THE AMERICAN JOURNAL OF PSYCHOANALYSIS: 37:155-161 (1977)

PROGNOSIS IN THE NEUROSES

Andrew Sims

I am as one for ever out of his e lement

C. Day Lewis I

I am using the word "neurosis" in this article in an epidemiological sense (taken from the International Statistical Classification of Diseases, Injuries and Causes of Death 2 categories 300-309). How do individuals considered neurotic interact with society, and how does their environment affect them? There is considerable overlap between neuroses and personality disorders, as well as affective disorders. Al- though neurosis is very common in the general population, there is a gradual increase of severity to be found from I) neurotics in the general population to 2) patients consulting their family doctors for predominantly psychiatric symptoms to 3) psychiatric out-patients to 4) psychiatric in-patients. ~ The follow-up findings of this report are mainly based on studies from Uffculme Clinic, Birmingham, U.K., in which all the one hundred forty-six patients treated for neuroses of mixed type in hospital in one year were followed-u p twelve years Jater with an interview by a trained interviewer usually at the patient's home. These studies are reported elsewhere. 3-I0

Greer and Cawley consider that an accurate knowledge of the natural history of neurosis can only be obtained by a follow-up study, and in order to allow for the operation of the vast number of environmental and other factors affecting the course and outcome in any given individual, it is necessary to study large numbers of patients2 ~ At follow-up I found a mortality considerably above that expected; 6 over ten percent of the previous neurotic patients were found to show established dependence on either alcohol or psychotropic drugs. 7 The metamorphosis of neurosis into psychosis was found to be an unusual event, probably associated most often with initial misdiagnosis. An identical fol low-up procedure to that undertaken with neurotic patients was carried out with a supposedly normal group of subjects. 8 Ninety percent of the normal group were found to have a satisfactory outcome at follow-up as compared to only forty-four percent of the neurotic group. It appears therefore that the disabilities associated with neurosis continue for a very long time, that those disabilities are concentrated within neurotics rather than distributed at random in the population, and that it is possible to demonstrate and quantify the disability. With a carefully planned follow-up study, an assessment of outcome can be measured by I) forming a global impression of how the patient compares now

A.C.P. Sims, M.A., M.D., M.R.C. Psych., Senior Lecturer and Consultant Psychiatrist, Department of Psychiatry, Queen Elizabeth Hospital, Birmingham, U.K.

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with his state when ill; 2) taking key symptoms or behaviours as indicators of overall progress, e.g. relief from phobia, 12 return to work; 13~4 3) forming a more com- prehensive assessment by summing a number of different relevant areas;9, ~1,~5 4) attempting to assess presumed dynamic changes rather than overt changes in symptoms or behaviour2 6

Freud suggested that assessment of neurosis would be "determined by the practical results--how far the person concerned remains capable of a sufficient degree of capacity for enjoyment and active achievement in life. ''~7 These assess- ments of outcome comprise evidence of social disruption, problems in the areas of work record, home relationships, marital and sexual relationship and material management, and neurotic symptoms and their treatment requirements. "No sur- vey can be better than its questionnaire. ''18 The validity of findings at follow-up rely very much on the techniques of tracing and assessing outcome, and so every step requires careful checking for reliability and for absence of serious bias in the sampling procedure. The global measurement of total outcome at follow-up incor- porates measures for symptomatic disturbance and social disruption, including the areas of work, marital and sexual relationship, home relationships, and material management.

What do I know about the patient I am presently treating that will allow me to make a prognosis? The information that psychiatrists consider important enough to record, they also use to form their own expectations for outcome, and they are reasonably accurate at making a prognosis in neurosis. I have two findings to support this statement. First, when psychiatrists gave a prognosis at the time of discharge of neurotic patients, a poor prognosis was found to be a significant predictor of poor outcome at twelve year follow~up. Second, three psychiatrists independently were asked to rate prognosis for a group of forty patients on a five-point scale, from satisfactory to unsatisfactory, after reading the detailed case summaries. Their prognosis for these patients correlated significantly with each other and with the total outcome assessed at follow-up interview.

