- 9.2. THE PHENOMENOLOGY OF NEUROSES: MECHANISMS OF OCCURRENCE, FORMS,

Lecture

Это продолжение увлекательной статьи про нервозы профилактика диагностика и лечение.

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trivial matters.
Irritability and quick temper manifest themselves especially upon repeated exposure to the psychotraumatizing stimuli that caused the illness. Heightened excitability
is usually combined with heightened exhaustibility, which is expressed in decreased working capacity, increased fatigability, and asthenia. Heightened excitability and rapid exhaustibility also show themselves in the easy onset of emotional reactions and at the same
time in their brevity and instability. Usually those functions of patients that are marked by heightened excitability are also characterized by heightened exhaustibility. The exhaustibility of these patients is also reflected in their impatience; waiting becomes unbearable.
Under certain circumstances patients are able to restrain themselves and not display heightened irritability, more often at work.
In the state of neurasthenia the quality of mental activity changes substantially:
the person loses the ability to cope with complex intellectual tasks, activity is carried out predominantly at the level of automatisms and loses its former
appeal (the patient's interests shift toward analyzing the psychotraumatizing factors, and later – toward their own health).
Neurasthenia manifests in three forms. The hypersthenic form of neurasthenia is characterized by excessive irritability, lack of restraint, impatience, heightened
sensitivity to insignificant stimuli, tearfulness, and attention disturbances.

The hyposthenic, or asthenic, form is characterized by a more pronounced component of asthenia proper – both mental and physical. Working capacity and interest in one's surroundings decrease, and a constant feeling of fatigue, listlessness, and lack of freshness appears, sometimes – drowsiness. The form of irritable weakness occupies an intermediate
position. In it, heightened excitability is observed together with weakness and exhaustibility, as well as easy transitions from hypersthenia to hyposthenia, from excessive activity to apathy (Karvasarsky B.D., 1980, 1990).
As an illustration of the manifestation of the three forms of neurasthenia, let us examine the symptomatology in
three pilots, described by A.I. Seversky (1965). Neurasthenia of the hypersthenic form
arose in a pilot born in 1920, with a total flight time of 5,000 hours. In the summer of 1958, during
flights he began to tire quickly, and heightened irritability, sweating, and sometimes aching pains in the region of the heart appeared. His sleep became disturbed: insomnia at night, drowsiness in the daytime. After intensive flights in August the complaints intensified, since the pilot violated the pre-flight regimen, and emotional experiences in flight, combined with a disrupted regimen of nutrition, work, and rest, caused a breakdown of higher nervous (mental)
activity. The patient's pulse was rhythmic, 86 beats/min. After medicinal and physiotherapeutic treatment, the patient's overall condition improved, he became less irritable and more balanced, and the pain in the region of the heart ceased. At the medical flight commission, in regard to neurasthenia of the hypersthenic form, taking into account the positive assessment from command, he was deemed fit for flight duty on non-jet transport
aircraft and helicopters.
Neurasthenia of the hyposthenic form arose in a pilot born in 1922, with a
total flight time of 4,000 hours. He complained of unstable mood (more often lowered),
reluctance to fly, constricting headaches, dizziness, nausea, forgetfulness,
irritability, unpleasant sensations in the region of the heart, and general weakness and listlessness of the body. He frequently suffered from flu and tonsillitis. In July 1959, after suffering catarrh (Gr.
katarrhoos – to flow) of the upper respiratory tract (catarrh – inflammation of the mucous membrane), he
began to notice fatigability and pain in the region of the heart during flight. From August 17 to 26, 1959
he was hospitalized for inpatient treatment. During this period his condition improved, and the pain in the region of the heart ceased. At the medical flight commission he was deemed fit for flight duty
on non-jet transport aircraft and helicopters.
Neurasthenia in the form of irritable weakness arose in a pilot born in 1922,
with a total flight time of 8,000 hours. After strenuous flight work with a disrupted regimen of
nutrition and rest, he began to experience irritability over the slightest pretext, sometimes without
any reason at all, rapid fatigability, headaches (especially after working in hot
weather), and brief stabbing pains in the region of the heart after episodes of agitation. Headaches began to occur from 1957. From 1959 they intensified, and unpleasant sensations appeared in the region of the heart. His living conditions before being drafted into the army were difficult; his father and mother frequently
quarreled. This environment (in other words – an improper style of upbringing) had a negative effect on the child's development. Lacking self-control since childhood, during episodes of agitation he would shout and swear.
The neurotic symptoms were as follows. Sleep disturbed: insomnia at night, drowsiness in the daytime. In conversation he becomes agitated, startles, is talkative and fussy. Heightened
sweating of the armpits and palmar surfaces of the hands is observed, as well as pronounced tremor of the fingers of outstretched hands and fibrillary contractions of the trunk muscles. Dermographism
is rapid, red, persistent, and diffuse. There is marked lability of the pulse. At the medical flight commission he was deemed unfit for flight duty.
Let us now examine the second form of neurosis – hysterical neurosis, or hysteria (Gr. hystera –
uterus). A.M. Svyadoshch (1982), following S. Freud, understands hysteria as an illness caused by the action of a psychic trauma, in the pathogenesis of which the mechanism of the «conditional pleasantness, desirability» of the morbid symptom plays a role. In other words, hysteria is a
neurosis in which the symptoms observed in a person (from behavioral peculiarities to
bodily ailments) are caused by the patient themselves – and this despite the patient's enormous desire to be rid of them, and all because the formation of the symptoms occurs during the period of affect and the accompanying amnesia (occurring during the period when consciousness is absent), while the struggle
against these symptoms takes place already in a state of consciousness, which was absent during the affect and knew nothing about how the symptoms had formed. Thus, in the first
place, the patient does not know why the symptomatology they have has arisen. In this
connection it must be noted that any neurosis exists only for as long as the
amnesia has not been overcome and the thoughts belonging to the state of affect have not been revived. A neurosis is an unconscious illness!
