The defining features of the personality disorders therefore fall short of meeting the diagnostic criteria for more serious mental illness. Yet, an understanding of these personal peculiarities and their less obtrusive traits may be of great help to the physician. This knowledge makes it possible to appreciate their role as sources of perennial complaint, self-concern, and family discord, and to explain a patient’s reactions that have interfered with diagnostic and therapeutic procedures during a medical illness. It is, however, quite common for extremes of personality to create depression and anxiety, either of which is amenable to medical and psychotherapeutic treatment. As a final comment, one should never underestimate the power of maturation to ameliorate the turmoil of adolescence and to settle the young mind.
ANXIETY DISORDERS (SEE ALSO CHAP. 23)
Although considered to be the most frequent of mental disturbances, the anxiety disorders are among the least understood. They were established as clinical entities in the late 19th century, but there are still major unresolved issues with respect to their nature, classification, and etiology. Descriptively, they are meant to include (1) anxiety disorder; (2) phobic disorder, which includes phobia of illness, social phobia, and agoraphobia; (3) obsessive-compulsive states; (4) hysteria; and (5) hypochondriasis. Former classifications included additional types called neurasthenia (dysthymia or depressive neurosis), which is now considered with the depressive illnesses, and “depersonalization neurosis” (dissociative disorders), which is a form of hysterical illness. Although each of these syndromes is clinically separable when occurring in pure form, experience shows that most patients suffer from symptoms of more than 1 type and thus are said to have “mixed neuroses.” In recent classifications, all of the neuroses have been again subsumed in 3 broad categories: (1) anxiety disorders (which include panic states, with and without agoraphobia, and the phobic and obsessive- compulsive neuroses); (2) somatoform disorders (comprising hysterical neurosis, or conversion disorder, and hypochondriasis); and (3) dissociative disorders.
An interesting view of the relative frequency and expression of mental disorders of the day was provided by an analysis of 1,045 consecutive psychiatric consultations at the New England Center Hospital during the years 1955 and 1956 in which the dominant psychiatric syndrome in approximately 20 percent of patients was an anxiety state. Other epidemiologic studies continued to disclose a strikingly high incidence of anxiety disorders in the general population (see the review of Winokur and Coryell). Lifetime prevalence figures indicate that at least 11 percent of the population is so affected—that is, some 25 million persons in the United States. Such information as is available suggests that the incidence of the neuroses is much the same in an urban population (midtown
New York) as it is in a rural one (Stirling County, Nova Scotia), indicating that socioeconomic, racial, and cultural factors are of limited importance. Furthermore, in times of calamity, such as the bombing of London, the incidence of neurotic symptoms was said not to have increased. Thus, it is probably an oversimplification to view neuroses as merely by-products of life in civilized society or reactions to environmental stress (see also Chap. 23). This raises the issue alluded to earlier and discussed more extensively further on: namely, the role of background personality traits in promoting extreme and persistent anxiety after a traumatizing event (posttraumatic stress disorder, PTSD; see Chap. 23).
The symptoms of the anxiety disorders typically arise in late childhood, adolescence, or early adult life. Admittedly, symptoms may be recognized for the first time after this age, but a good clinical rule is to suspect any mental illness that appears for the first time after the age of about 40 years to be either a depression or a dementia.