Diagnostic consideration of Morita shinkeishitsu and DSM-III-R
Abstract
The purpose of the present study was to empirically and objectively clarify the diagnostic standing of Morita shinkeishitsu, the subject of Morita therapy, by comparing and contrasting it with the operational diagnosis of the Diagnostic and Statistical Manual of Mental Disorders (3rd edition, revised; DSM-III-R). Morita therapists’ clinical diagnoses of 88 outpatients who requested Morita therapy were compared with the results of the independently conducted operational diagnoses (structured clinical interview for DSM (SCID) for DSM-III-R, the Japanese version). In view of the result of axis I diagnoses, Morita shinkeishitsu corresponds to anxiety disorders, although it is a complex that also embodies mood disorders, which were found in one-quarter of the cases, as well as personality disorders, which were found in half of the cases, especially cluster C (avoidant, obsessive–compulsive, and dependent personality disorders). Morita shinkeishitsu is almost equivalent to anxiety disorders (DSM-III-R, axis I), and is a complex, a part of which includes mood disorders and cluster C personality disorders.
INTRODUCTION
As the term ‘neurosis’ disappeared from the Diagnostic and Statistical Manual of Mental Disorders (3rd edition; DSM-III) in 1980, it was classified into various symptomatological categories.1 Even in modern Japanese psychiatry, the concept of neurosis has become almost obsolete. Nevertheless, in the history of psychiatry, the discovery of neurosis and its treatment (psychotherapy) have been inseparably connected. In Japan, having initiated Morita therapy in 1919, Morita divided neurosis into the shinkeishitsu type and the hysteria type; the former (later called Morita shinkeishitsu) being regarded as the subject of Morita therapy. Based on the symptoms, the shinkeishitsu type was further classified into obsession (being obsessed with ideas), ordinary shinkeishitsu (being obsessed with somatic symptoms), and paroxysmal neurosis (being obsessed with anxiety attacks and anxiety), although Morita did not recognize the essential difference among them.
At first, Morita used shinkeishitsu as a diagnostic term. Morita found that the various shinkeishitsu types of neurosis shared the same mechanism of symptom formation, which he called ‘toraware’. The meaning of toraware is ‘to be bound as by some intense preoccupation’. Second, Morita used the term shinkeishitsu to depict a nervous-prone personality with a hypochondriacal base.2,3 Morita thought that symptom formation and the shinkeishitsu personality were closely related. In treatment, the breaking through of toraware and modifying the shinkeishitsu personality were regarded as essential.
In other words, Morita shinkeishitsu is a term defining a group of neuroses that are considered to have a common psychopathology, ‘toraware’, and recovery process ‘arugamama’: accept reality as it is and lead a constructive life. The concern of individuals with Morita shinkeishitsu and the treatment method (Morita therapy) are closely connected as a single unit.2,3 This provides us with the meaningful information for the self-understanding of Japanese troubled by neuroses as well as for the choice of treatment.
In modern Japanese society, the term Morita shinkeishitsu (or shinkeishitsu) is used as a local diagnosis among Morita therapists, as a term that members of the self-help group for group-learning based on Morita therapy recognize themselves with and as a general term to refer to a characterological propensity to be worried about minute matters.
Thus, it has remained difficult for people outside the Morita school to understand what Morita shinkeishitsu is like. In the present study, an attempt to clarify the diagnostic standing of Morita shin-keishitsu was made by re-examining the subjects of Morita shinkeishitsu to give the operational diagnosis of DSM-III-R. Our investigation focused on (i) how a category of neuroses, Morita shinkeishitsu, can be located in DSM-III-R; (ii) the relationship between the subtypes of Morita shinkeishitsu and the operational diagnosis; and (iii) whether a characterological category corresponding to shinkeishitsu personality exists.