I.P. Pavlov (1933, 1951) decided to apply the doctrine of conditioned reflexes to explain hysteria. Usually the cerebral hemispheres, as the highest organ relating the organism to the surrounding environment, keep the subsequent divisions of the brain, with their instinctive,
reflex activity, under their constant influence. According to
I.P. Pavlov's reasoning, with the elimination and weakening of the activity of the cerebral hemispheres, a more or less chaotic activity of the subcortex, lacking due measure and coordination
with the conditions of the given situation, must be causally linked. Thus, the alert, active
state of the cerebral hemispheres, consisting in the continuous analysis and synthesis of external
stimuli, negatively induces the subcortex (negative induction – a phenomenon associated with the occurrence of a focus of excitation that causes inhibition of other nerve
centers) – it restrains its activity, releasing selectively only that part of its work
that is required by the conditions of place and time. Conversely, an inhibited, restrained state
of the hemispheres releases, or positively induces, the subcortex, that is, strengthens its
overall activity. Consequently, there is a fully sufficient physiological basis for
various affective outbursts and convulsive attacks to occur in hysterics during an acute and sharp restraint of the cortex under the influence of stimuli beyond its
capacity (and there are quite a few such stimuli given its weakness). Besides the fact that a chronic weakness of the cortex of various kinds is a basis
for the appearance of the described emergency and extreme states of the organism, it also inevitably
conditions the constant, continuous, particular state of hysterics – emotivity.
In hysterics, «affective acting» predominates: a separate focus of the cerebral hemispheres, connected with a tendency that has taken hold of the hysteric, becomes extraordinarily charged under the influence of emotions (owing to
irradiation, or spreading, from the subcortex). And, given the weakness of the cortex, this is enough for it to cause a strong, widespread negative induction, excluding control and the influence of the other parts of the hemispheres. And in them, in these parts, are –
the representation of other tendencies, traces of past stimuli, experiences, accumulated experience. To this is added another mechanism: strong excitation, connected with
emotions, raises the excitability of the cortex, and this quickly drives the stimulation to the limit and beyond
the limit of its working capacity. Consequently, transmarginal inhibition (inhibition arising in nerve cells in response to their supermaximal stimulation) is added to the negative induction. Thus, the hysterical subject lives to a greater or
lesser degree not a rational but an emotional life, governed not by cortical activity but by subcortical activity. A hysteric can, and indeed should, be pictured, even under
ordinary conditions of life, as being chronically hypnotized to a certain degree, since,
given the weakness of their cortex, even ordinary stimuli are supermaximal and
are accompanied by widespread transmarginal inhibition (Pavlov I.P., 1933, 1951).
Thus, against the general background of weakness of the cerebral hemispheres, hysterics constantly display, in various combinations, three particular physiological phenomena: an easy susceptibility to a hypnotic state of varying degrees, owing to the fact that even
ordinary life stimuli are supermaximal and are accompanied by transmarginal, widespread inhibition (the paradoxical phase); an extraordinary fixation and
concentration of nervous processes at individual points of the cortex owing to the predominance of the subcortex; and, finally, an excessive strength and extent of negative induction
(Pavlov I.P., 1933, 1951).

It should be noted that the above understanding of hysteria by I.P. Pavlov is valid for extremely pronounced hysteroid types, in whom the threshold for the occurrence of emotions is extremely
low. Besides the fact that the thresholds for the occurrence of emotions will differ among different hysteroid individuals, other personality traits characterizing the hysteroid group will also differ in degree of representation (see below). The personality traits of the hysteroid person combine
with one another and with other traits in the most diverse combinations, ultimately producing the full
spectrum of behavioral reactions of hysteroid personalities: for example, a hysteroid mindset,
implying covert manipulation of others, may combine with low or high intelligence, producing in the first case primitive (visible to the naked eye) forms of manipulation, whereas in the second case the manipulations will be quite sophisticated and subtle,
so that it may take more than one year to discern the hysteroid's true train of thought.
I.P. Pavlov was not the only author to link the occurrence of hysteria with a
specific state of the patients' psyche. Already at the end of the 19th century, the founder of psychoanalysis, J. Breuer, put forward the idea that hysterical symptoms arise in a special state, and the excitations that occur during this state become pathogenic
and carry over into the patient's normal state – consciousness, according to S. Freud. It was precisely the study of hysterical symptoms and the diverse states of patients' psyches succeeding one another
that allowed S. Freud to substantiate the existence, within the sphere of human mental activity, of consciousness and the unconscious, which will be discussed separately.
Thanks to prolonged clinical observation of patients with hysteria, it has been found that a given hysterical symptom is desirable, pleasant, for the patient,
giving certain everyday advantages – either a way out of a difficult situation for them, or
an escape from a reality that has become unbearable. Hence arose the notion of «flight into illness», of a «will to illness» as a characteristic feature of hysteria. This feature of hysterical symptoms manifested itself clearly during the First World War. It became evident that
at the root of hysterical fits, paralyses, deaf-muteness, and similar disorders in
soldiers lay a fear of returning to the front, in connection with which Kraepelin, in his textbook of psychiatry, designated these reactions as «states of protest against returning
to the front» (Svyadoshch A.M., 1971, 1982).
