Anxiety Disorders and Somatoform Disorders
As we have seen, there is no clear dividing line between disordered behavior and normal behavior, and it is therefore quite likely that many of the readers of this section will recognize the patterns of neurotic reaction from personal experience. Neurotics employ the same defense mechanisms used by all people in adjusting to life, but they react in ways that exaggerate the effects of these mechanisms. The patterns of behavior developed by neurotics (anxiety disorders) impair their efficiency and the quality of their lives.
As you read the text, try to answer the following questions.
The patterns of neurotic symptoms change as the society changes
When Sigmund Freud formulated psychoanalytic theory in Victorian Vienna, he developed his ideas from his clinical experience with neurotic patients. Freud's patients were the products of a highly structured, sexually repressive culture in which sex roses and family roles were clearly defined and rigidly enforced. The neurotic patterns Freud observed reflected this culture. They were, for the most part, neuroses in which specific fears, irresistible habits, paralysis or anesthesia of various parts of the body, or sexual impotence or frigidity provided clear indications of the crippling effects of neurotic processes.
Today, however, the patterns typical of the milder behavior disorders have changed. Therapists report that they rarely see classical neurotic symptoms in clinical practice. The usual patient reports a more generalized disorder in which the whole personality structure, rather than a specific part, is involved. This kind of pattern is more difficult to treat.
The fact that patterns of behavior disorder have changed does not mean that Freud's insights and therapeutic techniques have lost their value. Much of the understanding that clinical psychologists and psychiatrists apply to treatment of neurosis can still be traced to Freud.
We will discuss the various neurotic patterns as if they were separate and distinct, trusting that the student will heed our warning: Human behavior is very complex, and rarely, if ever, as clear and uncomplicated as our brief discussion might imply.
A neurotic presents a picture to the therapist of "misery, stupidity and symptoms" (Dollard and Miller, 1950). His misery is due to the anxiety he feels and the effects on his life which have resulted from his attempts to block the anxiety from consciousness through the mechanism of repression. Even though the neurotic may be highly intelligent, there are aspects of his own life about which he cannot think or behave rationally. Blocking the anxiety from consciousness produces a form of stupidity, and this stupidity is connected with his misery. In fact, it may produce part of the misery. His symptoms do reduce his anxiety to some extent, but they also reduce his effectiveness as a person and his freedom to explore all the alternatives that might otherwise be available to him. These same symptoms may also disrupt his relationships with his family, friends and associates.
Each anxiety disorder has its own pattern, but major types can be discerned. These are:
In each of these neuroses, the individual attempts to reduce the unpleasant feeling of anxiety; he defends himself against it by substituting a neurotic symptom or symptoms for the anxiety. The particular symptom or pattern of symptoms that develops is the result of the history of the individual's interactions with other people.
Anxiety reactions are characterized by nonspecific fears. The patient with an anxiety reaction has no idea why he feels afraid because the source of the fear has been repressed.
An individual in the grip of an anxiety reaction will appear extremely agitated. Profuse sweating, pounding of the heart, and difficulty in breathing are often observed. However, when questioned about the specific object of fear, the patient will be unable to answer. This anxiety without a specific object is called free-floating anxiety.
The mechanism theoretically responsible for the formation of the anxiety reaction is repression. Initially, the individual has a specific fear. Because he is unable to face this fear, it is repressed. The anxiety reaction is an outlet for the repressed fear.
Anxiety reactions often disrupt living patterns. The following examples represent common patterns of anxiety reaction:
Mr. S is a graduate student. For three days he has been afraid to leave his house to go to school because he fears that people will do something horrible to him. He has not seen or spoken to anyone during this time.
Miss J. a young salesclerk, spends her days at work in a state of extreme tension. She is constantly worrying that she will be fired because something is wrong with her. This generalized fear affects her concentration at work and, in fact, she is in danger of losing her job.
Together, Mr. S and Miss J exhibit most of the common symptoms of anxiety reaction. These may be listed as follows:
Phobic reactions are characterized by specific fears. These fears may be very close to the original anxiety-producing situation, such as the fear of sex. They may also be fears of situations that are only symbolically related to the original anxiety. A patient who fears an animal such as a wolf or a horse may find in analysis that the fear is based on a fear of his father.