For the purposes of quantifying outcome in neurosis it is unreasonable to sum the results of different studies. It is as inappropriate to add the results at outcome of different groups of patients receiving (or not receiving) psychotherapy as to give a global outcome with surgery. Scaling for outcome should be about an unchanged category--that is, it is possible to be worse at discharge from treatment or at follow-up as well as better. A psychiatrist cannot without prejudice interview and evaluate his own previous patients at follow-up; information is likely to be obscured by other factors. Despite the temptation to interpret unconscious con- flicts, the most reliable information at interview is the patient's description of what he does and has done in terms of work, marriage, relationships etc.

Is information recorded about patients at the time of admission for neurosis predictive of outcome? Our initial history information was derived from a clinical summary, psychiatric case notes, coded information on a punched card, nursing notes, social history, psychological assessments, results of investigations, copies of letters to and from hospital, prescription sheets etc. 9 Factors were investigated for

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predictiveness because 1) previous reports considered them predictive; 2) they were intrinsically likely to be predictive; 3) it was thought interesting to assess predictiveness without prior prejudice. Seventy-nine items of information known about the patient at the time of initial treatment were considered as potential predictive factors. Tests for significance were carried out for these factors compared with the total outcome using the chi-square test with one degree of freedom (four-fold contingency test). Of these items, twenty-six factors were found to be significant predictors. The following discussion considers the meaning of these factors in the natural history of neurosis.

Predictive usefulness of these factors depends upon their occurrence being significantly associated with a certain sort of outcome, the possibility of their quantification, and their occurrence sufficiently often to allow statistical testing. Of course these factors are not independent. There are many common clusters, such as the global effects of abnormality of personality, the fact that problems in relation- ships in one area will result in difficulties in other areas because the patient is still mixing with the same people, the fact that if the patient copes poorly in one area of his life situation he is likely to do so in other areas as well. For these and other reasons factors are interdependent, and a discriminant function analysis of the factors is being carried out.

At the time of admission, patients of the sample (those diagnosed as suffering from neurosis in one year's admissions) were asked what they considered caused their symptoms or illness. Various precipitating events were blamed by the patients. The duration of time since these events was not predictive of outcome but their nature was. Where the ascribed cause was a sexual, marital, family, or occupa- tional problem, the outcome was worse; where the precipitant was a physical illness or injury of the patient, or death or illness of a relative or friend, prognosis was better. It appeared from patients' descriptions that there was often a feeling of loss of self-esteem with the marital, familial, and occupational precipitants that was not present with the death and illness groups.

Of course, that problems should develop in these areas was intrinsically more likely in a person with some adverse features of his personality. His personality difficulties will make it intrinsically more likely that there will be ensuing problems with relationships, such as at work and in marriage. Similarly because of his neurotic predisposition, his occupational and marital choices may be less congen- ial, and more likely to result in problems. People with neurosis commonly describe either an inability to cope or, alternatively, coping but with difficulty. These people are likely to describe the difficulties caused by internal conflicts in terms of their social repercussions.

Prolonged duration of neurotic illness is related to development at younger age and to personality disorder. Also as the life choices of work and marriage and so on made about the age of twenty are influenced by neurotic illness, a pattern of continuing disturbance may be established through making less stable choices.

Personality traits were described by the psychiatrists summarizing the initial admission. Only forty percent of the neurotic patients were considered to have a

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normal personality. Personality was also assessed at follow-up by an interviewer ignorant of the previous assessment, and forty-one percent were found to have a normal personality. Assessment of abnormality of personality was significantly related on the two occasions, and the type of abnormality of personality was consistent.

Many symptoms and groups of symptoms were investigated, but only the com- plaint of difficulties with socializing was found predictive, and this symptom had a good prognosis. The reasons for this were probably that a person who is well enough motivated to improve his social abilities to seek help is likely to achieve an improvement and that the treatment milieu was suited to such people. It is probable that severity or number of symptoms is not a predictive factor because it subsumes two disparate subgroups: 1) those who chronically complain of severe symptoms irrespective of their environment and at various occasions are referred to a psychia- trist, their prognosis being poor; and 2) those who complain of acute, severe neurotic symptoms often following a situational crisis, their prognosis is good.