This example allows us to understand very well what such components of the psyche as consciousness and the unconscious actually are, and that it is precisely in the disruption of the dialogue between
these two groupings that the cause of the occurrence of neuroses lies. The information contained in the unconscious is represented by needs important to the person, in particular, the needs to be alive and healthy. In a person's consciousness lies other information – information about norms of behavior, morality, and ethics (and this information too is
represented by needs). In particular, the consciousness of soldiers who took part in combat operations contains the information that they are patriots and, as befits patriots, are ready
to fight for the good of the fatherland. After what was seen at the front line (the cries and suffering of the wounded,
cases of disablement, bloodied and disfigured corpses), the organism (namely the unconscious) «cries out» that it does not wish to return to this horror. But to allow oneself to become aware of this thought, to become aware of this thought, would mean admitting oneself to be a traitor,
a turncoat, a coward. Thus a conflict monstrous in its force is born – a conflict presupposing the coexistence of tendencies opposite in their direction (the organism does not wish to return to the front, just as it does not wish to become aware of this thought, admitting
itself to be worthless). The thought connected with the unwillingness to return to the front, owing to its inconsistency with the notions contained in consciousness, is never admitted into the sphere of consciousness,
and is repressed from it (repressed because, on rising from the unconscious into the more
conscious layers of the psyche, it causes acute, painful sensations, and in order not to experience
them, it is sent back, and with such force that the person cannot recall for a long time the
thoughts that had come into their head – a process of «active» amnesia takes place). Thus,
the thought is repressed – confined to the unconscious, subjected to active amnesia, but the paradox is that it is not forgotten and at any moment can make itself known. One of the ways it does so is to return to consciousness, but in such a form that the repressed unconscious thought is not
recognized by consciousness (is not given in the same formulation in which it existed at
the moment when it was repressed by that same consciousness). Conditions for its return are created
when situations of a particular threat to life and health arise: in particular, a minor wound to a
limb actualizes the unconscious thought of the danger of being at the front line,
which increases the severity of the wound to the point of paralysis of the limb, which is why
the existing symptom does not correspond to the severity of the wound as such (the nerve fibers are not damaged
by the wound, yet the paralysis is present). This is how a symptom appears that represents a part
of a thought once repressed. It is precisely through the symptom that one gradually learns the information
that was once repressed with such force. In the case under consideration, the symptoms are
various kinds of organ lesions that make it possible to avoid military service. At the level of
consciousness there is no conflict; the simulation is unconscious in nature, and for the patient themselves
it is an incomprehensible phenomenon. The person who lay on the couch, paralyzed and unable to satisfy
elementary physiological needs, thought that this was forever, and that they would have given much to be cured. Thus, hysteroid personalities are hostages of their own unrecognized, unconscious thoughts, whose existence allows them
to escape from one problem or another.

To eliminate hysterical paralyses, mutism, surdomutism, and blepharospasm in participants of the Great Patriotic War, the «ether mask» method of treatment was used
(Svyadoshch A.M., 1974), through which cure was achieved in almost 100% of cases.
The treatment technique consisted in the patient being told that at the root of their illness
lay inhibition (partial sleep) of a particular area of the brain, and that they would be
given a medicine that would remove this inhibition, in connection with which the disturbed function would be
fully restored. The patient is firmly fixed in a horizontal position. In
hysterical paralyses the paralyzed part of the body is left free in the process. It is important
that the patient, when fixed, feel that they cannot move. For this it is best to firmly fix the patient with several sheets and, moreover, to have one physically healthy person hold the wrist of one of the patient's arms with both hands, a second
– the wrist of the other arm, a third – to fix the head, a fourth – to hold the legs above the
knee. The patient's face is coated with petroleum jelly. Dentures are removed. An ordinary
anesthesia mask of sufficient size is taken, so as to cover the nose and mouth during any movements
of the jaws (it can easily be made from resilient wire; the Esmarch mask is usually
too small). It is lined with a thicker layer of cotton wool and gauze than usual, and 40–
80 ml of ether for anesthesia is poured into it, so that all the layers of cotton wool and gauze in the mask are thoroughly soaked
with ether. The mask is shaken to let excess ether drip off, and it is suddenly applied firmly to the patient's face for a period ranging from several tens of seconds to a minute and a half.
In response to the enormous concentration of ether vapors, the patient holds their breath. They do not
breathe for 5–20 seconds, after which a strong fear arises and the very first mild manifestations of hypoxemia (Gr. hypo – under + Lat. ox[ygenium] oxygen + Gr. haima –
blood) begin to appear – a decrease in the content and partial pressure of oxygen in the blood. The patient tries to throw off the mask, to break free, but breaking free is impossible; they are held firmly,
the mask pressed tightly. After some time, powerful psychomotor agitation begins, and at its height the hysterical symptom is removed. Thus, if the patient had a hysterical paralysis, they begin to violently kick their paralyzed legs; if there was hysterical mutism (muteness), a loud cry is heard – the mask is immediately removed. The patient is congratulated on their recovery, but is still held down. They are invited to
make sure that the function has been fully restored. Often, for the first 1–2 minutes, the patient
is confused and shows an incomplete elimination of the hysterical symptom. Thus, despite the doctor's energetic prompting, they only weakly move the legs that had previously been paralyzed. Then they are told: «Well then, there isn't enough strength yet, the strength in the legs is insufficient,
please» – someone present is invited: «Hold the patient's legs firmly, see for yourself what tremendous strength is in them», and immediately, taking the mask in hand, it is applied to the
patient's face. 2–4 seconds pass and the patient, with furious strength, kicks away the person who was holding their legs. The patient is then told: «Well, are you now convinced that the strength in your
legs has been fully restored» (Svyadoshch A.M., 1974).
Military operations almost always create conditions for the clash of needs
contained in consciousness and the unconscious. The dialogue between consciousness and the unconscious
can be demonstrated using the example of the thoughts of the Hero of the Soviet Union R.E. Aronova (1983)
– a pilot of the women's regiment of night bombers: «It happened that a tempting demon whispered
in my ear: “You see, there, ahead, an aircraft is going down in anti-aircraft fire. In a few minutes
the same will happen to you. Why are you climbing toward certain death?”. How could one not rejoice afterward that in such minutes the voice of conscience and duty proved stronger than this whisper!».
