Etiology and pathogenesis
The nature of neurotic disorders is exclusively psychogenic. However, ordinary daily stressors (workloads, financial difficulties, conflicts) do not cause neurosis on their own. Triggering the disease requires prolonged and individually significant psychotrauma, which often remains unnoticed by others.
A leading role is played by intrapersonal conflict — an insoluble contradiction between equally significant needs, where choosing one option means a painful rejection of the other. This state is also described as a conflict between "I want", "I must", and "I am". Clinically, this conflict manifests as anxiety, self-blame, doubts, and a feeling of a life impasse.
According to V.N. Myasishchev's classification (1960), each neurosis has its own type of conflict:
- Hysteria: contradiction between the desire to dominate and the unwillingness to assume responsibility.
- Obsessive-phobic neurosis and psychasthenia: the struggle between the pursuit of happiness and a hypertrophied sense of duty.
- Neurasthenia: the gap between real abilities and exaggerated tasks that a person sets for themselves.
Character is of immense importance: patients often create psychotraumatic situations themselves. At the same time, there are protective traits (perseverance, aggressiveness, shifting responsibility) that increase resilience to neuroses.
The biological foundation of anxiety is associated with an excess of catecholamines, a deficiency of GABAergic systems, as well as impaired metabolism of serotonin and endorphins. A predisposition to panic attacks, for example, is detected in individuals with low exercise tolerance (which is confirmed by sodium lactate and CO2 inhalation tests).
Panic attacks and obsessive-compulsive neurosis
Panic attacks [F41.0] are recurring attacks of intense fear lasting, as a rule, less than one hour. Previously, they were mistakenly diagnosed as diencephalic syndrome or sympathoadrenal crisis, and in general medical practice, patients are often diagnosed with "hypertension" and prescribed antihypertensive drugs that are ineffective in this case. In reality, there is no specific lesion of the autonomic nervous system; the attacks are associated with chronic stress and anxious apprehensions.
Obsessive-compulsive neurosis is characterized by a prolonged, chronic course (more than other neuroses). The range of situations provoking fears gradually expands. To relieve anxiety, patients use rituals — symbolic magical actions. In children, this may manifest as tics (isolated tics usually resolve after puberty). An important feature of such patients is their critical attitude toward the disease: they actively fight the symptoms, hide them from colleagues, and strive at all costs to maintain social status and working capacity. Antidepressants are successfully used for treatment, confirming the pathogenetic connection between obsessions and depression.
Hysterical and somatovegetative disorders
Sensory disturbances [F44.6] in hysteria are diverse: from anesthesia to paresthesias (itching, burning) and loss of hearing or vision. Their key sign is the mismatch with anatomical innervation zones. Pain is often described bizarrely, for example, as "a feeling of the head being squeezed by a hoop". This can lead to erroneous surgical interventions (Munchausen syndrome [F68.1], Briquet's syndrome [F48.8]).
Somatovegetative disorders [F45] affect any systems:
- Gastrointestinal tract: lump in the throat (globus hystericus), anorexia, nausea, swallowing disorders.
- Cardiovascular and respiratory: dyspnea, pseudoangina, arrhythmias.
- Urogenital: pseudocyesis, vaginismus, dysuria.
Unlike patients with obsessions, patients with hysteria do not limit contacts, but rather demonstrate their illness. They may receive guests in a wheelchair or pour tea with a healthy hand while demonstratively hanging the "paralyzed" one in a sling. Emotional lability is accompanied by a specific phenomenon — la belle indifférence (beautiful indifference), where the patient forgets about the severity of their imaginary disorders.
The course of hysterical neurosis is wave-like; exacerbations are strictly tied to new stressors (e.g., changes in living conditions or interpersonal conflicts). Complete recovery is possible if the trigger is removed, but with a prolonged conflict, a persistent neurotic personality development forms.
Briefly: answers to topical questions
Which groups of pharmacological drugs are used to treat obsessive-compulsive neurosis?
Four main groups of drugs are used for the pharmacotherapy of obsessive-compulsive neurosis.
- Antidepressants — have high efficacy, including TCAs, SSRIs, and MAO inhibitors.
- Tranquilizers — short-acting drugs are used to relieve acute anxiety attacks, while long-acting ones are used for long-term prophylaxis.
- Anticonvulsants — used for the prevention of fear and panic attacks.
- Mild antipsychotics — indicated in the presence of monothematic stereotyped fears.
What brain structures are involved in the pathogenesis of fear reactions and panic attacks?
Structures of the limbic system and brainstem are involved in the pathogenesis of fear reactions.
- Locus coeruleus (blue spot) of the pons is involved in fear responses.
- Reticular formation is involved in the regulation of anxiety and fear.
- Amygdaloid bodies (Corpus amygdaloideum) play a key role in the formation of fear and aggression.
- Amygdala of the temporal lobe and orbital area of the frontal cortex are involved in the formation of purposeful aggressive behavior; their stimulation causes fear, anger, and rage.
Class and exam questions
Is routine everyday stress a cause of neurosis?
No, ordinary everyday problems and overwork do not cause neurosis on their own. A prolonged, specific, and individually significant psychotrauma for the particular patient is required.
How to quickly distinguish hysterical sensory loss from neurological pathology?
In hysteria, zones of sensory loss (anesthesia, hypoesthesia) anatomically do not correspond to the innervation zones of nerve trunks and roots.
What is the main difference in behavior between patients with obsessions and patients with hysteria?
Patients with obsessive-compulsive neurosis fight the disease and try to hide it to maintain social status. Patients with hysteria are demonstrative, do not limit contacts, and emphasize their sick status.
What else to study on this topic
- Differential diagnosis of isolated childhood tics and generalized Gilles de la Tourette syndrome
- Complications of somatoform disorders: Briquet's disease and Munchausen syndrome
- Specifics of psychogenic amnesia and hysterical hallucinations
- Pharmacotherapy of neuroses: the role of sulpiride and fluoxetine
- Behavioral techniques: rules of conduct during a panic attack in a public place
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