Lecture
Premorbid, premorbid state, pre-illness (from Latin morbus — disease) — a state preceding and contributing to the development of a disease (on the border between health and illness), when the protective and adaptive forces of the organism are overstrained or sharply weakened (for example, exhaustion and hypothermia of the body before the development of pneumonia). It may either progress into a manifest form of the disease or, after some time, end with normalization of the body's functions .
The factors responsible for the premorbid state may be either congenital or acquired. These same factors subsequently influence the course of the disease should it occur .
In psychiatry, the premorbid state is distinguished from pre-illness (a narrower concept), whereas other sources consider these terms synonymous . Symptoms of the premorbid state are often observed in patients with cyclothymic depression (changes in personal affectivity).
Great significance in the formation of childhood neuroses in psychoanalytic studies was attributed to the emotional bond between mother and child in the early stages of life. Bowlby (1951) added a third instinct to Freud's foundational instincts (libido and aggression) - attachment. He defined attachment as "a behavioral complex serving the purposes of bonding to the mother figure or other trusted adults in the child's environment." Bowlby concluded that maternal love in infancy and childhood is as important for mental health as vitamins and proteins are for physical health. However, many authors consider it mistaken to speak of a long-term effect of relatively brief exposure to psychotraumatic factors (including the level of attachment between mother and child) in infancy. There is a viewpoint that the younger the child, the more significant the influence of biological factors in the genesis of neuropsychiatric disorders (the sensorimotor level of response in children under 3 years of age). A.I. Zakharov made substantial additions to the analysis of the mechanisms of intrapersonal conflicts as applied to childhood. He described the neurasthenic conflict as a contradiction between parental demands and children's capabilities, the hysterical conflict as a contradiction between the need for emotional recognition and the possibility of its satisfaction by the parents, and in anxiety neurosis he noted a weakness in the capacity for self-protection and a pronounced instinct of self-preservation, while in the obsessive-phobic type he identified a contradiction between duty and feeling, with the central fear being that of change: "not being oneself." The author considered fear one of the leading clinical manifestations of childhood neuroses and proposed differentiating the mechanisms of its emergence depending on the child's age. In early preschool age, this is the fear of "being no one," based on the pronounced need at this age for emotional recognition (fear of emotional isolation, loneliness). In late preschool age - the fear of "being nothing," i.e., of not being, of not existing (fear of death). In early school age - the fear of "being not right," i.e., of not conforming to generally accepted norms and the expectations of others, more often accompanied by stiffness or excessive motor activity. And finally, in adolescence - the fear of "not being oneself," i.e., of being painfully changed, such as the fear of infection, insanity, or changes in physical appearance, etc.
Both domestic and foreign authors emphasize the importance of conscious-psychological factors and the premorbid characteristics of the child (congenital and acquired) in the formation of neurotic disorders. In particular, among the social-psychological factors contributing to the development of neuroses in children, the following deserve attention: chronic disharmonious functioning of the family, improper upbringing (anxious-suspicious, family idol, overprotection, contradictory upbringing, emotional deprivation of the child), excessive parental ambitions, everyday drunkenness, symbiotic attachment to one of the parents, quarrels with siblings, one-sided maternal dominance, school conflict. In adolescents, there is also the conflict of emancipation, conflicts arising from grouping reactions with peers, and radical upheaval of life. Among the premorbid characteristics influencing the genesis of neurosis, most authors noted the significance of factors such as personality traits, character (its psychasthenic, sensitive, astheno-neurotic, hysterical accentuations), temperament, intelligence, the physical state of the organism and constitution, the system of personal relationships and self-esteem, and the hierarchy of values.
7 basic instincts (self-preservation, procreation, altruistic exploration, dominance, freedom, preservation of dignity), which affect the level of adaptability, i.e., the ability to adapt to changing living conditions.
According to A.N. Zakharov, children with neurotic disorders are characterized by: sensitivity, impressionability, emotional lability, spontaneity, naivety, a pronounced sense of "self," hyperconsciousness; impressiveness (internal type of emotional processing), inconsistency of development due to a mismatch between character and temperament; anxiety, suspiciousness.
Patients with neurasthenia were characterized by heightened responsibility and conscientiousness, and high sensitivity to criticism. They were distinguished by good working capacity and activity in the presence of high intensity and duration of emotions and a fairly pronounced level of anxiety. In addition, low indices of compliance were observed alongside a medium degree of such traits as decisiveness, frustration tolerance, and adaptability. The combination of these characterological features, together with a striving for excessive effort in major activities that exceeded their real capabilities, most often contributed to the development of a neurasthenic-type psychological conflict.
In the premorbid period, patients with hysteria were distinguished by inflated self-esteem, selfishness and egocentrism, relatively high activity, a low degree of decisiveness and purposefulness, and a considerable degree of suggestibility and self-suggestibility. They frequently showed a combination of pronounced sensitivity and anxiety with lability and impulsivity, and their need for contact and striving for leadership were combined with a medium degree of compliance and responsibility. Alongside certain traits of the psychasthenic type noted above, a number of patients in this group showed, in the premorbid period, manifestations of a certain schizoid quality, expressed as high sensitivity combined with emotional coldness and difficulty in making contact.