Just as a person who has suffered a severe psychic trauma becomes inadequate for some time, hysteroid personalities become almost as inadequate, but with much weaker psychotraumas. Thus, whereas in a person not prone to
hysteria a symptom with secondary gain can arise only with extremely severe
psychotraumas, in hysteroids it arises quite often – owing to a significantly lower threshold for the occurrence of emotions and the presence of a hysteroid mindset, involving an attempt to achieve what is desired by deceptive means. In other words, an ordinary person differs from a hysteroid person, in particular, in quantitative characteristics – the threshold for the occurrence of emotions, and consequently – the threshold for the occurrence of inadequacy (the quantitative difference becomes so great that it already produces a new quality). Because
emotional reactions arise more easily in hysteroids, they pass more quickly into a state of
affect, accompanied by amnesia; their psyche is characterized by considerable diffuseness – the thoughts connected with each affect that has occurred are isolated from one another,
which is why they are so changeable in their actions – presenting themselves as whatever is
most advantageous to be at a given moment.
The time has come to list the personality traits that will predispose a person to the appearance of hysteria following a psychotrauma:
1) a low threshold for the occurrence of emotions, giving rise to heightened suggestibility, self-suggestibility, impressionability, and emotivity (the ability to quickly infect those around one with emotions, as well as to be just as quickly infected by them oneself), as well as a more rapid transition into an affective state, during which consciousness naturally narrows, which is accompanied by a decrease (up to complete loss) of critical judgment and the launching of the program of hysteroid intellect, operating by the mechanism of
secondary gain (see point 3);
2) egocentrism – a thirst for heightened attention to one's own person, in connection with which deceitfulness and fantasizing are well developed – presenting themselves as whatever it is advantageous to be at a given moment; theatricality of experience also serves this same egocentrism (a storm of feelings on the outward plane in the absence of deep experiences
on the inward plane), a tendency toward posturing, a striving to rise above others,
humiliating them, mocking them, noting their blunders (hysteroids are the main
suppliers of tyrannical bosses, for whom power and money are needed so as not to feel inferior); egocentrism finds its expression in a jealous attitude toward the successes of others – hysteroids are offended when someone else is praised, rather than
them (hysteroids are the main suppliers of envy); in this connection hysteroids hasten to give
an interpretation of those actions of others that look positive or
successful – an interpretation in which arguments will be provided (for many –
quite skillful ones, in which their deliberately devaluing
character will be hard to detect) in favor of the idea that the said positive and successful actions are not
really so good after all (for example, it may be pointed out that although successful actions were indeed carried out by others, the motivation underlying this success is not at all
attractive or even deserves condemnation – hysteroids, after all, cannot allow
someone to be better than them!); the hysteroids' centering on their own person hinders
their capacity for reflection – they do not identify themselves with another person (do not transfer their «I»
into another), and therefore also cannot fully understand what another person feels;
3) a hysteroid mindset, presupposing the presence of algorithms for processing and
presenting information that allow covert manipulation of others through the existence of two plans of action (an internal one – for oneself only, and
an external one – for others only), necessarily linked to one another and aimed at obtaining the desired result from those around them, without voicing the essence of what is desired aloud (the actions of hysteroids are directed toward obtaining secondary gain from
their realization). In other words: on the internal plane there exists one piece of information
(connected with the true goal), while on the external plane different information is presented, which must ultimately act on those around them in such a way that they, having no idea of the hysteroids' true goal, will bring about that goal. The hysteroid
mindset, superimposed on the ease with which affect arises and the amnesia occurring during
it, gives rise to symptoms operating by the mechanism of secondary gain, which are
incomprehensible to the patient;
4) an absence of sensitivity to the state of others, which can be tested by directing a
sincere smile at the hysteroid (a smile that must not be connected with their state,
not connected with the fact that you are directing it in order to express your positive attitude toward them; the smile should reflect exclusively your own state): hysteroids are so centered on themselves that they do not respond with a change in their emotional state (their view of the smile does not change, there is no response); the same can
be noticed in the hysteroid's facial expressions: a hysteroid's facial expressions often do not correspond to
what can be seen in their eyes (facial characteristics do not correspond to the gaze).
The hysteroid mindset, like the psychasthenic one (discussed a little later), is formed over the course of life by the immediate environment – first and foremost by parents, who
demonstrate various manipulations without being aware of their existence (without recognizing them), nor
suspecting that a child's psyche is extremely receptive to the information given off by those around them and is formed precisely by means of this information. In this connection we cannot
fail to give a concrete example illustrating exactly how
hysteroid character traits are formed. A girl of 4 years old, walking together with her mother, who was holding her by the hand, suddenly began to be capricious and said that her legs hurt and she could not
walk any further. The girl's mother instantly understood that this was merely manipulation via the mechanism of secondary gain – a consequence of recent close contact with her grandmother, who possesses an extensive repertoire of manipulations via the mechanism of secondary gain. The girl's mother
did not reinforce this behavior (did not reinforce the conditioned reflex), quickly and
skillfully working out what to say to the girl: «Well, you've had your joke, daughter, now let's go, we
need to hurry, we're expected at home». The mother's behavior in this case was highly correct: if she had reinforced her daughter's behavior, this would have risked the formation
of hysteroid traits.
Speaking of the genesis of hysteroid character traits, it should be remembered that the method described above
of the formation of hysteroid traits in the girl, through the mechanism of borrowing (adopting, imitating adults), is not the only one. There exist four other common methods.
