People with a high level of anxiety have historically been referred to as ‘neurotic’. The term ‘neurosis’ derives from the Ancient Greek neuron (nerve) and loosely means ‘disease of the nerves’. The core feature of neurosis is anxiety, but neurosis can manifest as a range of other problems such as irritability, depression, perfectionism, obsessive-compulsive tendencies, and even personality disorders such as anankastic personality disorder. Although neurosis in some form or other is very common, it can prevent us from enjoying the moment, adapting usefully to our environment, and developing a richer, more complex, and more fulfilling outlook on life. The psychiatrist Carl Jung (1875-1961) believed that neurotic people fundamentally had issues with the meaning and purpose of their life. In his autobiography of 1961, Memories, Dreams, Reflections, he noted that ‘The majority of my patients consisted not of believers but of those who had lost their faith’. Interestingly, Jung also believed that neurosis could be beneficial to some people despite its debilitating effects.
The most original, influential, and contentious theory of neurosis is that of Sigmund Freud (1856-1939). Freud attended medical school at the University of Vienna from 1873 to 1881, carrying out research in physiology under the German scientist Ernst von Brűcke and later specialising in neurology. In 1885-86 he spent the best part of a year in Paris, and returned to Vienna inspired by the French neurologist Jean-Martin Charcot’s use of hypnosis in the treatment of ‘hysteria’, an old-fashioned term referring to the conversion of anxiety into physical and psychological symptoms. Freud opened a private practice for the treatment of neuropsychiatric disorders but eventually gave up the practice of hypnosis, instead preferring the method of ‘free association’ which involved asking patients to relax on a couch and say whatever came into their minds. In 1895, inspired by the case of a patient called Anna O, he published the seminal Studies on Hysteria with his friend and colleague Josef Breuer. After publishing The Interpretation of Dreams in 1899 and The Psychopathology of Everyday Life in 1901, both public successes, Freud obtained a professorship at the University of Vienna where he began to gather a devoted following. He remained a prolific writer throughout his life, publishing (amongst others) Three Essays on the Theory of Sexuality in 1905, Totem and Taboo in 1913, and Beyond the Pleasure Principle in 1920. After the Nazi annexation of Austria in 1938, he fled to London, where he died the following year of cancer of the jaw. His daughter, Anna Freud, became a distinguished psychoanalyst who developed the concept of ego defense mechanisms (see other posts on this blog).
In Studies on Hysteria, Freud and Breuer formulated the psychoanalytic theory according to which neuroses have their origins in deeply traumatic and consequently repressed experiences. Treatment requires the patient to recall these repressed experiences into consciousness and to confront them once and for all, leading to a sudden and dramatic outpouring of emotion (catharsis) and the gaining of insight. This can be achieved through the methods of free association and dream interpretation, and a relative lack of direct involvement by the psychoanalyst so as to encourage the patient to project his thoughts and feelings onto him – a process called ‘transference’ (by contrast, in ‘countertransference’ it is the psychoanalyst who projects his thoughts and feelings onto the patient). In the course of analysis, the patient is likely to display ‘resistance’ in the form of changing the topic, blanking out, falling asleep, coming late, or missing an appointment; such behaviour merely suggests that he is close to recalling repressed material but afraid of doing so. Other than dream interpretation and free association, other recognized routes into the unconscious are parapraxes (slips of the tongue) and jokes. For this reason, Freud famously noted that ‘there is no such thing as a joke.’
In The Interpretation of Dreams (1899), Freud developed his ‘topographical model’ of the mind, describing the conscious, unconscious, and a layer between the two called the preconscious which, though not conscious, could be readily accessed. Freud later became dissatisfied with the topographical model and replaced it with a so-called ‘structural model’ according to which the mind is divided into the id, ego, and superego (see figure). The id is fully unconscious and contains our drives and repressed feelings and emotions. It is dominated by the ‘pleasure principle’, and so seeks out immediate gratification. The id is opposed by the partly conscious superego, a sort of moral judge arising from the internalisation of parental figures and, by extension, of society itself. In the middle sits the mostly conscious ego. Dominated by the ‘reality principle’, the function of the ego is to reconciliate the id and the superego and thereby enable us to engage with reality. Neurotic anxiety arises when the ego is overwhelmed by the demands made upon it by the id, the superego, and reality. To cope with these demands, the ego employs defense mechanisms to block or distort impulses from the id, thereby making them more acceptable and less threatening. A broad range of ego defence mechanisms have since been recognised.
For Freud, the drives or instincts that motivate human behaviour (‘life instinct’) are primarily driven by the sex drive or ‘libido’ (Latin, I desire). This life-instinct is counterbalanced by the ‘death instinct’, the unconscious desire to be dead and at peace (the ‘Nirvana principle’). Even in children the libido is the primary motivating force, and children must progress through various stages of psychosexual development before they can reach psychosexual maturity. Each one of these stages of psychosexual development (except the latent stage) is focussed on the erogenous zone – the mouth, the anus, the phallus, or the genitals – that provides the greatest pleasure at that stage. For Freud, neuroses ultimately arise from frustrations encountered during a stage of psychosexual development, and are therefore sexual in nature. Freud’s stages of psychosexual development are summarised in the table below.
The Oedipus/Electra complex is arguably the most controversial of Freud’s theories, and can be interpreted either literally (as Freud intended it to be) or metaphorically. According to Freud, the phallic stage gives rise to the Oedipus complex, Oedipus being a mythological King of Thebes who inadvertently killed his father and married his mother. In the Oedipus complex, a boy sees his mother as a love-object, and feels the need to compete with his father for her attention. His father becomes a threat to him and so he begins to fear for his penis (‘castration anxiety’). As his father is stronger than he is, he has no choice but to displace his feelings for his mother onto other girls and to begin identifying with his father/aggressor – thereby becoming a man like him. Girls do not go through the Oedipus complex but through the Electra complex, Electra being a mythological Princess of Mycenae who wanted her brother Orestes to avenge their father’s death by killing their mother. In the Electra complex, a girl this time sees her father as a love-object, because she feels the need to have a baby as a substitute for the penis that she is lacking. As she discovers that her father is not available to her as a love-object, she displaces her feelings for him onto other boys and begins to identify with her mother – thereby becoming a woman like her. In either case, the main task in the phallic stage is the establishment of sexual identity.
Although much derided in his time and still today, Freud is unquestionably one of the deepest and most original thinkers of the 20th century. He is credited with discovering the unconscious and inventing psychoanalysis, and had a colossal influence not only on his field of psychiatry but also on art, literature, and the humanities. He may have been thinking of himself when he noted that, ‘The voice of intelligence is soft, but does not die until it has made itself heard.’ (‘Die Stimme des Intellekts ist leise, aber sie ruht nicht, ehe sie sich Gehör verschafft hat.’)