There are many types of phobias, including:
A phobia is an excessive fear of a particular object or situation which usually has no basis in reality
It is certainly not necessary to remember the exact names of these phobias; they are only a small sample of a very large number of possible fears. Virtually anything can become the object of a phobia, and once the phobia is established it is sometimes extremely difficult to cure. The phobic person avoids the situation that frightens him and gives himself no opportunity to learn that it is not as terrifying as it appears to be.
An example of a typical phobic reaction is given by Fenichel:
A patient's agoraphobic fears were accompanied by the feeling that his legs were being pulled, or that they were running away of their own accord. Analysis showed that the prohibition of his masturbation coincided in time with his learning to walk. As a little boy, he took much pleasure and narcissistic pride in walking. His legs and theirfunctions had usurped the place of the thwarted functions of the penis. A subsequent intensification of old conflicts permitted the fear of castration to become manifest, in the new field as a fear of losing his legs.
Obsessive-compuisive reactions involve recurrent ideas (obsessions), or irresistible impulses to act in certain ways (compulsions), or both. An obsession is an idea derived from a feared situation or event, and it sometimes arises out of a phobia. For example, someone who is claustrophobic may continually think of being trapped in a small space, as if constant attention to the feared situation were important in the attempt to avoid it at all costs. Obsessions may also come from counterphobic attitudes, as in the case of a person who is terribly afraid of death and therefore becomes a physician or a test pilot. In obsessive-compulsive neurosis, there is a strong impulse to perform certain acts repeatedly
Compulsions are actions that must be performed, even though they may not have any value in and of themselves. Compulsions often have a ritualistic character. The classic example of compulsive behavior is repeated handwashing, but touching rituals, counting sequences, and many other ritualistic behavioral patterns fall into this category. A compulsion may be experienced as a command like "Go and wash your hands," or as a threat like "You will spread disease if you don't wash your hands."
A typical case of obsessive-compulsive reaction, showing both obsessive thoughts and compulsive acts, is given by Fenichel as follows:
A patient . . . complained in the f rst interview that he suffered from the compulsion to look backward constantly, from fear that he might have overlooked something important behind him. These ideas were predominant: he might overlook a coin Iying on the ground; he might have injured an insect by stepping on it; or an insect might have fallen on its back and need his help . . .
Obsessive-compulsive neurotics who do not have severe symptoms can often function very well in some situations. They do particularly well in jobs requiring orderliness and precision. To a certain degree, society expects its jet mechanics, accountants and bank tellers to be somewhat compulsive, and rewards them, and all others whose roles require great care and thoroughness, for their compulsiveness. As we shall see later, the obsessive-compulsive neurotic resembles the obsessive-compulsive personality. The latter is a character disord- ,. The ,n these two is made on the basis of the individual's perception of his obsessions and compulsions. If he sees them as alien to himself, suffers from them, and wants to rid himself of them, he is neurotic. If he sees them as part of his personality and does not suffer from them, he has a character disorder.
Conversion reactions involve a loss of some physiological or mental function. Recorded case histories include memory loss, blindness, deafness, paralysis, anesthesia, sexual impotence and frigidity. Whether the symptom is physical or mental, a function is always lost in conversion reactions, and the function affected is related to the cause of the anxiety.
For example, an adolescent girl who was Breuer's first patient is described by Fenichel (1945) as follows:
Anna 0. had a paralysis of her arm whenever she was unconsciously reminded of her feelings toward herfather. At the time her father died she had been sitting at his bedside with her arm pressed against the chair at the side of the bed
The early psychoanalysts saw many conversion reactions, and actually perfected psychoanalytic techniques in treating them. However, few conversion reactions are seen today, especially among the privileged people who make up the clientele of most therapists. When conversion reactions are seen, they generally occur among less well-educated and more superstitious social groups.
Hypochondriacal reactions involve physical symptoms that mimic real diseases, such as heart trouble, indigestion, and every other sort of genuine physical distress. The anxiety manifests itself in disease symptoms that seem real to the patient, but which have no organic basis.
