Themes in the Pathogenesis of "Neurosis"

Two major themes of pathogenesis of neurosis permeate 19th century literature, by the end of which it was almost universally agreed that mental disorders could only be the result of disorder or disease of the brain, reflecting a confluence of neurological and psychiatric thought (Jacyna, 1982; Rosenberg, 1989). Firstly was the concept of predisposition to develop nervous disorders ("neuropathic predisposition"), which included that of "hereditary degeneration" as put forward by the French psychiatrist Morel (Alexander and Selesnick, 1967). Intimately linked to this was the concept of "commotion" of the predisposed nervous system, due to environmental or psychic factors, including dangerous and unsafe occupations, living in densely populated and disease-ridden cities, poor diet, and exposure to external agents such as alcohol or narcotics (Parkin, 1966; Alexander and Selesnick, 1967). These factors would conspire to "excite" the central nervous system, resulting in "dissociation" of mental processes from their usual reflex mode (Hart, 1927), the specific symptomatology in a given patient depending upon which part of the brain was affected (Drinka, 1984). [Table. 1]

Two of the common diagnoses then (and since) can be analysed in this way: "neurasthenia" and "hysteria".


Neurasthenia ("nervous exhaustion") was formulated by the American neurologist Beard in 1869 (Rosenberg, 1962). The nervous diathesis was held to be a deficiency of "nerve force" which may be inherited. Neurasthenia, the symptoms of which were legion, could arise from the excessive expenditure of nerve force ("overload") or from any interference with the nutrition of the nerves. Common environmental causes of neurasthenia were said to be excessive mental work, loss of sleep, sexual excesses (especially youthful indiscretions), errors in diet, alcoholic liquors, the use of strong tea and coffee, and the habitual use of opium, chloral and other analgesics (Kellogg, 1900) Unless the condition was recognised and treated, more serious neurological and other illnesses could develop in later life or even in succeeding generations - a remarkable tautological and teleological assertion.

A parallel construct, "psychasthenia" or "lowering of mental energy", developed under the influence of the French psychiatrist Janet (Kolk and Hart, 1989). Psychasthenia represented a "decreased capacity for creative adaptation to reality", resulting in "interference with effective action" and the "deflection of the mind into ruminations, phobias and anxiety".

Both neurasthenia and psychasthenia continued to be used in the first half of this century, though not without attracting scepticism, as diagnoses for non-specific symptoms (fatigue, depression and irritability) which were attributed to a variety of physical and psychological stressors that could sap the vitality of the nervous system (Mennell, 1940).


The diagnosis of hysteria dates from the time of the ancient Greeks and Romans, originally referring to those diseases of women which were attributed to the influence of the uterus, ostensibly due to either its tendency to wander from its proper place or its abnormal secretions (Nemiah, 1975).

In the 17th century the view was put that hysteria was a disorder of the central nervous system which was emotionally induced. This theory proved remarkably persistent. For example, Tilt (1881), an obstetrician, wrote in 1881: "There is no emotion without visceral reaction, and the inordinate reaction of the sexual organs on a predisposed nervous system shows itself by hysteria" and the "starting-point of hysteria is, in most cases, an aura, like that preceding an epileptic fit, starting from the ovaries, to react on the brain and on the spinal cord."
During the latter half of the 19th century, under the influence of a number of French physicians, including Briquet, Charcot, Babinski, Bernheim and Janet, the concept of hysteria evolved from a somatic disturbance of that portion of the brain responsible for receiving affective sensations to a state of "dissociation of consciousness", wherein certain neurophysiological processes become entirely split off from the mainstream functioning of the nervous system, thus permitting ideas to operate independently of the conscious state (for review see Hart, 1927). These functional derangements were perceived to be the result of severe "commotion" of mind and body, leading to their dissociation. According to Str|mpell (1894), "Every nervous affection may be called 'hysterical' (the name is certainly not a suitable one, but is in common use) which depends on a derangement of the normal connection between the psychical and the, in the narrower sense of the word, physical processes". As commonly used in 19th century medicine, hysteria reflected the physician's difficulty in distinguishing between nervous, or functional illnesses and the "physical ailments they mocked or masked" (Rosenberg, 1989).

With the rise to prominence of the Freudian school of psychoanalysis, hysteria was classified as a psychoneurosis (Crichton-Miller, 1925). Psychoanalysts proposed that emotional conflicts existing at an unconscious level ("commotion") could be converted into highly symbolic bodily symptoms (commonly pain), thus freeing the person of the need to resolve the conflict and, in so doing, experience the associated anxiety. Simply stated, "... in general, a human being prefers physical to mental pain, and that, in consequence, relief from mental pain is experienced on the incidence of physical pain" (Crichton-Miller, 1925). Motor disturbances (for example, cramps, spasms and contractures without organic explanation) and sensory disturbances (for example, variable and intermittent anaesthesia, paraesthesia, hyperaesthesia and chronic pain) were said to be prominent features of (now-called) conversion hysteria (Glover, 1949) These symptoms were seen - and are still by some contemporary writers - as a "subconscious alteration of the sensory and voluntary motor system, or both, producing bodily dysfunction" (Weintraub, 1988), despite both the tautological nature of the proposition and its consequent untestability.

In essence this represented a transition from the concept of reflex function of the nervous system to a revival of dualism (Knapp, 1975).

Next: The Relationship between Trauma and "Neurosis"

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