METHODS
Subjects
The subjects consisted of 88 outpatients (65 male and 23 female) who visited the Department of Psychiatry, Jikei University School of Medicine, Daisan Hospital, Japan, requesting Morita therapy, over a period of 6 months from February 1995. With the consent of the patients, three evaluators (one psychiatrist and two clinical psychologists) conducted DSM-III-R semistructured interviews (SCID, Japanese version, axis I and II).4
Three psychiatrists who are experienced Morita therapists conducted diagnostic interviews with the patients independently from the semistructured interview, and identified those who were Morita shinkeishitsu and those who were not Morita shinkeishitsu, the latter for whom Morita therapy is not indicated and whose motivation is lacking or whose expected prognosis is unfavorable with Morita therapy. The subjects of Morita shinkeishitsu were further divided according to the two traditional classifications. One is to classify them into typical and atypical types, and the other is Morita's symptomatological classification consisting of obsession (including obsessive disorders and taijin-kyofu-sho (TKS)), ordinary shinkeishitsu, paroxysmal neurosis, and others. The former classification of typical and atypical types pertains to prognostic estimates with Morita therapy. The typical type is a group of patients whose prognosis is considered favorable and who show a high capability for introspection and self-mastery of their problems, together with high motivation for treatment. The atypical type refers to a group of patients whose prognosis is favorable to a certain degree with some expected stalemates, and who show limited introspection and attitude of self-mastery, and unclear motivation for treatment.
Two of the aforementioned three psychiatrists independently diagnosed 14 cases (nine TKS cases and five others) with sufficient historical data and classified them into typical and atypical types of shinkeishitsu as well as the different types of TKS (TKS; TKS severe type; TKS of other types). As a result, the diagnoses were identical regarding typical and atypical types, for which the kappa coefficient was 1.00. As for the types of TKS, the diagnoses were identical in eight out of nine cases, for which the kappa coefficient was 0.83. Agreement among the diagnosticians was high in both classifications, indicating sufficient interrater reliability. The other psychiatrist was expected to show a similar rate of agreement in his diagnosis based on the fact that he had evaluated inpatient cases in the same team for 8 years.
RESULTS
Distribution of Morita shinkeishitsu based on clinical diagnosis
Among the total of 88 cases, 83 (94.3%) were given the diagnosis of Morita shinkeishitsu, among which 28 (31.8%) were identified as being of the typical type, while 55 (62.5%) and five (5.7%) were diagnosed as atypical type and non-Morita shinkeishitsu type, respectively. In the following analysis, the subject will be limited to the 83 cases of Morita shinkeishitsu.
Morita shinkeishitsu and DSM-III-R
Axis I diagnosis
In the axis I diagnosis, symptoms in line with the chief complaint such as anxiety and fear, which are the motivation for Morita therapy, were the major sub-ject for the diagnosis, while other complaints were regarded as comorbidity. The results of axis I diagnoses can be divided mainly into anxiety disorders and others. Anxiety disorders were found in 68 cases (81.9%) and the residual cases of 15 (18.1%) fell into other categories. The breakdown of anxiety disorders was as follows: 28 cases (33.7%) of social phobia, 26 cases (31.3%) of obsessive–compulsive disorder, 10 cases (12.0%) of panic disorder, three cases (3.6%) of agoraphobia without history of panic disorder, and one case (1.2%) of generalized anxiety disorder. Thus, anxiety, fear and obsessive–compulsive symptoms comprised almost all the cases.
Besides those detailed in the previous section, no axis I diagnosis was given to seven cases, among which five cases were given axis II diagnoses and two cases were not given any diagnosis. The residual eight cases did not demonstrate a notable propensity, which included two cases of hypochondriasis, one case each of major depression, dysthymia, alcohol dependence, continuous psychotic disorder, psychotic disorder, and undifferentiated somatoform disorder.
Symptomatological classification of Morita shinkeishitsu and axis I diagnosis
By comparing the symptomatological classification of Morita shinkeishitsu and the axis I diagnoses, 22 (95.7%) of 23 cases that were clinically diagnosed as obsessive–compulsive neurosis among the obsession cases met the criteria for the axis I diagnosis of obsessive–compulsive disorder, indicating a high rate of agreement in the two diagnoses.
