prinz-horn, Schilder, Waizsacker) that when mentioning N., no one speaks of diseases anymore, but only of types of reaction. Having indicated that for N. with an autonomic basis it is more correct to use the term 'neuropathies,' Redlich proposes the following classification of symptom complexes that were previously attributed to N.: I. Neuropathies of organic origin, where there are special congenital mechanisms (bereitliegende Mechanismen); these neuropathies are usually divided into genuine and symptomatic: epilepsy, migraine, Ménière's vertigo. II. Autonomic vaso- and trophoneuropathies (vegetoses of Laignel-Lavastine). III. Endocrinopathies. IV. Psychogenies (psychopathies). V. Neuropathies associated with intoxication and exhaustion (neurasthenia). Reichardt gives approximately the same division, and under neuropathies he understands such neuropathic constitutions that express themselves autochthonously or reactively arising symptoms from the autonomic nervous system outside the area of mental life. 'The close connection of the autonomic nervous system with the psyche, resp. emotional life, is undeniable,' says Reichardt, 'but it is undeniable that neuropathies and psychopathies can also arise separately; there is a whole series of neuropaths who remain mentally completely stable.' Neuropathic reactions are reactions without psychogenic influence, for example, vasomotor reactions to alcohol or thermal influences, extrasystole from stomach distension, etc. However, one should not speak of a neuropathic constitution, but of neuropathic constitutions with various kinds of increased excitability in the autonomic area. Reichardt attributes to neuropathies a) what was called organ neuroses: pathological tendency to vomiting, constipation, etc.; b) vasomotor instability (tendency to reactive or autochthonous variability of pulse, blood pressure, reactive extrasystole, increased dermographism, urticaria, cyanosis of extremities, etc.); c) tendency to dizziness, migraine, sleep disorders; d) tendency to tremor and clonus phenomena (although most tics are of purely organic origin); e) tendency to autonomic-trophic reactions [fluctuation in weight, irregular secretory phenomena (sweating), sensitivity to cold and heat, trophoneurotic edema]; f) tendency to idiosyncrasies in the autonomic area (reactive fainting, pavor nocturnus); g) neuropathic phenomena in the field of sexual functions: ejaculatio praecox, increased pollutions, etc. Reichardt also attributes to neuropathies the autonomic reactions that arise on the basis of massive, affecting the whole body emotional irritations (shock reaction: prolonged changes in pulse, trembling, sleep disorders, shock stupor, etc.). All reactions with the participation of mental moments Reichardt attributes to psychopathies in the broad sense of the word (psychogenies and psychopathies). Thus, it should be recognized that the term 'neuroses' should be abolished at present. It goes without saying that in this case, while attributing the majority of former N. to psychogenies and psychopathies, we must be far from a metaphysical understanding of the psychogenic. However, this in no way removes the problem of psychophysical unity. On the contrary, it is only now being placed on the rails of genuinely scientific resolution, and the development of the personality is understood historically as the problem of the 'division of the one' (see Character, Psyche, Psychogenies).