The hypochondriac is not a malingerer or liar; he really experiences his symptoms and believes them to be physiological. Thus many such neurotics go to physicians for treatment. Some physicians report that more than half of their patients come to them with complaints that are actually neurotic symptoms. It is often difficult to rule out organic disease without considerable study and laboratory tests. In hypochondriasis the person experiences the symptom but not the disease
As an example of hypochondriacal reaction, we will again quote Fenichel:
A patient with a severe vasomotor neurosis suffered from attacks of pseudo angina pectoris (heart trouble). The attacks appeared for the f rst time when the patient, soon after the death of his mother, learned that his father, too, had become seriously ill. The patient . . . who was fixated to his parents and had hitherto been unable to live without them, thus found himself suddenly confronted with the danger of having to face life alone. The pseudo angina had for him, f rst of all, the obvious meaning of an identification with his father, who was ill with heart disease. The patient lost interest in his parents as well as in other objects and devoted himself to his attacks and his fear of dying . . .
Hypochondriacal reactions are easily distinguished from psychosomatic illnesses, because they do not include any real physiological damage. In diseases which are psychosomatic, such as colitis, ulcers, and certain forms of heart disease, there is actual harm done to the body as the effect of psychological reactions. In ulcers, for example, worry and stress stimulate excessive gastric secretion with consequent damage to the stomach or intestinal wall.
Now test yourself without looking back.
1. Define anxiety._____________________________________________________________________
2. The most frequently encountered symptom of an anxiety reaction is:
a. an irresistible impulse to perform a certain act again and again.
b. diffuse or free- floating anxiety not associated with a definite situation or object.
c. bodily symptoms in the absence of organic defect that serve the purpose of handling anxiety.
3. List some of the other important symptoms manifest in anxiety reaction._______________________________________________________
4. When her mother-in-law comes to visit her, Mrs. A suddenly becomes totally deaf. She complains of the hearing loss but does not appear to be upset by it. The doctor finds no organic basis for her deafness.
This is the case history of:
a. an anxiety reaction.
b. a conversion reaction.
c. a phobic reaction.
d. an obsessive-compulsive reaction.
5. An obsession is:
a. a bodily symptom.
b. a recurrent idea.
c. a free-floating anxiety.
d. an impulse to perform an act repeatedly.
6. A phobic reaction is:
a. the fear of an object or situation that has become the symbol of the real object of
b. the fear of a symbolic object or situation when the real object of anxiety has become repressed.
c. a morbid fear of an object or situation without any realistic cause for the fear.
7. The following are examples of different kinds of neurotic reactions. Label them.
a. Before leaving for school every morning an adolescent girl looks in the mirror at least twenty times to be sure that the back of her dress is not soiled. She then asks her mother and sister to look just to make sure.______________________________________
b. A 50-year-old housewife finds it impossible to do her daily errands because she is afraid to leave her house. She feels that there is something about her that other people might see and ridicule.____________________________________
c. A middle-aged man quit after only two days at a new job. He had been given a very small private office, and he could not cope with his terror of confined spaces. ________________________________
8. In theory, which of the following may include real physiological damage?
a. Hypochondriacal reaction
b. Psychosomatic illnesses
ANSWER KEY PAGE 50
7 OR MORE CORRECT PAGE 41
FEWER THAN7 CORRECT PAGE 34
When environmental stress becomes overwhelming a neurotic person may react in many ways, all of which serve to reduce anxiety. Defense mechanisms include substituting symbols for the feared object, replacing psychological troubles with physiological ones, and repression.
In a neurotic reaction, a defense mechanism is used to reduce____________________________________________7
Defense mechanisms operate to reduce anxiety in all neurotic reactions. Check the reaction(s) in which you would expect a defense mechanism to reduce anxiety.
a. Hypochondriacal reaction
b. Conversion reaction
c. Obsessive-compulsive reaction
d. Phobic reaction
Anxiety is a feeling similar to fear, marked by tension, uneasiness, worry, and dread. The object of anxiety is often ill-defined or not clearly perceived.
