A Matter of Personality

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Tangled Emotions

What Ever Happened to Neurosis?

Poster boy for neurosis
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In a funny sequence in the delightful Disney animated fairy tale, Tangled, Rapunzel steps down from the tower that the woman whom she thinks is her mother has insisted she stay cooped up in all her life. She goes outside and touches the ground for the very first time - without the "mother's" knowledge.

She immediately experiences severe mood swings as she goes back and forth from the heights of ecstasy to the depths of despair over and over again in a very short period of time. One minute she is joyously marveling at the feel of grass as she runs through it. The next minute she is crying and wailing, "Oh, I'm a terrible daughter!" Soon thereafter she once again beams as she thrills in splashing through her first pool of water. Shortly after that she anxiously frets that she is hurting the woman who raised her and whom she loves.

The Harvard Guru of Treating Children with Anti-Psychotic Medication, Joseph Biederman, would probably diagnose her as bipolar. The male character who enticed Rapunzel to come down out of the tower, however, is a much better psychiatric diagnostician. He observes that she seems to be at war with herself.

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Ah yes, neurosis. That old Freudian psychoanalytic term that signifies a conflict going on within a person (intrapsychic conflict) that allegedly creates the severe anxiety and self-defeating behavior seen in patients who come for psychotherapy. Different psychoanalytic, existential, and humanistic, and family systems psychotherapy theoreticians (that is, those from certain schools of thought within the field) disagree over precisely what it is that "neurotic" people are most often conflicted, and some schools use an alternate term such as approach-avoidance conflict. The different schools of thought may protest that they are not talking about the same phenomenon. They are.

Freud thought the conflict was between our internalized values and our biological urges - most frequently urges associated with aggression and libido (psychic and emotional energy associated with biological drives).

Psychoanalyst Heinz Kohut thought the conflict was over our needs to be validated, depend on other people to get our needs met, and have a place to fit in within a family - a family that may provide us with none of those things.

Experiential therapists such as Carl Rogers and Fritz Perls thought it was over what our social system wants us to do and our need to self-actualize (achieve one's full potential through creativity, independence, spontaneity, and a grasp of the real world).

Erik Erikson saw it as a struggle to negotiate different developmental stages over our lifetime, such as the struggle between the forces of identity and role confusion during adolescence or the struggle between the forces of integrity and despair in the elderly.

Existential therapists think it concerns our need to find meaning and connection in an absurd universe in which our own death looms.

Family Systems pioneer Murray Bowen thought it was between the forces of togetherness and the forces of individuality.

In my own psychotherapy model, which I call Unified Therapy, I see neurosis mostly as a phenomenon that involves more than one person. For instance, a child trying to do what his parents expect of him of him may get mixed messages from the parents. This happens because the parents are ambivalent about what they want the child to do but cannot admit it, even to themselves. The child then feels an inner conflict between how to respond - which of the two mutually exclusive requests should he follow. The parent's neurosis creates, in a sense, a neurosis in the child.  It is contagious!

 

With a married couple, as so often turns out to be the case, both members may be ambivalent about the same issue and drive one another crazy as they both give off mixed messages to each other. The very thing that attracted the couple to one another sometimes becomes the very thing that drives them apart. For instance, one well known type of couple from couples therapy is that of an emotionally constricted and fearful male who is attracted to a spontaneous and freely-emoting female. To put it crudely, emotional constipation is attracted to emotional diarrhea. After a while, however, he tires of her impracticality and he starts to wish that she were more like him. They both experience an approach-avoidance conflict.

 

No reason exists to think that any of the above concerns from the different schools of thought, or any combination of them for that matter, might not all be important in different individuals .

 

Almost all of the conflicts, one might note, have something in common.  They start with a battle between doing what others expect of us and following our own internal needs and desires. Social conformity versus going our own way. Such conflicts are hardly a novel or esoteric concept, and certainly they are well known to all of us.

Yet the term neurosis has almost disappeared from the psychiatric lexicon. This has been a huge mistake, in my opinion.

 

The term neurosis was all over the place in the first two editions of the diagnostic Bible of the American Psychiatric Association (APA), the DSM, until the DSM III came out in 1980. Then it was unceremoniously dropped. To be sure, it had been invoked as a causative factor in disorders and behaviors with which we now know it had no business being associated, such as severe obsessive-compulsive disorder, homosexuality, and even schizophrenia.

 

However, just because it was not one of the major causative factors for some psychiatric or behavioral conditions does not mean, of course, that it is not a major causative factor for any of them. Surely all of us think twice about doing our own thing when we might be disowned by our parents or thrown in jail if we were to indulge ourselves. Yet we still have our own idiosyncratic, powerful personal needs and desires. That such conflict creates anxiety in us which then leads us to some strange behavior is almost indisputable.

Starting with the DSM-III, the powers that be wanted the list of psychiatric disorders to be merely descriptive and not get into the highly controversial area of what actually causes them (etiology). Saying intrapsychic conflict is a major cause of a disorder is just psychoanalytic theory, so the reasoning goes. And analysts have without a doubt been wrong about a great many things.

So instead psychiatrists are now stuck with the only official list of diagnoses in medicine that avoids the whole question of the causation of disorders. It's like a compendium of the symptoms of infectious diseases that never mentions viruses, bacteria, or parasites!

 

David M. Allen, M.D., is a Professor of Psychiatry at the University of Tennessee and author of the book How Dysfunctional Families Spur Mental Disorders.

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