Among 35 cases of TKS, 24 (68.6%) were diagnosed as social phobia, many of which were also given other axis I diagnoses. Because the relationship between TKS and social phobia is important, this will be discussed in a different article. Among 10 cases of paroxysmal neurosis, six cases met the criteria for panic disorder in axis I diagnosis, one for agoraphobia without history of panic disorder, and one for generalized anxiety disorder. Thus, eight out of 10 were included in the category of anxiety disorders. As for the six cases of ordinary Morita shinkeishitsu, no particular tendency was observed. There were nine cases that did not fall into any of the three shinkeishitsu categories, among which three were without any axis I diagnosis and three were diagnosed as social phobia. These did not show any notable tendency (Table 1).
| Axis I diagnosis | OC neurosais | % | TKS | % | Paroxysmal neurosis | % | Ordinary neurosis | % | Others | % | Total | % |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Social phobia | 24 | 68.6 | 1 | 10.0 | 3 | 33.3 | 28 | 33.7 | ||||
| Panic disorder | 3 | 8.6 | 6 | 60.0 | 1 | 16.7 | 10 | 12.0 | ||||
| OC disorder | 22 | 95.7 | 1 | 2.9 | 1 | 10.0 | 1 | 16.7 | 1 | 11.1 | 26 | 31.3 |
| Agoraphobia w/o history of PD | 1 | 4.3 | 1 | 2.9 | 1 | 10.0 | 3 | 3.6 | ||||
| Generalized anxiety disorder | 1 | 10.0 | 1 | 1.2 | ||||||||
| Subtotal | 23 | 100.0 | 29 | 82.9 | 10 | 100.0 | 2 | 33.3 | 4 | 44.4 | 68 | 81.9 |
| Major depression | 1 | 2.9 | 1 | 1.2 | ||||||||
| Dysthymic disorder | 1 | 16.7 | 1 | 1.2 | ||||||||
| Alcohol dependence | 1 | 11.1 | 1 | 1.2 | ||||||||
| Undifferentiated somatoform disorder | 1 | 11.1 | 1 | 1.2 | ||||||||
| Hypochondriasis | 1 | 2.9 | 1 | 16.7 | 2 | 2.4 | ||||||
| Continuous psychotic disorder | 1 | 2.9 | 1 | 1.2 | ||||||||
| Psychotic disorder | 1 | 2.9 | 1 | 1.2 | ||||||||
| No diagnosis | 2 | 5.7 | 2 | 33.3 | 3 | 33.3 | 7 | 8.4 | ||||
| Subtotal | 6 | 17.1 | 4 | 66.7 | 5 | 55.6 | 15 | 18.1 | ||||
| Total | 23 | 100.0 | 35 | 100.0 | 10 | 100.0 | 6 | 100.0 | 9 | 100.0 | 83 | 100.0 |
- DSM-III-R, Diagnostic and Statistical Manual of Mental Disorders 3rd edition revised; OC, obsessive–compulsive; TKS, taijin-kyofu-sho; PD, panic disorder.
Typical and atypical Morita shinkeishitsu and axis I and II diagnoses
Among typical type cases, 25 (89.3%) cases were given axis I diagnoses and 14 (50.0%) were given some axis II diagnoses. As for the atypical type, an axis I diagnosis was given to 51 cases (92.7%), and 25 cases (45.5%) were given some axis II diagnoses. In both types, approximately half of the cases met the criteria for some axis II disorders, and no significant difference was found in the rate and number of axis II diagnoses between the two groups.
Comparing the axis I diagnoses of typical and atypical types, anxiety disorder was found in 24 cases (85.7%), and four cases (14.3%) fell into other categories in the typical type, while the numbers amounted to 44 (80.0%) and 11 (20.0%), respectively, for the atypical type, which showed no statistically significant difference (Table 2).
| Axis I diagnosis | Typical | % | Atypical | % | Total | % |
|---|---|---|---|---|---|---|
| Social phobia | 15 | 53.6 | 13 | 23.6 | 28 | 33.7 |
| Panic disorder | 6 | 21.4 | 4 | 7.3 | 10 | 12.0 |
| OC disorder | 3 | 10.7 | 23 | 41.8 | 26 | 31.3 |
| Agoraphobia w/o history of PD | 3 | 5.5 | 3 | 3.6 | ||
| Generalized anxiety disorder | 1 | 1.8 | 1 | 1.2 | ||
| Subtotal | 24 | 85.7 | 44 | 80.0 | 68 | 81.9 |
| Major depression | 1 | 1.8 | 1 | 1.2 | ||
| Dysthymic disorder | 1 | 1.8 | 1 | 1.2 | ||
| Alcohol dependence | 1 | 1.8 | 1 | 1.2 | ||
| Undifferentiated somatoform disorder | 1 | 1.8 | 1 | 1.2 | ||
| Hypochondriasis | 1 | 3.6 | 1 | 1.8 | 2 | 2.4 |
| Continuous psychotic disorder | 1 | 1.8 | 1 | 1.2 | ||
| Psychotic disorder | 1 | 1.8 | 1 | 1.2 | ||
| No diagnosis | 3 | 10.7 | 4 | 7.3 | 7 | 8.4 |
| Subtotal | 4 | 14.3 | 11 | 20.0 | 15 | 18.1 |
| Total | 28 | 100.0 | 55 | 100.0 | 83 | 100.0 |
- DSM-III-R, Diagnostic and Statistical Manual of Mental Disorders 3rd edition revised; OC, obsessive–compulsive; PD, panic disorder.