Check the example(s) of anxiety below.
a. Mr. X feels that something awful is about to happen,
but he does not know what it is.
b. Mr. Y believes that he is the incarnation of the Buddha. This makes him divinely happy.
c. Mr. Z is a "bundle of nerves," even when everything is going well at home.
A woman sees her doctor with the following complaint: "I constantly feel very nervous as though something awful is about to happen. I can't sleep at night. I think my nerves are shot. I can't understand it; everything is all right at home."
The doctor finds no evidence of an organic disease that would account for these symptoms.
The woman is probably suffering from ___________________________________4
In the anxiety reaction, when the impulse causing the anxiety is repressed, free-floating anxiety is produced. The person does not know what he is anxious about. He has repressed it.
Mrs. K feels faint and frightened only on subways; her anxiety is ________________________________
Mr. L is always nervous and jumpy without apparent cause; his anxiety is ___________________________________________(free-floating/not free-floating) .
A young man dashes into a hospital emergency room and says that he feels very apprehensive but he doesn't know why. His heart is pounding, he is breathing hard, and his hands and forehead are sweating.
In this example, the patient:
a. is exhibiting a general anxiety.
b. is specifically anxious about a situation or object.
In free-floating anxiety, the anxiety is:
a. tied in with a definite situation or object.
b. diffused and generalized.
What is the main symptom of an anxiety reaction?______________________________________________3
2 not free-floating
3 fear apprehension
4 neurotic anxiety
5 a, b, c, d
6 a, c
What is the characteristic defense mechanism for anxiety reactions?
Mr. C, a businessman, is always worried about losing his job
because he finds it more and more difficult to keep his mind on his
work. He is suffering an anxiety reaction. Check the symptoms
probably shown by Mr. C.
b. Difficulty in concentration
c. Generalized fear
f. Extreme alternations of mood
Miss W is a college student who is on probation. The routine examination by the college physician reveals an anxiety reaction. Miss W is afraid to go to parties and dances because she is nervous, shy and self-conscious. She is always worried about grades, clothes, studies, and her family. Her academic troubles stem from her inability to concentrate on anything for very long because she is nervous and apprehensive.
What typical symptoms of anxiety reaction are present?
A very common manifestation of repressed anxiety is seen in the hypochondriacal reaction. People suffering from this type of neurosis undergo genuine physical distress, although their symptoms only mimic those of real disease.
Mrs. L is constantly complaining about a persistent sore throat and backache. Three doctors have examined her and pronounced her to be in sound health. Several tests show that there is no organic damage to either her throat or back. Mrs. L continues to feel pain in these two areas. Mrs. L has repressed her original anxiety. Her present illness takes the form of a hypochondriacal reaction. In this reaction the neurosis:
a. is turned into actual physical symptoms.
b. causes actual organic damage.
In hypochondriacal reaction, the patient's original anxiety is
repressed. The resulting anxiety is:
b. felt as physical pain.
c. does actual physiological damage.
Mrs. Q suffers from sharp pains around her heart. A cardiac specialist finds that there is no actual heart damage involved, even though her symptoms do mimic those of real heart disease.
Mrs. O is probably suffering from a_______________________________________4
Another way of coping with anxiety is to transform it into real bodily troubles. This reaction to the anxiety produced by psychological stress is known as the conversion reaction because psychological difficulties are converted into physiological complaints
Conversion reactions are characterized by symptoms such as blindness, deafness, and paralysis, for which no organic explanation can be found.
A young soldier entering combat for the first time suddenly develops paralysis of the right index finger. Neurological examination reveals no evidence of nerve or muscle disease which might account for the paralysis.
The case history is that of conversion reaction. In a conversion
reaction, psychological stress is converted into:
a. loss of a bodily function.
b. free-floating anxiety.
1 shyness, free-floating anxiety, constant worrying, difficulty in concentration, generalized fear or apprehension
4 hypochondriacal reaction
A housewife develops complete loss of feeling over the left half of her body. This loss of sensation begins at the exact midline of her body. Neurological tests all indicate no neurological disorder.
The most likely diagnosis in this case is__________________________2
1) Mr. D's severe stomach pains seem to indicate that he has ulcers. However, a medical examination and X ray show that there is no organic damage to his gastric system.
