The first thing that many patients ask when they present with serious anxiety problems is “Am I going mad?” Very often, people with anxiety states feel that they are teetering on the edge and that loss of control is imminent. Indeed, many people become obsessed with the idea that they will lose control in front of their family, friends or strangers and behave in a bizarre, inappropriate or even violent or a dangerous way. These feelings of loss of control are triggered by high levels of arousal and consequent muscle tension. Thus, if one feels “keyed up” for no apparent reason, the brain is alert to the possibility of action. In turn there is a misinterpretation on the part of the sufferer, that something dreadful is about to happen. Other sufferers of anxiety (in all its shapes and forms) fear that their anxiety may progress to madness and they may end up being locked away in an institution. Indeed, some mental health professionals perpetrate the idea that serious mental illness, such as schizophrenia or manic depression can develop from an anxiety state.
This article is designed to set the matter straight.
Neurosis is a term which covers a whole array of mental health problems, ranging from anxiety and simple phobias to severe and long-standing obsessive/compulsive disorder. In between the term captures mild and moderate levels of depression, stress reactions of one sort or another and an array of conditions which are probably best seen as exaggerated forms of normal thinking, behaviour and feeling. Indeed, who amongst us has not had some sort of neurotic reaction, whether it be an anxiety attack, an obsessive thought, or a reaction to stressful life events? On the other hand, psychosis refers to very specific conditions and these are largely covered by two umbrella categories, i.e. schizophrenia and manic depressive disorder. Schizophrenia is probably best seen as an umbrella term to cover a variety of different conditions, but these are essentially characterized by a condition wherein the personality fragments and the sufferer is handicapped in a wide range of areas. Schizophrenia sometimes comes on acutely and then disappears. However, in the majority of cases it is a condition which has a waxing and waning course, often leading to a very impoverished life. Sufferers often have hallucinations and delusions, i.e. they hear voices and suffer false beliefs, which are impervious to any logical reasoning, in addition their thoughts show considerable disorder.
Sometimes there is a lack of coherent speech and generally motivation to lead a normal life is impaired and personality, behaviour and drive deteriorate over time. Schizophrenia is present in perhaps 1% of the population and is probably caused by a number of different biological factors. Increasingly, it is being seen as a neurological illness rather than a mental health problem caused by stresses and strains. Although, some people with schizophrenia suffer anxiety, it is impossible for people with anxiety disorders to develop schizophrenia as a result of their anxiety disorder. Anxiety sufferers should be reassured that they cannot develop schizophrenia as part of their anxiety state, no matter how bad the anxiety becomes. The symptoms of schizophrenia and the deteriorating course can be linked to changes in brain structure and functioning, which are entirely different to those associated with anxiety.
Manic depression is also a severe condition, often running a life long course where there are violent swings of mood. We all, of course, have “ups and downs” in the way we feel, but manic depressives swing from a very extreme form of elation and over-activity to the depths of depressive despair, with the condition becoming so bad that people are sometimes in a stupor, being unable to feed themselves or even get out of bed. The person may swing from one state to the other but, commonly, they may be deeply depressed with spells of normality in between, with only rare periods of elation. These periods of elation and over-activity are called “hypomania”. During this phase, the person often loses contact with reality and may hear voices. The depression experienced by sufferers of manic depression is of a much greater depth than that experienced by sufferers of anxiety and cannot be explained by external circumstances. People with anxiety states can feel profoundly depressed, but usually this depression is a direct result of feeling chronically anxious. Again it is impossible for anxiety depression to become manic depression.
On a more optimistic front, new treatments, mostly medication, are being involved for both schizophrenia and manic depressive illness although; it must be noted that cognitive behaviour therapy techniques are being developed for both conditions. New techniques in examining the brain with magnetic resonance imaging and other forms of scanning are helping neuro-scientists to understand the pathology of these conditions.
