Ok no problem. You must do you can do

Thank you, David!

Neuroticism is itself a state of psychic abnormality and hence, such patients have depression as well as anxiety issues So, it is quite obvious that, they won't cooperate in the therapeutic treatment

I would not say that highly neurotic patients do not cooperate with treatment, nor would I say neuroticism is a barrier to treatment. Patients come to therapy because of all sorts of symptoms and difficulty functioning. There are many way to address anxiety, but if you a pt. resistant to tx, then you have to address the resistance. This is something that psychodynamic therapists are trained to do; I don't know how those who only use CBT address resistance.

Hi I can give a GP perspective however I suggest similarities exist between doctor and therapist.

Firstly I do agree that neuroticism is a type of anxiety disorder so needs therapy in its own right. I imagine that the questioner slides to someone who seems difficult to help as they are even neurotic about the therapy etc

Then they barriers need to be addressed

Some patients seem to have a fear of actually resolving their problems.. This is a form of illness behaviour. Maybe it's irrational fear or maybe it's because there is a secondary gain to remaining ill. Some patients have a very fragile ego and cannot address their emotional pain directly without feeling overwhelmed.

Trust is a key issue with many long term neurotic patients. The best therapy is to build trust between patient and doctor. Expectations must be managed carefully. So build hope that matters can improve yet not overnight and not without long term effort and commitment. The physician must learn not to take it personally when a patient is awkward. The patient will have an ambivalent feeling towards the GP. On the one hand they may wish to believe their doctor to be the best ever. This is a common need. No doctor should fall into the trap of believing this in a narcissistic way. There will be a risk of patient dependency on the reassurance the doctor gives the patient. Codependency can arise too. However the doctor should gently but firmly guide the patient into the direction of self reassurance and self esteem. This will mean upsetting the patient sometimes and not meeting their agenda. However a successful overcoming of these minor conflicts of opinion leads to a much stronger therapeutic relationship. Firmness with kindness. Tough love some would call it. Many such patients have had a series of broken relationships due to a failure to survive conflicts. So for a relationship with the doctor or therapist to survive long term as with a GP despite these ups and downs is incredibly powerful.

The problem of a persistently resistant patient is very difficult. You can only take a horse to water but not make it drink. One can just keep pointing out that they are coming for help because clearly matters are not right so they should consider trying a new approach.

Finally the current bogie on mental illness is the Recovery Agenda. This is where the patient determines with some help from the therapist what Recovery would look like to them. In other words what matters most to them. So for someone with anxiety it might be that they yearn for a social life again. So focus motivation on these goals as they are patient focussed, and make them realistic and achievable. Keep them time limited but they can always be revised when not 100% achieved.

Finally when there is resistance consider revisiting the diagnosis. It may be that there needs to be reevaluation ... Many mentally ill patients seem to have attracted several labels over many years. I am not saying these were all wrong but there is a risk of a diagnostic label being wrong and yet believed by colleagues for a long time with ineffective therapies tried only for some wise person to reevaluate it and discover another more appropriate diagnosis and treatment.

I may have misread the questioner's meaning and if so please forgive me. Otherwise I hope this adds some value. Welcome any feedback

Sohrab Panday

GP and Mental Health Commissioner

Sorry but bogie was meant to be spelled VOGUE

Damn autospeller!

Thank you all for your answers.

I wouldnt automatically deem neuroticism as an abnormal psychological state, as I view traits (including n) as a continuum. Indeed, some argue that people high in n have lower drop out rates from therapy. But then again, it can pose other difficulties within the therapeutic course.

I read up on some of your suggested papers, and gained some new insights that hopefully will lift my coursework.

Will continue to invest it. Thank you all again, and merry Xmas!

I see I am VERY late to this discussion, but neuroticism is hard to resist. Dr. Sohrab, your points are very nearly inline with Karen Horney, M.D. who published but also wrote about 5 books, specifically on neuroticism. In sum, and I agree, she found that infants who signaled parents (mothers) and were not answered in a TIMELY and ACCURATE manner (not perfect, just, you know, you fed her when she cried and that was accurate b/c she was hungry and you did it within a reasonable time frame) were going to develop mild, moderate or severe neuroticism. This obviously happens prior to language, motor coordination or knowledge of self, and produces a basic anxiety about the world in the infant. Dr. Horney was very compassionate in her books, and while she was crystal clear how parents filter/interpret the world for infants in most instances, and often do it badly, she never implied nor stated that parents were neglectful or intentionally hurting their children. She did say, in the late 50's, the situation was simply getting worse, and that once children felt basic anxiety, as they grew, they attempted to avoid pain and become the kind of kid that would elicit a timely and accurate response from their parents. Horney saw this response on the child's part as absolutely normal; if this is the situation a child is presented with, given their developmental level and limitations, plus their very human need to avoid pain and feel known, then it is human to actively attempt to remedy it. Its the very remedy though that persists into adulthood, causing the original baby to have this nagging feeling of not being good enough (and how many Americans say that?), and attempting to control their environment (hence the anxiety symptoms plus rigid responses, and a stereotyped manner of dealing with others that usually sticks around if rewarded) as an adult. The fear that if you were to get too close you might see the real them, and no, they can't say that in words, its a knowledge, an experience gained directly from their early interactions, but its so powerful that a neurotic patient will absolutely 'choose' looking crazy over trying a treatment that they witnessed as at least somewhat effective.

Horney describes the attributes, the beauty, the talents, quirks, all the individual-ness each of us is born with, and how once a developing child has 'decided' to be super nice, always available in order to get their needs met, they have effectively distroyed their individuality. Which, as she rightly points out, contains the factors that would allow the person to get to know themselves, and deal with their problems as well as navigate this social world. According to Horney, very few neurotics get better, usually the mild ones that weren't completely isolated growing up, and can tolerate distress, but mostly, they trust you. She is gone now but our situation in this country is far worse: you can look at any manner of research and find we have less time for our kids; we know less about them than our cats; if we could do it over, most of us would not have kids; we are tired, we aren't up to the task. On the upside, neuroticism is very easy to distinguish from social phobia or any anxiety or mood disorder, or even negative affectivity. Good night, Kelly

In Italy there's Dr. Marinella Paciello working and writing about neuroticism also from a clinical point of view. Hope this helps.

Luca