The first of these is connected with the fact that parents make their love for the child dependent on
the behavior the child displays. This gives rise to a terrible dependence on the parents' mood, on their attitude, since the child wishes to receive love from the parents not at
certain moments in time, but constantly, and it is precisely for this reason that the child is forced to remain in
constant search of this love, of approval from the parents, and later – from
those around them as well. That is, hysteroid character traits, having formed as directed toward seeking approval from the parents, are subsequently transferred to all other people as well, from whom they expect this same approval and love.
The second method of forming hysteroid traits is connected with compensatory mechanisms: unable to satisfy one important need or another, a person tries
to achieve success in something else, which naturally is accompanied by positive emotions that extinguish the dissatisfaction connected with the blocking of those important needs
that the person cannot satisfy. In this case, egocentrism and the striving for success
will be connected with a striving to reduce the distress connected with certain blocked needs
of vital importance.
The third method of forming hysteroid traits is connected, as paradoxical as this may seem at first
glance, with a psychasthenic organization of the psyche (predisposing to obsessive-compulsive neurosis), with the hysteroid structure in this case being secondary in
relation to the psychasthenic one. The psychasthenic, driven by endless attempts to protect themselves from situations that are for them insoluble (owing to the existence of erroneous algorithms for processing information, which, as a rule, are set by the wild upbringing programs of parents), actively resists them, seeks new ways of counteracting them, and
when, by trying out new methods, they settle their gaze on the mechanism of secondary
gain, experimentation with which yields the desired result, they remain for a long time in the power of this mechanism. Thus, the psychasthenic organization of the psyche forces
the neurotic to make use of mechanisms of secondary gain. In other words, hysterical
symptoms serve as a means of combating psychasthenic symptoms!
The fourth method of forming hysteroid traits is set by raising the child in the
«family idol» style (see Chapter 7).
Psychosomatic disorders in hysteria can be divided into four groups: motor, sensory, vegetative-somatic, and mental (Svyadoshch A.M., 1971, 1982).
The motor disturbances in hysteria include:
· hysterical convulsive fits;
· hysterical paralyses (Gr. paralysis – relaxation) – loss of motor function with an absence of muscle strength;
· hysterical pareses (Gr. paresis – weakening) – weakening of motor function with
a decrease in muscle strength;
· hysterical hyperkineses (Gr. hyper – over + kinesis – movement) – physiologically
purposeless involuntary movements;
· hysterical contractures (Lat. contractura – narrowing, contraction) – limitation
of the normal range of motion in a joint;
· hysterical blepharospasm (Gr. blepharon – eyelid + spasma – tonic spasm) –
spasm of the eyelid portion of the orbicularis oculi muscle, leading to closure of the eyelids;
· hysterical aphonia (Gr. aphonia – muteness) – absence of a resonant voice with preserved whispered speech;
· hysterical mutism (Lat. mutus – mute) – muteness.
Among sensory disturbances, the most characteristic are hysterical blindness, deafness, and disturbances of sensitivity.
The vegetative-somatic manifestations of hysteria include disturbances of cardiac activity (owing to the wide familiarity of the symptomatology of these conditions they are most often imitated), of respiration, of the gastrointestinal tract, as well as vegetative and sexual disorders.
Mental disturbances in hysteria include:
· hysterical amnesias (Gr. a – negation + mneia, mneme – memory);
· Ganser syndrome (a twilight state characterized by the patient's notions of having developed dementia, which will allow them to be freed of responsibility or any obligations);
· pseudodementia (Gr. pseudos – falsehood + Lat. dementia – madness) – false dementia;
· puerilism (Lat. puerilis – childish) – absurd, childish behavior unbecoming of an adult;
· hypochondriacal manifestations of hysterical origin.
As B.D. Karvasarsky (1990) reports, out of the total number of neurosis patients (2,901 people) receiving inpatient treatment, the diagnosis of hysteria was made in 817 patients:
111 men and 706 (!) women. Only in 78 of the 817 patients were the so-called classical hysterical symptoms noted: hysterical fits (7), paralyses (5), pareses (15), hyperkineses (18), blepharospasm (13), astasia-abasia (Gr. a – negation + stasis – standing +
basis – step), or the inability to stand and walk (10), aphonia (6), amaurosis (Gr. amauros – dark), or blindness (3), mutism (1), surdomutism (Lat. surdus – deaf + mutus – mute), or
deaf-muteness (3).

Another example of a psychosomatic disorder of the hysterical type is
the occurrence of headache in one of the laboratory staff members we observed (Evstigneev D.A., 2010, a). Since the symptomatology is hysterical, the headache, despite
the fact that the patient fought against it and suffered from it, must necessarily carry some secondary gain. The secondary gain consisted in the following. The headache appeared upon approaching the binocular microscope at the patient's workstation, so that she could no longer
sit at her workstation and was forced to leave it. The patient's psyche did
everything to avoid working with the binocular microscope, since her supervisor had for many
years tormented her and given her all manner of pointless assignments – all for the purpose
of burdening her with useless work. At the same time, if assignments involving work with the

microscope were given by other laboratory staff members, the headache was absent
in the patient in that case.