At the Institute of Psychiatry where I work, a great deal of research is being carried out in both schizophrenia and manic depression and, indeed, some of my own work is now directed towards helping the sufferers of schizophrenia. The more one sees of these conditions, the more one realises that they are very different from anxiety disorders.
Readers of this article should therefore know that the distinction between neurosis and psychosis is very clear and that you as an anxiety sufferer will not cross the boundary.
Neurosis Or Psychosis? – Some Further Thoughts
In 1997, I was asked to write an article about the difference between neurosis and psychosis and to address the fears that patients with anxiety states have that they are “going mad”. Subsequently, an article entitle Neurosis or Psychosis? was published in the newsletter in December 1997, January 1998, June 1999, August 2001 and August 2003. In this article, I argue very strongly that it was impossible for anxiety states to develop into schizophrenia or for anxiety to develop into manic depression. In this, I simply wished to reassure readers who had fears of going mad that this would not happen. Subsequently, I have had a letter from a lady who suffers psychosis, which has caused me to think more about this topic and perhaps offer some further clarification.
As the main point of the article was to reassure anxiety sufferers that they could not “go mad”, I did not consider other aspects of the relationship between neurosis and psychosis. Perhaps I should have mentioned that, as schizophrenia and manic depression are fairly common condition (about 1% of the population will suffer from schizophrenia during their lifetime, and probably 1% will suffer from manic depression during their lifetime) it is of course possible that some sufferers of schizophrenia and manic depression will also have very commonly occurring anxiety states, panic attacks and obsessive compulsive disorder. Therefore, these individuals are in need of assistance for both problems and I know, of course, that there are some members of No Panic who also suffer psychotic illnesses, such as schizophrenia and manic depression, but derive a great deal of benefit from their membership of No Panic in helping with their anxiety-related symptoms. The lady who wrote to me recently, made the point that, very often, drugs are the only intervention on offer for people with psychosis and it is clear to me that sufferers of schizophrenia and manic depression often need considerable psychological treatment. in addition. Indeed, the recent guidelines from the National Institute for Clinical Excellence (NICE) make it clear that sufferers of schizophrenia should be availed of cognitive behaviour therapy for their psychotic symptoms. There is now a great deal of evidence to show that these symptoms can be helped with CBT. In turn, therefore, it is very reasonable to suggest that CBT and other evidence-based approaches be used to help people with anxiety states who may also suffer from schizophrenia.
In the article, I also drew attention to the difficulties produced by schizophrenia and manic depression and, in particular, described impaired motivation. In my original newsletter article, I was of course talking in generalities and I do, of course, appreciate that some people with schizophrenia do retain good motivation to lead a normal life and often make valiant efforts to continue functioning, despite suffering a very debilitating illness.
In conclusion, therefore, I wanted now to add some afterthoughts and also to indicate that anxiety states are very commonplace and widespread and that they may accompany a range of other problems. I firmly believe that No Panic has a great deal to offer sufferers of anxiety states and related conditions and that, as an organisation, we should be inclusive, rather than exclusive. I recall discussing the nature of anxiety with Colin Hammond more than a decade ago and I remember us discussing the fact that anxiety states were very similar across, literally, millions of people in this country, but that each sufferer was a unique individual with their own particular expression of their problem. When I see patients as a treating specialist, I have to keep to the forefront of my mind that the person in front of me is a unique individual with a unique constellation of factors relating to background, upbringing, beliefs, culture and of the way that their problem manifests itself. Anxiety is a great leveller and I know, by my own experience, that sufferers of anxiety come from every walk of life and every background that you can think of. Perhaps in my earlier article, I did not emphasise enough the way that different people may manifest their particular problem, but, overall, I wish to stand by my basic assertions in that article and to reassure those who have such fears, that anxiety problems don’t make you go mad!
Professor Kevin Gournay is an Emeritus Professor at the Institute of Psychiatry. He has more than 35 years of experience and is the author of more than 130 articles and books. He is based in Cheshunt Hertfordshire.