The divide between neurosis and psychosis originated well before Sigmund Freud's psychoanalytical ideas. People used to think anxiety, psychosomatization, and obsessions and compulsions were problems of irritated or frazzled nerves; in fact, this lay distinction has continued with the approval of psychiatrists who should know better until fairly recently. People who were psychotic had a more central disorder of the nervous system: a mental illness. Really, the distinction between a neurotic disorder and a psychotic disorder is a pretty arbitrary one. Neurotic disorders have their source in the brain just like psychotic ones.
If the difference between neurosis and psychosis is thought to be one of severity instead, the various psychiatric disorders still cannot be clearly delineated into neurotic and psychotic. A severe manifestation of obsessive-compulsive disorder may be more debilitating than a mild case of paranoid schizophrenia. Also, the distinction between Axis I disorders (in the DSM-IV-TR) and Axis II disorders (in the DSM-IV-TR) is somewhat arbitrary. Personality disorders show brain differences just like Axis I disorders. People with some personality disorders, particularly the Cluster B ones, are at high risk of "losing control" because of high impulsiveness or highly reactive mood. How is this really any different from a brief psychotic episode even though personality traits are considered to be at fault? Sure, the patient may not exhibit delusional thinking or hallucinatory perception, but their thinking may become quite incoherent in such episodes. Their behavior is obviously disruptive to themselves and others when their personality disorder is at its worst. Why is psychosis narrowly wrapped around a break from reality defined by delusional thinking, hallucinatory perception, disorganized thinking, and apathy? A person with chronic schizophrenia has a vastly unusual personality, but this is not classified as a personality disorder. A psychopath, whose brain has anomalies just like a schizophrenic patient's brain does, is considered legally sane even though their brains are definitely malfunctioning for our society. A psychopath does not have genuine delusions, at least as they are traditionally defined; but they have "cognitive distortions" or "cognitive biases" that place them into conflict with society. Psychopaths presume hostile intent; if someone "cuts them off" on the road, it was intentional and not a careless (negligent but at least not intentional) mistake. Psychopaths tend to assume a hostile, cynical world where people are constantly struggling against one another. This belief is not as bizarre as a paranoid schizophrenic person's paranoid delusional system, but it is psychically disruptive! Psychopaths also have underreactive and underdeveloped frontal lobes; this controls impulses, emotions, and long-term planning. Schizophrenic people also often develop problems with executive function as their illness progresses. Yet the psychopath is sane because their personality, however unlikeable it is, is still intact and seemingly reasonable! Psychopathy is just one example of the uselessness of these divisions between neurosis, psychosis, and personality disorder.
23 Aug 2005, 4:33 pm