Psychosomatic illnesses of the hysterical type can even lead to the patient's death. As an example, let us consider a situation that occurred in the spring of 2010. The head of one of the vocational-technical schools, having a prolonged and bitter conflict with one of the school's staff members, entered into collusion with one of a student's parents with the aim of compromising the said staff member. To achieve this goal the student's mother
wrote a statement disparaging the school staff member. This statement was used by the head to dismiss the staff member – she was offered a choice between two
alternatives: dismissal for cause or by her own choice. The trauma
of the dismissal for the staff member was unprecedented – both because of the many-year conflict
(the desire to win at all costs, to defend her interests), and because of the injustice of the situation that had arisen. This state tore her apart inwardly: she was furious and depressed at the same time. At the cost of an enormous effort of will she agreed to resign of her own accord. According to the labor code, an employee has the right to receive material assistance in the event of dismissal. The staff member decided to make use of this right and
wrote an application for a one-time material assistance payment, to which the head
responded with a refusal. When informed of the refusal, the staff member declared: «Well, he'll give something else then!» [meaning
– for her funeral]. And so it came to pass: two months later she died of a stroke. The secondary
gain in this case consisted in punishing the head by her own death (since she could not punish him by law) – so that everyone would know that it was he who had driven her to death, so that
everyone would condemn him.
Let us recall that thoughts occurring during the period of affect are realized, made into reality: thanks to the biochemical shock caused by the blocking of needs, a door opens into the unconscious, whose capabilities are far broader than those of consciousness (signals occurring during affect reach the innervated substrate (a given organ) via the nerve fibers most rapidly, and the formation of new conditioned reflexes is extraordinarily facilitated). This is precisely why a thought of death arising in a state of
consciousness is never realized, whereas this same thought in an affective (unconscious)
state will be realized. In connection with the situation described, clarifications should be made
to the definition of suicide (Lat. sui – self + caedere – to kill). Suicide is customarily understood as
the conscious taking of one's own life. But this is not entirely so. The wish for death can be unconscious and is realized without externally manifesting actions, which is characteristic of classical suicide: hanging, use of medications, wrist-cutting, use of
weapons. In such an (unconscious) form of suicide, few suspect that the person's death was connected with their own wish (everything is attributed to one illness or another).
Obsessive-compulsive neurosis (obsessive-compulsive, or anxiety-phobic) arises under the action of a psychic trauma and includes various
kinds of obsessions: obsessive representations (images), obsessive thoughts, obsessive fears – phobias (Gr. phobos – fear) – and obsessive actions – compulsions (Lat. impulsus – push,
impulse). Psychic traumas of great force can directly cause obsessive phenomena: owing to the release of an enormous quantity of biologically active substances
during the affect (biochemical shock), a very durable pathogenic conditioned reflex is formed.
As A.M. Svyadoshch (1971, 1982) points out, obsessive experiences can be caused by conditioned-reflex stimuli that were indifferent in the past and became
pathogenic as a result of coinciding in time with conditioned and unconditioned reflex
stimuli that caused a feeling of fear. Thus, for example, fear caused by cardiovascular disturbances, having coincided in time with being on a city square, may subsequently be evoked by it as a conditioned reflex (appearing on a square, and subsequently, as a variant, in any open space, will evoke a fear of cardiac insufficiency).
The main symptom of the illness is obsessive states that involuntarily intrude into consciousness, the groundlessness of which the patients understand, and against which they struggle, but
cannot overcome. Obsessive representations often bear the character of vivid obsessive
memories. These include certain visual images, melodies, individual words or phrases, from the images of which the patient cannot free themselves. Patients often
show a tendency to evoke in themselves images of a certain character, for example, of one person
or another, of exposed genitals, or of filth. Obsessive images very often
arise in the form of extraordinarily vivid obsessive memories, reflecting the
psychotraumatizing influence that gave rise to them.
Obsessive thoughts may be expressed in the form of obsessive fears, memories, blasphemous thoughts, and idle philosophizing. In obsessive doubts, there usually arises an agonizing uncertainty about the correctness or completeness of a given action, with a
tendency to check its performance again and again. A.M. Svyadoshch (1971, 1978, 1982) gives a very interesting example of obsessive doubt in the form of a patient's fears about whether the
front door of his house was locked. This kind of doubt first arose in him when, one morning, descending the stairs, he was heading to work. He went back – the door turned out to be
locked. The obsessive doubt did not leave him and grew ever stronger. After the young man left home, his wife would lock the door with every conceivable bolt, latch, and lock.
Despite this, many times a day he was forced to leave work and return home
to check that the door had not been left open. He understood the groundlessness of his anxiety, fought against it, but could not overcome it. The state lasted 3 months. By character the
patient was pedantic, meticulous, sociable, and had difficulty switching from one type of
activity to another. In the past he had shown no obsessive states of any kind. The patient could not connect his condition with any particular cause; it seemed to him to have arisen without any external cause. In the course of a psychotherapeutic conversation it emerged that
he was married for the second time and had loved his first wife. But after two years of living together he became very
quick-tempered and irritable. His relations with his wife began to deteriorate. One day, coming
home, he found the door to the apartment open and, on the table, a note from his wife informing him that she had left him. He suffered greatly over this, asked her to return, but she
was adamant. After 1.5 years he remarried. The marriage proved successful. They lived together about two years, when suddenly the phenomena of obsession described above appeared.
His wife noted that in recent weeks the patient had become very quick-tempered and irritable. Relations between the spouses deteriorated. The patient himself did not notice this. After psychotherapy was carried out, aimed at clarifying the connection between the once-unlocked door left by his first wife and the fear of losing his second wife, not a trace of the obsessive doubt remained.
In the case described, at the time his first wife left him, a durable conditioned connection was formed, including such components as the cooling of relations, accompanied by the patient's irritability (first component), the wife's departure (second component), and the open door remaining after the wife's departure (third component). These components of the conditioned reflex, owing to the release of an enormous quantity of biologically active substances during the affect, fused together, and the resulting conditioned reflex moved into the sphere of the unconscious. But if a conditioned reflex is in the unconscious and the person does not know of its existence, this by no means means it does not exist and that
it cannot make itself known at any moment. The revival of the described conditioned reflex from the
unconscious became possible thanks to the appearance of one of the components of the conditioned
connection – the quick temper and irritability of the patient in his dealings with his second wife. It was precisely this circumstance that activated the entire conditioned-reflex connection.