Work factors were more important for male patients and marital factors for female. The neurotic is likely to put himself at a disadvantage in his choice of and in his attempt to obtain occupation, and this will have repercussions in how he performs his work and in the relationships he makes at work.

Complaint at the time of admission of problems with accommodation or finan- cial state seemed to be associated with the neurotic's difficulty in coping with life circumstances. There was a tendency for those with worse outcome both to complain more and to manage their affairs worse. The poor outcome found in those receiving social work help does not indicate that social work was harmful, but simply that those patients with the greatest social difficulties and the worst prog- nosis were more likely to be referred to the social worker.

Marital problems were a problem particularly for female patients. The tendency of an unfavourable position from which to make choices at critical life periods combining with the consequences of adverse personality is seen most clearly with marital difficulties. Neurotic disability at marriage is likely to result in a less propitious choice of partner. With this choice of partner an unsatisfactory relation- ship may result, and the spouse is more likely to show behaviour or personality problems. Our patients in Birmingham, U.K. were predominantlyworking class, for whom it was usual to get married between the ages of twenty and twenty-five and to be fairly close in age to their spouse. For the neurotic group, age over twenty-five at marriage may reflect some degree of assortative mating in that the spouse as well as the patient may have some characteristics making them intrinsically a less attractive option in relationships. When the spouse was aged under twenty various adverse social factors associated with early marriage are likely to result in later difficulties. It was noteworthy that the relationship with the spouse was a significant predictor but the sexual relationship was not. When adverse marital factors were summed, it was found that an adverse marital and sexual relationship was highly predictive of poor outcome at follow-up.

At follow-up those who were found to have done less well were more likely at

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the time of admission to describe early affective disadvantage, i.e. an unhappy childhood, and/or disturbed relationship between the parents during the patient's childhood. This is presumably associated with the patient's later difficulties in forming satisfactory affective relationships. Psychiatrists are reasonably accurate in predicting outcome in neurosis, and so those they select for psychotherapy have a better prognosis than neurotic patients admitted for other reasons. Similarly those admitted as in-patients are, on the whole, more neurotically disturbed than day patients.

Treatment for neurosis in the clinic in the initial year consisted of the clinic milieu, some large groups, anxiolytic drugs, and more extended psychotherapy for a few selected patients. Certain factors associated with treatment predict outcome. When the nurses' comments on the patient's response during treatment is un- favourable; when the psychiatrist feels the patient has failed to improve by the time of discharge; when the patient finds treatment so unrewarding that he fails to attend for appointments; outcome is worse. A large number of letters were written from hospital when the patient had more social problems, e.g. letters to a social work agency or housing department of the Local Authority. More case notes were written during the hospital admission for patients who caused more difficulties and had a less satisfactory hospital course.

The initial social state was a significant predictor of outcome, but the initial symptomatic state was not predictive. If the number of significant predictors for each patient was summed, it was possible to give each patient a predictive factor score. These two scores, the initial social state and the neurotic predictive factor score, were both predictive of outcome and measures of severity of neurosis at the time of initial hospital treatment. It has been found in another study 19 that scores for these two measures are significantly higher for neurotic patients who subsequently died than for matched neurotic patients who had not died at follow-up.

This is a study of the natural history of neurosis; the background of disability which psychotherapy is intended to treat. One important finding is 1Lhe long lasting nature of neurosis and the frequency of serious permanent sequelae. It is fruitless arguing whether constitution or early learning are more important iin the develop- ment of neurosis. It is enough to say that the neurotic diathesis is communicated in early life through the family, that neurotic mothers pass on the habit of making choices in a neurotic manner, and that the adverse sequelae tend to be self- perpetuating.