2) Miss P is paralyzed in both legs. The doctors who examine her find no evidence of nerve or muscle damage.
Which of the two case studies illustrates conversion reaction?_______________________________
What neurotic reaction does the other case study illustrate?____________________________________4
Miss X went to see a torrid love movie. Immediately after leaving the theater she was unable to see. She consulted a physician but no physical basic reason for her blindness was discovered.
This is an example of:
a. anxiety reaction.
b. conversion reaction.
A fourth way of handling unbearable anxiety is the obsessive- compulsive reaction. In this type of reaction, the neurotic attempts to deal with the original anxiety by adopting a pattern of persistent ideas and ritualistic actions while the real cause of anxiety is repressed.
Mr. J thinks his apartment door is unlocked. He often stops what he is doing during the day to check on it. At night he keeps getting up to make sure it is locked.
The obsessive idea is his thinking that_____________________________________
The compulsive act is____________________________________________________________1
Mrs. A finds herself constantly preoccupied with the fear that her son will be hit by an automobile on his way home from school. Even though she knows this thought is irrational, she cannot stop herself from thinking it.
a. an obsession.
b. a compulsion.
When out walking, Mr. C must glance over his shoulder every fifteen paces to be sure he has not dropped anything. Even when he is not carrying anything he must do this; should he neglect to do this he feels very uncomfortable.
Looking over his shoulder is an example of_______________________________ (an obession/a compulsion) .
It serves to_____________________ (reduce/ increase) anxiety.
An obsession is:
a. a recurrent idea.
b. a bodily symptom.
c. a free-floating anxiety.
d. an irresistible impulse to perform a certain act repeatedly.
1 his door is unlocked;
checking the door
2 conversion reaction
3 a compulsion
,4 Case 2
Another neurotic defense mechanism is the phobic reaction. Here, anxiety is detached from its original object or situation, and attached to a symbolic object or situation.
In contrast to anxiety reactions, the phobic reaction is characterized by very specific fears. These fears may be associated with particular objects or situations such as a fear of cats or a fear of enclosed spaces.
In phobic reactions, the cause of anxiety is repressed and the anxiety becomes attached to:
a. the real object.
b. a symbolic object or situation.
Mrs. G is terrified of wide-open spaces. Through psychotherapy she understands that this sort of landscape symbolizes the lack of protection she felt as a child.
This is a(n)_________________________________________ reaction.
Morbid fear of a symbolic object or situation characterizes the_____________________________ reaction to neurotic anxiety.
Which of the following is a phobic reaction?
a. Miss Z is so afraid of insects that she will not leave
b. Miss B does not seem to be afraid of anything in particular, but she washes her hands many more times each day than is necessary for cleanliness.
What kind of neurotic reaction does the other example illustrate?
Check the appropriate boxes to indicate what symptoms are present in each reaction.
NOW TAKE PROGRESS CHECK 2
1. Mr. B, a young salesman, has become increasingly disturbed about his work because he feels tense and embarrassed whenever he meets a potential customer. Mr. B shows the symptoms of:
a. a conversion reaction.
b. an anxiety reaction.
c. an obsessive-compulsive reaction.
d. a hypochondriacal reaction
2. A feeling similar to fear that is marked by uneasiness and dread is a major symptom in neurosis called______________________________________________
3. An irresistible impulse to perform a certain act again and again is a(n) ______________________________
It is a symptom of the neurotic reaction called_____________________________________
4. In a conversion reaction, original neurotic anxiety is converted into:
a. bodily symptoms.
b. free- floating anxiety.
c. specific fear of a symbol.
d. recurrent thoughts.
5. Label these examples of different kinds of neurotic reactions.
a. Mr. T cannot pass a lamp post without touching it. If he is walking beside a row of lamp posts, he feels he must also count them. If someone prevents him from doing these things he feels very uncomfortable.
b. Mrs. Y has a terror of heights. She refuses to go near windows when she is in a tall building or to live in anything but a first floor apartment.
c. Mrs. R is always nervous and jumpy. She sometimes feels as if something terrible is about to happen to her.
ANSWER KEY PAGE 50
4 OR MORE CORRECT PAGE 41
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