An interesting case of obsessive fear occurred with one of the crew members after an aviation incident, the main culprit of which was an unprofessional commander. After
the aviation incident, the patient experienced an overwhelming feeling of fear when riding in a car, if he was in the role not of driver but of passenger (Evstigneev D.A., Kopysov V.Kh., 2007).
The phobia arose via the mechanism of the conditioned reflex: the unprofessional commander piloting
the aircraft is associated with the driver of a car (also controlling movement and responsible for
safety), and in this connection the patient fears that a similar situation will repeat itself. The patient's
psyche protects itself from the probability of the occurrence of emergency situations by means of
fearing all situations in which someone else, rather than he, is responsible for traffic safety. In addition, the mechanism of generalization of the pathogenic conditioned connection, which occurred in this case and manifested itself in the spread of the pathogenic conditioned connection to
other similar situations, is connected not only with the fact that a new conditioned reflex arose via the mechanism of association, but also with the fact that the patient's psyche cannot in any way allow itself to show fear in the aircraft cockpit, since showing fear closes off the possibility of working in his profession – it blocks a need so important for any professional. It is well known
that aviation specialists, owing to the fact that they regularly undergo medical examinations as part of
medical flight expertise, are extremely concerned that they not be suspended from work due
to the discovery of some illness or another. Unfortunately, it must be stated as a
fact that some medical workers create fertile ground for the occurrence of iatrogenies, some examples of which we have already examined within the framework of psychosomatic disorders in neurasthenia. This is done by medical personnel both unconsciously
(owing to a lack of elementary sensitivity, as well as a lack of knowledge about iatrogenies and their consequences), and quite consciously (pursuing one gain or another).
As V.N. Myasishchev (1955, 1960) points out, the growth of a pathological conditioned-reflex connection (the process of generalization) is characteristic not only of obsessive-compulsive
neurosis, but also of hysteria.
Another example of obsession can be seen in the behavior of a teacher who, having previously been in an unfavorable work environment where sudden changes of schedule were practiced, at his new job would each time repeatedly check the schedule's correctness, doubting whether he himself had correctly remembered the order of classes (Evstigneev D.A., Karnaukhov
V.A., 2005).
A.I. Seversky (1965) gives the following example of obsessive phenomena. A pilot born in 1911, with a total flight time of 10,000 hours, was admitted to hospital on March 3, 1958. He complained of heightened irritability, rapid fatigability, restless sleep, headaches, unpleasant sensations in the region of the heart, shortness of breath, obsessive thoughts, and a fear of death. In 1943, during one of the enemy's bombing raids, he was severely frightened and became irritable from that time on. Headaches appeared, sleep was disturbed (4–5 hours per day), and
traits of an anxious-suspicious (psychasthenic) character also became more pronounced. A deterioration of his general condition
occurred in 1956, which had a negative effect on his flying activity. In 1957 shortness of breath appeared, along with pain in the region of the heart, and he began to be constantly troubled by various thoughts connected with heart disease, that «he would soon die». Examination showed: the patient's pulse
rhythmic, 72 beats/min, emotionally labile, irritable, with pronounced
tremor of the fingers of outstretched hands observed. According to his service record, he
does not participate in social activities, has no friends, and leads a withdrawn way of life. He reacts painfully to remarks from superiors. His state of health has a negative effect on his practical
activity; he has been suspended from flying. The medical flight commission deemed him unfit for flight duty.
It is important to emphasize that regarding the examples given above as some kind of serious mental pathology, viewing them as something exotic or unusual, would be
more than incorrect. Obsessions are characteristic of many people, and they are most often not inclined to
speak about it, and if they do speak of it, then either to close relatives or
to medical workers who inspire trust (sometimes regardless of the doctor's
specialization).
In obsessive fears, patients are agonizingly afraid that they will not be able to perform some
action or carry out some act when it is required, for example, to answer without blushing (ereuthophobia), to perform a sexual act, to urinate in the presence of others, to fall asleep, and so on. Obsessive fear can sometimes lead to a disturbance of the corresponding function and produce the picture of an expectation neurosis (Svyadoshch A.M., 1971, 1982).
Obsessive fears (phobias) are the most diverse and occur most often. They include:
· fear of death – thanatophobia (Gr. thanatos – death) from all manner of causes;
· fear of the possibility of committing suicide;
· fear before a sexual act – coitophobia (Lat. coitus – coitus, sexual act);
· fear of contracting syphilis – syphilophobia (Gr. syphilis – derived from the name
Syphilus – a person with syphilis), rabies, glanders, cancer – cancerophobia (Lat.
cancer – cancer), mental illnesses – lyssophobia;
· fear of contamination – mysophobia;
· fear of open spaces, streets, squares – agoraphobia (Gr. agora – square),
of enclosed spaces – claustrophobia (Lat. claustrum – confinement);
· fear for the condition of one's heart – cardiophobia (Gr. kardia – heart).
An important feature of phobias is that the fear in them is conditional (Lat.
condition – condition), that is, it appears only under certain conditions – in a given
situation or with the arising of certain representations, and does not arise apart from this.
The occurrence of obsessive-compulsive neurosis, like that of neurasthenia and hysteria, is brought about by psychotraumatizing conflict situations that give rise to the coexistence of contradictory tendencies. This also includes situations leading to a clash of the

sexual or other drive with notions of the inadmissibility of its satisfaction
(Svyadoshch A.M., 1971, 1982). For example, a feeling of hatred that has arisen toward a close person,
a wish for their death, coming into conflict with notions of the inadmissibility of such wishes, can lead to the occurrence of an obsessive fear of sharp objects and a complex
protective ritual.