Morita shinkeishitsu and mood disorder
Among the cases of Morita shinkeishitsu, 21 were diagnosed as mood disorders, consisting of 11 dysthymic disorders and 10 major depressions. Two cases were given only the diagnosis of mood disorder (dysthymic disorder and major depression), and the other 19 cases showed comorbidity with anxiety disorders.
Looking at the subtypes of Morita shinkeishitsu, two cases (7.1%) of major depression and five cases (17.9%) of dysthymic disorder were found in the typical type, which amounted to seven cases (25.0%) out of a total of 28 cases. In the atypical type, eight cases (14.5%) of major depression and six cases (10.9%) of dysthymic disorder were found, which together added up to 14 cases (25.6%) out of a total of 55 cases. A significant relationship between the comorbidity of mood disorder and the types of Morita shinkeishitsu was not observed. In regards to the comorbidity of mood disorder in Morita's symptomatological classification, comorbidity was found in three cases (13.0%) of obsessive–compulsive neurosis, 13 cases (37.1%) of TKS, two cases (20.0%) of paroxysmal neurosis, one case (16.7%) of ordinary shinkeishitsu, and two cases (22.2%) among the other categories. The rate of comorbidity was highest in TKS cases.
Morita shinkeishitsu and personality disorder
In regards to the relationship between axis II diagnosis and Morita shinkeishitsu, approximately half of the cases were given some axis II diagnoses; 39 cases (47.6%) met the criteria for some axis II disorders, and 43 cases (52.4%) did not. In a group of anxiety disorders, 30 cases (44.1%) were given some axis II diagnoses, while in a group of other disorders, the number was nine (64.3%).
As for the breakdown of axis II diagnoses, the number of cases with cluster C disorders stood only at 23 (28.0%); cases with disorders of cluster C and other clusters numbered 10 (12.2%); cases with disorders of other clusters only, six (7.3%); and cases with no axis II disorder, 43. The combined number of cases that showed some cluster C disorders amounted to 33 (40.2%).
By order of prevalence, among cluster C disorders, avoidant personality disorder was most prevalent (16 cases, 19.5%), followed by obsessive–compulsive disorder (15 cases, 18.3%), and dependent personality disorder (11 cases, 13.4%). Among cluster A disorders, the most frequently seen disorder was paranoid personality disorder (eight cases, 9.8%), and among cluster B disorders, narcissistic personality disorder was most prevalent (five cases, 6.1%), followed by borderline personality disorder (three cases, 3.7%), and histrionic personality disorder (two cases, 2.4%).
DISCUSSION
Diagnostic consideration of Morita shinkeishitsu
In the present study it was found that, from the perspective of DSM-III-R, Morita shinkeishitsu refers to a complex consisting of various diagnoses of different levels. First of all, Morita shinkeishitsu can be considered as a syndrome for which the major symptoms are obsession and compulsion, phobia and anxiety, a group included in the anxiety disorder group. Obsessive–compulsive neurosis included in Morita's symptomatological category of obsession almost entirely corresponded to obsessive–compulsive disorder. It was also found that TKS and social phobia are similar concepts, which will be discussed in detail in another article. In addition, it was also shown that paroxysmal neurosis was almost equivalent to panic disorder and its related disorders, while there was no corresponding diagnostic category for ordinary Morita shinkeishitsu. The aforementioned result supports the result of a previous comparative study of DSM-III and Morita shinkeishitsu based on case histories.5 In other words, the group of patients for whom Morita therapy is indicated and expected to prove effective consists of individuals with panic disorder, social phobia and obsessive–compulsive disorder, all included in the anxiety disorder group.
