Epidemiology

Individual neurotic symptoms are common in the community, as well as in primary and secondary care, and thus can be regarded as normal. These include:

Neurotic symptoms are often seen in general practice, resulting in significant societal burden. They may be the predominant symptoms in one-sixth of individuals seen there, and relevant in up to one-third. Sufferers often present with physical symptoms. Individuals suffering from neurosis are more frequently seen in a psychiatric outpatient clinic than as inpatients in a psychiatric hospital. Neurotic disorders are the most common psychiatric condition, at any one time affecting up to 10% of all individuals, and over 15% in a lifetime.

With the high incidence of neurotic symptoms in the general population, questions arise in individual cases as to whether such symptoms should be regarded as abnormal or whether such individuals are regarded as mentally ill. Should these symptoms be merely viewed as an individual’s way of dealing with the problems of everyday life, or do they represent a formal mental illness? Mild neuroses, in fact, often remit spontaneously or with mild reassurance. However, individuals with neurosis are more likely to seek medical consultation, often owing to fear of physical illness, and accurate diagnosis avoids inappropriate medical investigations.

Comorbidity, especially with depression, substance misuse and personality disorder, is common. Neurotic disorders often precede the development of depression.

In the differential diagnosis of neurosis, one should ask why this particular patient is presenting at this particular time with this particular symptom. If an individual presents with neurotic symptoms for the first time after the age of 35–40 years, it is probable that they may be due to a depressive disorder or, alternatively, to underlying organic disease.

Aetiology

Predisposing factors leading to the development of neurosis are often similar to those important in the development of personality disorder. In fact, neuroses often arise in those with abnormal personalities, as these lead such individuals into social and emotional difficulties to which they overreact emotionally.

Environmental factors such as family and early background are important, but there is increasing evidence for a genetic inherited predisposition to neurosis.

The vulnerability of the general population to developing a neurosis under stress follows a normal distribution, as for height or weight (Figure. 10.1). The incidence of neurosis rises with increasing environmental stress (Figure. 10.2). Even normal stable personalities will develop neurosis under severe environmental stress, as can be seen in individuals involved in natural disasters and in war time. During the First World War, the incidence of neurosis approached 100% in individuals in the trenches for prolonged periods, and this was similar in bomber crews during the Second World War after more than 30 missions. Although one person’s stress may be another’s pleasure (owing to the individual’s background and personality), certain situations such as combat are experienced as stressful by over 95% of individuals. Lower percentages experience stress in examinations or public speaking, and up to 50% of the population find job interviews stressful. Although not associated with external stresses, sensory deprivation (either experimentally or as experienced by hostages kept in solitary confinement) and, to a lesser extent, boredom can also result in extreme stress and anxiety.

Figure 10.1 • Vulnerability to developing neurosis.

Figure 10.2 • Incidence of neurosis with environmental stress.

A number of theories have been developed to explain neuroses. In Freudian psychoanalytic theory, neurotic symptoms are seen as the expression of intrapsychic anxiety due to unresolved emotional conflicts dating from childhood. Freud initially proposed that anxiety represented repressed libido (mental energy or drive). Later, he considered that it reflected the birth experience, but he eventually replaced this theory with that of anxiety being a response of the ego to instinctual emotional tension. Freud differentiated the term anxiety neurosis, which he thought had a biological causation, from psychoneurosis, which included anxiety hysteria (phobic or situational anxiety), obsessive–compulsive neurosis and hysteria, all of which he saw as arising from unconscious conflicts. Learning theory has conceptualized the neuroses as learned maladaptive responses associated with a temporary reduction in anxiety. There is also evidence to suggest some genetic predisposition for the development of individual types of neuroses, although this may be predominantly through genetic influence on the development of personality.

As stated above, stress factors can be precipitating factors for neuroses in vulnerable individuals, and environmental factors, including family and marital factors, and social conditions such as poor housing and unemployment, may be perpetuating factors for such disorders. Table 10.1 summarizes factors associated with the development of neurotic and stress-related disorders.

Table 10.1 Factors associated with development of neurotic and stress-related disorders

Treatment

Evidence-based guidelines, e.g., from the National Institute for Clinical Excellence (NICE) in the UK, are now available. Each condition will be discussed in turn. Cognitive behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are often effective. SSRIs should be continued for one year after response. However, CBT may be more effective in preventing relapse.

Prognosis

The overall prognosis in these conditions is generally regarded as good, with up to 50% of individuals recovering without treatment, and up to 70% with treatment, within two years. However, up to half of individuals seen by a GP will remain symptomatic one year later, and for those seen by a psychiatrist, about half will still be handicapped after four years. Good prognostic indicators include a stable premorbid personality and the development of acute symptoms in response to transitory stresses. Poor prognostic factors include chronic and/or severe symptoms at presentation, persisting social problems and inadequate social support. There is an excess of mortality among those with neurotic disorders, largely because of increased rates of completed suicide.

Normal anxiety

Anxiety is a mood, usually unpleasant in nature, accompanied by bodily (somatic) sensations and occurring with a subjective feeling of uncertainty and threat about the future. The term ‘fear’ is used to describe a normal and appropriate mood when the danger can be perceived and defined. Most of the bodily changes seen in anxiety are caused by increased sympathetic adrenergic nervous system discharges, i.e. Cannon’s fight or flight reaction (Figure. 10.3), which results in the release of adrenaline and other catecholamines. In our ancestral past such a reaction would prepare us to deal with a real physical threat, but today we may merely experience such reactions when under stress in everyday life, for instance in a traffic jam.

Figure 10.3 • Physiological changes in Cannon’s fight or flight reaction.