Let us give an example from our own practice. In the spring of 2001 a young man, returning home around midnight
after meeting with an acquaintance, was brutally beaten by three teenagers.
For the whole of that night he could not fall asleep – both because of the psychotrauma he had suffered, and because of
the concussion he had sustained (a general cerebral syndrome was observed), and because
an important business trip to another city had been arranged for the following day, which could not
be cancelled. Throughout the entire trip (on the bus, at the bus station) many people aroused
his suspicion, and criminal intentions were attributed to them (Evstigneev D.A., Karnaukhov V.A.,
2005). After what had happened, for a long time he could not pass the place where the crime had occurred without fear (especially in the evening hours). In addition, at the time of the
beating the young man had in his hands a valuable book, given to him by his acquaintance a few minutes before the incident. This book continued for a long time to evoke unpleasant sensations in him – he tried not to read it without
urgent need and not to take it out of the house («what if something happens»). Over time these fears passed without any outside intervention or treatment. As can be seen from the description, the symptomatology observed in the young man included quite diverse elements of obsession.
Among the personality traits predisposing to the occurrence of obsessive-compulsive neurosis are:
1) a psychasthenic mindset, presupposing the presence of erroneous algorithms for processing and evaluating information (formed under the pressure of the neurotic's immediate environment), owing to which incorrect conclusions are drawn from the information analyzed: intellectual abilities are by their nature conditioned-reflex formations and are set by the understanding of cause-and-effect relationships between units of one piece of information or another, and if the cause-and-effect relationships forming in a child's psyche do not correspond to the real connections between
objects, a distorted perception of reality is formed;
2) insecurity, a tendency toward doubt, suspiciousness;
3) weakness and inertness of nervous processes;
4) a striving toward total planning of one's own actions (running through the most probable variants of the development of events and constructing algorithms of behavior in
them) with the aim of not getting into unpleasant situations (the psychasthenic, for

various reasons unable to realistically assess the surrounding situation, forms a complex, multi-level informational labyrinth, in whose captivity their life proceeds).
Obsessive-compulsive neurosis can arise in individuals with various typological
features. According to A.M. Svyadoshch (1971, 1982), it is frequently encountered in individuals with weakness or insufficient mobility of nervous processes. Various factors that asthenize
the nervous system (injuries, infections, intoxications), by disturbing the mobility of nervous processes, thereby contribute to the occurrence of obsessive-compulsive neurosis.
According to E.K. Yakovleva (1958), obsessive-compulsive neurosis is predisposed to by
great impressionability and excessive sensitivity combined with a tendency toward delayed external discharge, contributing to fixation on complex life circumstances that are emotionally distressing for the patients. According to V.N. Myasishchev (1955), impressionability represents a combination of sufficiently intense excitability with a tendency toward inhibition of outward discharge: the result is an exaggerated inhibition of the external reaction, intensifying the tension and consolidation of the excitatory process, which leads to the formation of stagnant morbid points. E.K. Yakovleva (1958) emphasizes that the study of obsessions, which are in their essence conditioned-reflex formations, requires a thorough acquaintance with the patient's entire life history: «the study of the pathogenesis of obsessive states is possible only from the standpoint of a genetic study of the patient's personality. In each
particular case of illness it is necessary to clarify the features of the situation, the pathogenicity of which is often determined not so much by the external influence itself,
as by its individual significance for the patient, conditioned by their entire past
experience».
E.K. Yakovleva (1958) not only studied the history of the illness's development and the patient's life history, but also used a wide range of physiological and psychological techniques:
· electroencephalography, conducted at rest and under conditions of various kinds of stimulation;
· an associative experiment with simultaneous recording of the galvanic skin response;
· the proofreading method (patients were asked, in accordance with strictly stipulated
instructions, which changed during the experiment, to cross out certain
letters);
· study of conditioned motor reflexes on verbal reinforcement.
As an illustration of exactly how the author analyzed the causes of obsessions using the methods mentioned, let us examine the case of a fear of death from

heart disease in a 29-year-old young man. The patient was tormented by obsessive thoughts that
his heart might suddenly stop (Yakovleva E.K., 1956, 1958). Because of this he constantly listened to his own sensations, checked his pulse, and constantly sought treatment and examinations. During the war he served in the navy; there were no concussions or wounds. He experienced many difficulties, but there were no neurotic reactions. After demobilization he continued to work as a financial officer, and at the same time began studying at a finance institute. Married,
family conditions quite favorable. By character conscientious, somewhat indecisive, but demanding of himself, disciplined. His colleagues at work assessed him
as a modest, knowledgeable, conscientious worker, but at the same time very soft. He was marked by a sufficient strength of nervous processes and their balance, with some traits
of inertness. 1.5 months before falling ill he was sent on a business trip to conduct a
very important audit. He set off on the trip reluctantly, fearing that he would not
cope with the work due to insufficient experience and knowledge. The working conditions proved
difficult. First, the audit work was complex, causing a great deal of difficulty, requiring urgent decisions (including the removal of a number of employees of the organization
being audited). Second, the air temperature reached 30–40°C. Owing to great overexertion the patient fainted, and this served as the trigger for the development of the illness.
On admission to the clinic the heart showed no organic changes, blood pressure was 110/80–120/80, the pulse was rhythmic, of good filling, 60–70 beats per minute. Marked sweating, trembling of the eyelids and fingers were observed. No local organic neurological symptoms were found. Consciousness clear, anxious, fixated on feelings of fear. Examination of the brain's bioelectrical activity revealed: a significant predominance of
fast potentials, the presence of theta rhythm, an absence of reactions to stimuli addressed
to the first signaling system, and to verbal stimuli (addressed to the second signaling
system), even ones emotionally