Next, it was shown that approximately one-quarter of Morita shinkeishitsu cases had comorbidity with mood disorders. In the past, the Morita school paid little attention to the comorbidity of Morita shinkeishitsu and mood disorders. This can be attributed to the difference in the diagnostic procedures between Morita shinkeishitsu and DSM-III-R. In the diagnostic procedure for Morita shinkeishitsu, importance was placed on delineating the common mechanism of toraware. However, as dual diagnoses were made possible with DSM-III-R, we were able to identify the comorbidity of mood disorders and personality disorders in Morita shinkeishitsu cases. As a result, it became clear that Morita shinkeishitsu is a complex of various clinical units delineated by DSM-III-R.
Furthermore, this comorbidity with mood disorders can be explained in two different ways. One is the possibility that Morita shinkeishitsu related to the pathology of anxiety has become comorbid with depressive symptoms along with changes in society. The other pertains to the possibility that there is a group within the group of individuals with mood disorders who have the psychopathology of toraware and shinkeishitsu personality traits, for whom Morita therapy is indicated.
Third, almost half of the Morita shinkeishitsu cases met the criteria for personality disorders. It had been supposed that Morita shinkeishitsu was not related to any specific personality disorder.5 It was supported again in the present study that no significant relationship between individual personality disorder and Morita shinkeishitsu personality traits exists. However, the results of our study indicate a relationship between Morita shinkeishitsu and cluster C (avoidant, obsessive–compulsive, and dependent personality disorders). Individuals with Morita shinkeishitsu personality are sensitive to others’ evaluation of themselves, and are not only avoidant and dependent but also self-centered, obsessive– compulsive and perfectionist.2,6–9 In other words, in description, Morita shinkeishitsu personality can be considered as a composite of the three personality traits delineated in cluster C. Those who presented a high intensity of these traits may have met the criteria for a cluster C personality disorder.
Thus, the diagnosis of Morita shinkeishitsu according to axis I and II of DSM-III-R can be summarized as a complex for which the chief diagnostic category is anxiety disorders, a part of which is related to mood disorders and personality disorders.
Typical and atypical Morita shinkeishitsu and DSM-III-R
In regards to the relationship between Morita's classification of typical and atypical types and axis I and II diagnoses of DSM-III-R, the only significant finding was that atypical cases showed a high prevalence of obsessive–compulsive disorder. No significant relationship was found among other variables, such as the distribution of anxiety disorder and other disorders, and the prevalence of axis II diagnoses and cluster C personality disorders. In other words, the distribution of axis I and II diagnoses of DSM-III-R did not differentiate the two types based on prognostic estimates. The criteria for the two types must be further scrutinized.
Comparison between the concept of Morita shinkeishitsu and DSM-III-R
The DSM-III-R as a set of operational diagnostic criteria abolished the traditional concept of neurosis, which was classified into diverse disorders from a symptomatological perspective.1,10 This provided a framework for objective diagnosis, which serves as a common or official language. Furthermore, investigation of the biological basis and the efficacy of pharmacological therapy for these disorders has been vigorously conducted in an attempt to delineate the variety and uniqueness of each category. For example, the existence of a unique clinical entity has been strongly advocated for obsessive–compulsive disorder, social phobia, panic disorder, major depression, and dysthymic disorder.1,10 In contrast, Morita shinkeishitsu represents a clinical unit constructed on the hypothesis that there is the common mechanism of toraware and the recovery process, not based on the symptomatology such as anxiety and fear.2,3 The present study demonstrated that Morita shinkeishitsu is a complex of various clinical units, for which uniqueness has been advocated. It is required of the Morita school to submit objective and empiric evidence through outcome studies of the validity of the hypothesis of a common psychopathology and recovery process embodied in Morita shinkeishitsu, transgressing various clinical units with supposed uniqueness. In addition, investigation of how the diagnostic categories of DSM-III-R are related to the psychopathology of toraware and the recovery process is necessary. Such inquiries, involving comparing and contrasting the two different diagnostic systems, will contribute to the further understanding and better treatment of anxiety and mood disorders.