In the premorbid period of patients with obsessive-compulsive neurosis, what stood out above all was a low degree of activity, self-confidence, decisiveness, and purposefulness combined with pronounced anxiety and apprehensiveness — that is, traits characteristic of the psychasthenic type. For some patients, a characteristic combination was heightened impressionability and excessive sensitivity together with a tendency to suppress outward expression of emotional reactions, and, in connection with this, a constant fixation on complex life circumstances that were significant to them, which was also fostered by their tendency toward self-suggestion. Given the high degree of responsibility and conscientiousness, high sensitivity to criticism, and a medium degree of ability to avoid conflict, the formation of an obsessive-phobic-type psychological conflict becomes more likely, most often in the sphere of the patient's moral and ethical attitudes.
One of the principal etiological factors of a social nature is improper upbringing within the family. Patients with hysterical neurosis were characteristically raised in an atmosphere of coddling, indulgent upbringing marked by unprincipled compliance toward the child, and an unwarranted emphasis on existing and nonexistent merits and positive qualities, which leads to an inadequately inflated level of aspiration. The character traits typical of hysteria may, on the other hand, form under conditions of indifferent treatment of a "rejecting" type, as well as in an atmosphere of harshly despotic, suppressive upbringing.
The formation of personality traits predisposing to the development of obsessive-compulsive neurosis is fostered by improper upbringing in an atmosphere of excessive guardianship, overprotection, intimidation, suppression of independence, and deprivation of one's own initiative. Of particular importance is the presentation of contradictory demands.
The premorbid personality features of patients with neurasthenia are formed above all under conditions that stimulate an unhealthy striving for success without a realistic assessment of the individual's strength and capabilities.
Identifying the psychotraumatic factor involves a number of difficulties. In neurasthenia, the predominant experiences are long-term, individually significant, and not always noticeable to others. In most people, prolonged physical strain and interpersonal conflicts do not lead to the onset of neurasthenia. Situations of intrapersonal conflict prove more pathogenic (conflict with one's own conscience, dissatisfaction with a situation combined with fear of change, a situation of choice in which each of the possible decisions leads to irreplaceable losses, etc.). Premorbid personality features are of great importance for the formation of neurasthenia: features of the nervous system (strength, balance); character accentuations; recently suffered illnesses (→ a weakened organism); features of self-reflection; subjective attitude toward the situation; features of experiencing the psychotraumatic event. Infantilism, extraversion, demonstrativeness, and emotional lability correlate with hysterical symptomatology; apprehensiveness, anxiety, caution, pedantry, and responsibility correlate with obsessive-compulsive neurosis. There is a certain specificity to premorbid features: in hysteria, the conflict consists in an extremely inflated level of aspiration combined with an underestimation of real conditions and possibilities; heightened self-esteem, activity, need for contact, striving for leadership, suggestibility and self-suggestibility; egocentricity, emotional coldness; a medium degree of decisiveness and purposefulness; a medium degree of compliance and responsibility. In obsessive-compulsive neurosis (and psychasthenia), the conflict lies in the contradiction between desires and a heightened sense of duty; a low degree of activity, self-confidence, decisiveness, and purposefulness is noted; heightened demandingness and apprehensiveness, sensitivity to criticism; a tendency to fixate on significant situations. In neurasthenia, the conflict lies in a mismatch between abilities and personal skills, and inflated demands on oneself; heightened working capacity and anxiety are noted; reduced compliance; medium decisiveness. Individuals who can easily shift responsibility for an unpleasant situation onto others, who are prone to aggression and indignation, and who strive at any cost to overcome obstacles that arise, rarely develop neurasthenia.
+The personality characteristics of patients with neurosis are largely determined by heredity. Approximately 20% of relatives of patients with phobias also suffer from this disorder. The likelihood of neurosis occurring differs across various age periods. "Crisis" periods are distinguished, during which the development of neurosis is especially likely - the pubertal period, the period of early maturity (25-35 years), and the period preceding menopause. The role of improper upbringing in early childhood (lack of attention from the mother) and the peculiarities of intra-family relationships in the emergence of neurosis are also noted. In families of alcoholics, even a young child is left to fend for themselves. Subsequently, the child is raised by the street. Such children grow up callous, selfish, deceitful, and self-centered, responding to remarks from relatives and close ones with hysterical reactions and even typical hysterical fits. Neuroticization is promoted by pathologizing parenting styles, an inconsistent parenting style, and cases where parents use differing approaches. In socially well-off families, improper upbringing can have a dual and opposite character. This includes parental despotism, upbringing in the spirit of "the authority of kindness." Children are required to strictly carry out all instructions. There is constant talk of "must not" and "must," without explanation of why the prohibition is required. This provokes a protest reaction in the child, which is quickly suppressed by punishment. A style of upbringing opposite to despotism can also contribute to the emergence of neurosis. Such a child does not know the words "must not" and "must." He grows up pampered and coddled, all his whims are fulfilled immediately, and impermissible actions and misdeeds are forgiven. When such a child ends up in a children's group, it is not easy for him to find mutual understanding with his peers. He wants to command others and bend them to his will. A conflict begins, into which parents and teachers are drawn. The child develops a neurosis.
Comments