We all attempt to adjust our lives to maintain anxiety at an optimal level for us as individuals. However, like pain, anxiety is a useful warning and should not be suppressed with drugs or alcohol. It is the central nervous system’s alarm system to protect us from threat, and is activated by environmental cues. There is an inverted U-shaped relationship between anxiety and performance developed by Hebb in 1955 known as the Yerkes–Dodson law (Figure. 10.4). This was based on an experiment on white mice being encouraged by low-, medium- and high-intensity electric shocks to learn to locate a compartment in a box. Medium-intensity shocks produced the fastest learning. Performance is reduced at low and very high levels of anxiety: thus poor examination results are obtained by those with low anxiety levels who do not care whether they pass or fail, and by those who become so highly anxious that they cannot concentrate. The Yerkes–Dodson law predicts that anxiolytic drugs reduce performance in someone with a low anxiety level, but when a deterioration in performance is caused by high anxiety, the reduction of symptoms by anxiolytic drugs should improve performance, for example in examination phobia. In assessing an individual’s true level of anxiety, one should bear in mind that the complaint of symptoms of anxiety may lie anywhere along the Yerkes–Dodson curve. The individual may also be very anxious during a formal interview, but not so for long periods during the day, or vice versa. It is useful to distinguish between trait anxiety, which is a lifelong personality characteristic, and state anxiety, which is a temporal disorder with a discernible time of onset.

Figure 10.4 • Yerkes–-Dodson law.

Anxiety is present usually where there is some possibility of choice of action. This may explain why some individuals facing execution, where there is no hope, do not appear anxious. Other factors such as depersonalization and denial may also be relevant, as may also a paranoid attitude to circumstances in that such an individual believes that others will ‘get’ them anyway, sooner or later.

Generalized anxiety disorder

This is also known as anxiety neurosis, anxiety state or anxiety reaction, and is characterized by unrealistic or excessive anxiety and worry, which is generalized and persistent and not restricted to particular environmental circumstances, i.e. it is ‘free-floating’.

Clinical features

These are summarized in Figure 10.5 and Table 10.5. Individuals will not have all the psychic (affective) and somatic symptoms, but will tend to have the same symptoms during each exacerbation, for example palpitations or trembling.

Figure 10.5 • Somatic clinical features of generalized anxiety disorder.

Table 10.5 Psychological features of generalized anxiety disorder

Symptoms	Characteristics
Psychic	Feelings of threat and foreboding
	Difficulty in concentrating or ‘mind going blank’
	Distractible
	Feeling keyed up, on edge, tense or unable to relax
	Early insomnia and nightmares
	Irritability
	Noise intolerance (e.g. of children or music)
Panic attacks	Unexpected severe acute exacerbations or psychic and somatic anxiety symptoms with intense fear or discomfort
	Not triggered by situations
	Individuals cannot ‘sit out’ the attack
Other features	Lability of mood
	Depersonalization (dream-like sensation of unreality of self or part of self)
	Derealization (dream-like sensation of unreality of world)
	Hypnogogic and hypnopompic hallucinations (when, respectively, going off to or waking from sleep)
	Perceptual distortion (e.g. distortion of walls or the sound of other people talking)

Males and individuals from lower social classes and some cultures are more likely to complain of somatic rather than psychic symptoms. It is important to understand that these are real and not merely ‘all in the mind’, and it is reassuring to the patient to be told this. In keeping with Cannon’s fight or flight reaction, in which there is stimulation of adrenergic neurones leading to the release of adrenaline and other catecholamines, autonomic hyperactivity results in increased heart rate and palpitations and an increased rate of breathing, which results in a sensation of breathlessness. In turn, hyperventilation (sometimes referred to as the hyperventilation syndrome) results in the individual excessively blowing off carbon dioxide, leading to hypocapnia, which induces peripheral vasoconstriction and a ‘pins and needles’ sensation (paraesthesia). This can be countered by breathing into and out of a paper bag.

It is thus easy to understand how a patient, unaware of the normal physiology of anxiety, can get into a vicious cycle of anxiety and worry about somatic symptoms. The patient may forget the original stress that precipitated the episode and become preoccupied about dying from a heart attack (sometimes referred to as cardiac neurosis or the effort syndrome). Such a fear would be increased if chest pain is also experienced owing to anxiety-induced increased muscle tension. Muscle tension is caused by increased blood flow to the muscles as well as increased tone, and contributes to the complaint of fatigue. The term neurasthenia (fatigue syndrome) has been used in the past to refer to a neurosis where fatigue is the predominant symptom.

Depersonalization and derealization are sometimes associated with generalized anxiety disorder and are disorders of self-awareness. In depersonalization, an individual has an altered or lost sense of personal reality or identity. In derealization, an individual’s surroundings feel unreal. Individuals find these symptoms unpleasant and difficult to describe, and are relieved when they are acknowledged by professionals. Such feelings can occur in normal individuals, especially those suffering loss of sleep, as well as in a primary depersonalization–derealization syndrome. They are also seen in individuals suffering from depression, schizophrenia, alcohol and drug intoxication and withdrawal, and epilepsy. It may also be induced by prescribed medication. Although unpleasant, they are bearable compared to panic attacks, which are associated with higher levels of anxiety (Figure. 10.6).

Figure 10.6 • Anxiety levels in panic attacks and depersonalization.

History taking should explore the use of alcohol, caffeine and illicit drugs as possible explanations for anxiety symptoms, as well as any association of symptoms with precipitating events. The individual may have a tense and worried facial expression and posture, and may be tremulous, pale and/or sweaty. There may be overbreathing and also evidence of agitation (purposeless activity due to anxiety), with pacing of the floor and fidgeting. Physical examination should exclude organic causes such as thyrotoxicosis. Although investigations for thyrotoxicosis might be justified, other physical causes of anxiety, such as phaeochromocytoma, are sufficiently rare for routine investigation not to be cost-effective, unless clinically indicated.