Twelfth medical report to the committee from the medical director : presented: 31st December, 1938 / The Cassel Hospital for Functional Nervous Disorders.

  • Cassel Hospital for Functional Nervous Disorders (Richmond, England)
Date:
[1939?]
Catalogue details

Licence: In copyright

Credit: Twelfth medical report to the committee from the medical director : presented: 31st December, 1938 / The Cassel Hospital for Functional Nervous Disorders. Source: Wellcome Collection.

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    A physical examination revealed no evidence of organic disorder. A study of his mental status showed that there was no serious disturbance of mood and no formal disorder of thought content. A diagnosis of an anxiety neurosis was made. Treatment could be divided into two stages. In the first stage he was given a thorough reassurance on the basis of the physical examination. This had been done before without much effect, but on this occasion it was associated with a detailed explanation of the origin of his symptoms through psychological factors. This explanation was repeated many times with illustrations of actual occurrences of physical symptoms in connection with psychological difficulties in the past and present. The need for repetition is a matter which must be stressed. The same points have frequently to be driven home from many different angles before the patient is able to accept them. He began to assume a somewhat different attitude towards his symptoms and at this stage an analysis of his personality difficulties was undertaken. He was able to discuss con¬ structively his relationship with his mother and to see how the difficulties which had arisen in this respect had been carried over into his relationship with his wife. The whole question of his marital relationship with her was thoroughly discussed, and he realised that he had adopted false standards of pride and had been childish and demanding. A detailed analysis of his ambitions in his work and other fields was also undertaken, and he was able to modify his perfectionistic attitude towards success and failure. Towards the end of his period of treatment his wife came to stay near at hand, and he found that his attitude towards her had changed considerably. He was less dependent upon her and less jealous, and at the same time able to discuss his feelings with her more frankly and openly than before. He had a slight relapse a few weeks before leaving, and it was found that this was associated with a feeling that his recovery ought to be such as to render him free from any symptoms of any kind whatever. He had always felt that good health should be absolute and not relative. This was typical of his perfectionistic attitude towards many other matters which had been discussed. He was able to see it in this light and his anxiety symptoms quickly faded into the background. At the end of his treatment he was able to tolerate minor physical discomforts without undue concern. This case might have been formulated in many different ways. In his attitude towards his work and bodily health the patient had a need for perfection which might be termed obsessional. The occurrence of the symptoms in periodic attacks might lead one to emphasise the importance of any depression which was found. If, however, a longitudinal section of the case history is considered, the gradual development of pathological anxiety upon a background of imperfect personality development is clearly seen. This can be expressed in simple terms which are ultimately satisfying both to the psychiatrist and to the patient. Such a formulation cannot be termed superficial, nor can it be said to deal exclusively with conscious factors. On the contrary, many matters were brought forward of which the patient had not been previously conscious and many of them were reached through dream analysis and free association. The whole treatment occupied a period of three months and the patient achieved understanding of his personality problems on both an emotional and intellectual plane. The next patient to be presented is an example of a depressive reaction. The case is of particular interest in that it demonstrates most vividly the danger of accepting without the most searching enquiry the constitutional origin of a recurrent depressive illness. In this case the symptomatology differed sharply from the previous case in that an evident mood disturbance was the outstanding feature of the illness. It is reasonable to assume that this patient had a constitutional tendency to react with depression instead of with anxiety to her personality problems. Her problems were,