The efficacy of treatment in neurosis can only be reasonably assessed at long- term follow-up. It is more satisfactory to concentrate on global improvement rather than improvement of individual symptoms. Outcome can be assessed by summing the symptomatic and social states at follow-up. Social state quantifies the presence of social disruption in terms of problems with work, home relationships, marital and sexual relationship, and material management.

There is an excess death risk for neurosis and this is increased for those more severely neurotically disturbed. 6.19 There is also an increased risk of alcoholism and drug dependence developing by the time of follow-up. 7 There was not found to be

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any general tendency for neurosis to develop into psychosis. An unfavourable outcome in neurosis is predicted by various factors which are

known about patients at the time of admission to hospital treatment. These appear to be associated with the psychiatric assessment of abnormal personality, with affective disadvantage in childhood, and with the presence of disabling neurotic symptoms at the period of life in the late teens and early twenties when decisions are made which affect the rest of life. When these inauspicious circumstances combine, the person seems to involve himself in a way of life that creates further difficulties. He has difficulty in coping with the usual crises of life. He develops neurotic attitudes of hopelessness which prevent motivation for improvement and are shown in therapy by less cooperation from the patient in his treatment, more unrewarded effort by the therapists, and a greater tendency to refer the patient to other helping agencies. The marital and sexual relationship is an especially sensi- tive predictor. The poor-prognosis neurotic establishes a less satisfactory marital relationship and then patient and spouse have more problems in continuing the relationship.

There is a continuum for severity of neurosis from those described above, who are of worst prognosis, to the subclinical neurotic syndrome, occurring in one-third of the general population at the other end. 2° Treatment methods need to be improved for helping the most severe group. It is postulated that the predictive factor score could be modified to equilibrate the severity of neurosis of patients receiving different forms of treatment and thus different methods could be com- pared. With such serious morbidity and even mortality, it is reasonable to regard neurosis as a fit subject for medical attention, research, and evaluation of treatment.

References

1. Lewis, C. Day. The Neurotic. Poems 1943-1947, 1948. 2. W.H.O. International Statistical Classification of Diseases, Iniuries and Causes of Death,

eighth ed., Geneva, 1965. 3. Sims, A.C.P. The consequences of severe neurosis. Practitioner 216:321-329, 1976. 4. Sims, A.C.P. Importance of a high tracing rate in long-term medical follow-up studies.

Lancet 11:433-5, 1973. 5. Sims, A.C.P. Some epidemiological findings in severe neurosis. In Current Themes in

Psychiatry (Gaind, R. and Hudson, B.L., eds.), 1977. 6. Sims, A.C.P. The mortality in neurosis. Lancet 11:1072-1076, 1973. 7. Sims, A.C.P. Dependence on alcohol and drugs following treatment for neurosis. Br. J.

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11. Greer, H.S. and Cawley, R.H. Natural History of Neurotic Illness. Sydney, 1966. 12. Terhune, W.B. Phobic syndrome; study of 86 patients with phobic reactions. Arch.

Neurol. Psychiatry (Chicago) 62:162-172, 1949. 13. Denker, P.G. Results of treatment of psychoneuroses by the general practitioner: A

follow-up study of 500 cases. N.Y. State J. Med. 46 (2):2164-6, 1946. 14. Pose, V. and Schmieschek, H. Second success statistics of the individual therapy

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changes in untreated neurotic patients: 1 Improvements that are questionable on dy- namic criteria. Br. J. Psychiatry 114:525-551, 1968.

17. Freud, S. Introductory Lectures on Psychoanalysis (tr. J. Riviere). London: Allen and Unwin, 1922.

18. Moser, C.A. Survey Methods in Social Investigation. London, 1958. 19. Sims, A.C.P. Mortality in neurosis: an investigation of hypotheses. Annual Meeting of the

Royal College of Psychiatrists. London, 1976. 20. Taylor (S.J.L.T., baron) and Chave S. Mental Health and Environment. London:

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Reprint requests to Department of Psychiatry, Queen Elizabeth Hospital, Birmingham BI5 2TH, U.K.