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clothymic, and obsessive-compulsive personality types there are obvious similarities to major types of psychiatric illness Thus, among patients who develop paranoid schizophrenia, a considerable number will have had the attributes described under paranoid personality type Similarly, among patients who develop schizophrenia of another type, the history will frequently disclose a preexistent schizoid personality In fact, it may be dif cult to judge where the personality disorder left off and the schizophrenic illness began Similarly, it seems clear from several family studies that the cyclothymic personality is related to manic-depressive disease Obsessive-compulsive personality is related not only to obsessivecompulsive neurosis, as one might expect, but also to depressive disease The de ning features of the personality disorders fall short of meeting the diagnostic criteria for the neuroses 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, which may have interfered with diagnostic and therapeutic procedures during a medical illness Personality disorders, like personality itself, are pervasive, enduring, and little in uenced by the physician, although often the contacts between physician and patient over many years and repeated reassurance and explanations of how best to cope with dif culties may serve as a stabilizing force The use of medications to in uence some aspect of personality should be avoided unless there is evidence that the peculiarity of personality has developed into a full-blown neurosis However, one should never underestimate the power of maturation to ameliorate the turmoil of adolescence and to settle the young mind

Though considered to be the most frequent of mental disturbances, the neuroses are among the least understood They were established as clinical entities in the late nineteenth century, but there are still major unresolved issues with respect to their nature, classi cation, and etiology Descriptively, the neurotic disorders include the following syndromes: (1) anxiety neurosis; (2) phobic neurosis, which includes phobia of illness, social phobia, and agoraphobia; (3) obsessive-compulsive neurosis; (4) hysteria; and (5) hypochondriasis Former classi cations included additional types called neurasthenia (dysthymia or depressive neurosis), which is now considered with the depressive illnesses, and depersonalization neurosis (dissociative disorders), which is probably a form of hysterical neurosis Although each of these syndromes is clinically identi able and separable when occurring in pure form, experience shows that most patients suffer from symptoms of more than one type and therefore are said to have mixed neuroses In the most recent classi cations, all of the neuroses have been again replaced by three broad categories: (1) anxiety disorders (which include panic states, with and without agoraphobia, and the phobic and obsessive-compulsive neuroses); (2) somatiform disorders (comprising hysterical neurosis, or conversion disorder, and hypochondriasis); and (3) dissociative disorders It is evident from these and several other attempts at classi cation that a single de nition one that would satisfactorily explain the attributes of all the neuroses is still to come Syndromes as different as hypochondriasis and panic reaction are not likely to lend themselves to a unitary explanation If there is a central feature

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of the neuroses, however, it is thought to be anxiety, which runs as a kind of leitmotif through all of them Even in hysterical neurosis and sociopathy, in which patients seem indifferent to their disabilities, there is often a strong undercurrent of anxiety In an epidemiologic survey sponsored by the National Institute of Mental Health, it was estimated that approximately onethird of the population of the United States, at some point during their lives, have some type of mental disorder In this survey, disorders related to chronic alcoholism were the most common, followed by anxiety, alterations in mood, and obsessive-compulsive, phobic, conversion, and so-called posttraumatic stress disorders A different view of the relative frequency of mental disorders was provided by an analysis of 1045 consecutive psychiatric consultations at the New England Center Hospital (now New England Medical Center) during the years 1955 and 1956 In this tertiary referral hospital, the dominant psychiatric syndrome in about 20 percent of patients was an anxiety state Other epidemiologic studies have also disclosed a strikingly high incidence of anxiety disorders in the general population (see the review of Winokur and Coryell) Lifetime prevalence gures indicate that at least 11 percent of the population is so affected ie, 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 relatively little importance Furthermore, in times of calamity, such as the bombing of London, the incidence of neurotic symptoms was said not to have increased Thus one tends to dismiss as an oversimpli cation the notion that neuroses are merely by-products of life in civilized society or reactions to environmental stress (see also Chap 24) The symptoms rst arise in late childhood, adolescence, and early adult life Admittedly, neurotic symptoms may be recognized for the rst time after this age, but a good clinical rule is to suspect any mental illness that appears for the rst time after the age of 40 years to be either a depression or a dementia that is due to degenerative or other organic disease of the brain.

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The term anxiety neurosis was introduced by Freud in the latter part of the nineteenth century to describe a syndrome consisting of general irritability, anxious expectation, anxiety attacks, somatic accompaniments or equivalents of anxiety, and nightmares In anxiety neurosis, this symptom complex constitutes the entire illness However, as indicated earlier, parts of this constellation also appear in several other psychiatric diseases manic-depressive psychosis, schizophrenia, hysteria, and phobic neurosis Its closest link is with depression, which it resembles in another respect namely, there is a strong hereditary factor in both, as pointed out by our colleague, Mandel Cohen in 1940 The term used in DSM-IV is anxiety disorder, of which phobias, obsessive-compulsive disorder, panic attacks, and so-called posttraumatic stress disorder are the important subdivisions

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