We Should Embrace the Word "Neurotic"

We could do everyone a favor if we accept rather than police the term.

Posted Jun 15, 2018

Suicidal behavior, I recently argued, usually “stems from an intersection of three things: 1) difficult circumstances resulting in major stress or trauma; 2) a neurotic temperament; and 3) an internal narrator who hates and attacks the negative feelings. Together, these elements result in a horrible spiral or depressive loop.”

As has happened before, a few commentators criticized my willingness to use the term “neurotic.” One stated: “One thing I find paradoxical in such a compassionate, relational approach is the use of 'neuroticism.' It's nothing if not a shaming category; even if not used with clients, it pretty clearly, IMO, is by definition pathologizing and shaming." Another commentator agreed, and said that seeing the word was “jolting.”

These folks are raising an important point, and they have good, compassionate intentions. Potentially stigmatizing language should be considered and avoided when appropriate. However, the key qualifier here is when appropriate. And it is important to keep in mind that good intentions often pave the road to less-than-desired places.

So when should we police word usage? When the words have been transformed so that they are explicitly used to stigmatize. Words like "moron" and "imbecile" are good examples. When should we not police words? When the words describe situations that are bound to carry some negative connotations, but are not designed or generally used for the purpose of injuring. And we should not confuse the negative connotation in the description with the intent to do harm.

Let’s use cancer as an example. For those worried about a diagnosis, cancer can become the “c-word.” This is understandable because cancer describes a very undesirable condition. However, this negative association does not mean that physicians should replace "cancer" with "the c-word" or start describing cancer patients as "people who have some cells exhibiting unfortunate rates of replication."

"Neurotic" has parallels. Let's face it, it is, generally speaking, not great to be highly neurotic. Mental disorders, by definition, describe conditions that are deemed harmful, at least in many respects. It is not ideal to have schizophrenia, bipolar, major depression, and on and on. Now, of course, neuroticism is not technically a mental disorder, but it is associated with them, and thus it inevitably carries some negative associations. Such associations are found in the nature of what it describes.

Let’s be clear about what the term means. The word has two primary usages, and I like both of them. First, there is the historical usage of the term in clinical psychology and psychiatry. In the early days, it was contrasted with "psychotic," and together, "neurotic" and "psychotic" formed the broadest way to differentiate mental disorders. "Psychotic" referred to people who were suffering and who had lost touch with the conventional shared reality. Delusions and hallucinations were the classic psychotic symptoms. In contrast, "neurotic" referred to people who were suffering, but had not lost touch with reality any more than folks in the general population. Anxiety and depressive conditions were the bulk of neurotic conditions. Interestingly, the distinction between neurotic and psychotic gave rise to the term “borderline.” Folks in this category were in the "borderline territory" between neurotic and psychotic. Like neurotic folks, they generally maintained contact with reality (i.e., the did not have florid delusions or hallucinations). However, they had serious difficulties functioning and were poor candidates for psychoanalytic treatments, as they would decompensate quickly into extreme or rigid states. Although this usage of "neurotic" has largely fallen out of favor, this basic classification of personality functioning (i.e., healthy, neurotic, borderline, psychotic) almost replaced the categorical approach to personality disorders in the DSM-5.

Clinically, the term "neurotic" became associated with excessive and problematic negative reactions, which in turn would create maladaptive patterns for the individual. Consider, for example, someone who was very shy, coped by avoiding all contact with people, and then was desperately lonely. This can be well-described as a vicious neurotic cycle. That is, the strategy of avoidance created more and more problems and concomitant suffering. Indeed, avoidance-based coping is often the root of many maladaptive, neurotic conditions, and many different approaches to therapy agree that some form of exposure and leaning into and accepting one’s fears without running away is key to overcoming neurotic patterns. This pattern of adaptation can be thought of as the “character” meaning of the term.

The other meaning of the term is found in trait personality research, and thus refers to the temperament meaning. (Note it is often useful to divide personality into character, or learned styles of adapting, and temperament, which includes broad dispositional tendencies). Research on personality traits has generally yielded a five-factor model, with one factor labeled "neuroticism." As I describe here, trait neuroticism refers to the “set point” of the negative emotional system in adults. People high in trait neuroticism “idle” at higher levels of negative affect, are more reactive to stressful events, experience stronger negative emotions, and take longer to settle down after becoming upset. Not surprisingly, high levels of trait neuroticism are closely connected with anxious and depressive conditions. Some folks want to refer to these folks as “sensitive” so that patients and others don’t have to deal with the negative associations of the term "neurotic."

I encourage us to think about the implications of this move. The root of many neurotic patterns is found strong negative reactions, which lead to safety behaviors that ultimately trap the person in vicious, maladaptive cycles. Given this, isn’t it problematic if mental health professionals try to police the term so that people don’t have to confront the label? The message here is clear: The word "neurotic" is dangerous and potentially stigmatizing and, we, the powerful mental health professionals, want to protect you so you avoid what might be a “jolt” if you encounter the word. This knee-jerk harm avoidance impulse is a major feature of our modern culture, and there are many problems embedded in it. 

I think the reverse approach is much healthier, which is why I advocate embracing the word. Doing so sends the opposite message: "Neurotic" is a word that may or may not describe you. If it does apply to you, lean into it, take ownership of it, and see what you can learn from it. If you do that, you will habituate to it, and it will lose its power to harm you.

More Posts