CHAPTER XVITHE PSYCHONEUROSES AND NEUROSES
The words neurosis, psychosis and psychoneurosis are of obscure origin and have had a varied significance from time to time. Murray[332]defines psychosis as a psychological term indicating "a change in the psychic state; an activity or movement of the psychic organism, as distinguished from neurosis" which he speaks of as a "change in the nerve-cells of the brain prior to, and resulting in, psychic activity." Huxley in discussing this subject in 1871 made the following differentiation: "In all intellectual operations we have to distinguish two sets of successive changes—one in the physical basis of consciousness and the other in consciousness itself; one set which may, and doubtless will, in course of time, be followed through all its complexities by the anatomist and the physicist, and one of which only the man can have immediate knowledge. As it is very necessary to keep a clear distinction between these two processes, let the one be called neurosis and the other psychosis."
Von Feuchtersleben used the latter word in its present psychiatric significance in his "Lehrbuch der Aertzlichen Seelenkunde" in 1845. Its repeated appearance in the first volume of theAllgemeine a Zeitschrift für Psychiatriein 1844 would strongly suggest a frequent use of the term in the German psychiatry of that day. It was unknown in English works until quite recently, although the word is found in Maudsley's "Responsibility in Mental Diseases" (1874)—"No wonder that the criminal psychosiswhich is the mental side of the neurosis, is for the most part an intractable malady, punishment being of no avail to produce reformation." Lewes, in "The Problems of Life and Mind" published after his death in 1879, makes a very significant remark: "Pathologists call it a psychosis, as if it were a lesion of the unknown psyche." Clouston's 1911 edition makes no reference to psychoneuroses as such.
The word neurosis has been much more extensively employed in medical literature. William Cullen, a well-known professor in the University of Edinburgh, in his "First Lines of the Practice of Physic" in 1774, said: "I propose to comprehend, under the title of neuroses, all those preternatural affections of sense or motion which are without pyrexia, as a part of the primary disease." In his "Synopsis Nosologicae Medicae" in 1785 he divided diseases into four general classes: Pyrexia or febrile diseases; neuroses or nervous diseases, as epilepsy; cachexiae or diseases resulting from bad habit of the body, as scurvy; and locales, or local disease, as cancer. Brachet,[333]who was one of the earlier writers on the subject of hysteria, defined that disease in the following words in 1847: "Hysteria is a neurosis of the cerebral nervous system, which manifests itself more or less brusquely by crises of general chronic convulsions and by the sensation of a globe ascending in the course of the oesophagus, at the upper extremity of which it becomes fixed, causing there a menace of suffocation." Briquet, another French writer, expressed somewhat similar views in 1859. The word neurosis as now used may be said to refer to a functional disturbance of the nervous system, which, if directly due to etiological mental factors, is spoken of as a psychoneuroses.
Just what diseases are to be included under the grouping of neuroses and psychoneuroses is another question.Practically all of the older authorities, at least, have agreed on hysteria and neurasthenia. When we get beyond this point, however, there are wide differences of opinion. Oppenheim, in his second edition, under the heading of neuroses, included hysteria, hypnotism and hypnosis, neurasthenia, morbid fears, imperative ideas, astasia-abasia, traumatic neuroses, hemicrania, headache, vertigo, epilepsy, eclampsia, chorea minor, Huntington's disease, paralysis agitans and many other conditions.
Krafft-Ebing[334]was responsible for the following delimitation of the psychoneuroses, which he admits to be "somewhat dogmatic" and has used for many years largely for didactic purposes: "1. Parasitic, accidentally acquired diseases in individuals whose cerebral functions were previously normal and whose disease could not be foreseen. 2. Disease based upon temporary disposition (grave physical disease and the simultaneous action of powerful exciting causes), hereditary predisposition not excluded, but only latently present in the brain of one easily affected, but previously normal in its functions. 3. Tendency to cure of the disease and infrequency of relapses. 4. Slight tendency to transmission to descendants, and when it occurs, in benign forms (psychoneuroses). 5. Typic course of the disease picture. Mania, as a rule, arises from a melancholic initial stage; and so-called secondary conditions are the terminations of primary conditions. The disease picture, even when it appears, has a certain duration and independence. The whole course of the disease is quite narrowly limited in time, and goes on either to recovery or dementia. 6. No tendency to periodicity of the attacks or the grouping of symptoms. 7. Sanity and insanity are sharply defined, and in striking contrast." In this group he includes mania, melancholia, acute curable dementia and primaryhallucinatory delirium. He describes hysteria, neurasthenia, etc., under the psychic degenerations with paranoia and speaks of them as constitutional neuroses. His psychoneuroses certainly do not come within the general acceptation of the term at this time but represent the views of a certain school of German writers.
More recently the words neurosis and psychoneurosis have been used as synonymous terms by many writers. Kempf has even gone so far as to suggest discarding the word psychosis completely. In any event, the view that we should only designate as psychoneuroses such functional conditions as are clearly due to psychic causes seems to be gaining ground. The term neurosis is generally applied at this time to diseases primarily physical rather than mental in their symptomatology. The prominence of psychogenic factors has been given great weight in recent literature. In the second edition of his work on Psychiatry, Diefendorf makes the following statement: "Neuroses are commonly designated as a group of diseases characterized by changing and transitory nervous disturbances, to be distinguished from psychoses by the fact that the symptoms do not involve the mental field. But in practice psychoses without nervous symptoms or neuroses without mental symptoms are not encountered."
Since the term was first introduced by Morel in 1860, many French writers, such as Régis and Magnan, have emphasized the importance of the insanity of degeneracy. This included moral insanity, the sexual perversions and various other psychopathic conditions as well as the obsessions, compulsions, impulsions, phobias, doubts, etc., now recognized as psychogenic in origin and usually assigned collectively to the psychoneuroses under the designation of psychasthenia. In his sixth edition Kraepelin included both hysteria and epilepsy in his group of neuroses, while constitutional peculiarities of character, as well as compulsive and impulsive insanity with sexualperversions, were classified under the psychopathic states (degenerative insanity). In his seventh edition epilepsy was described as a separate entity. In the eighth edition we find a new grouping. The psychogenic conditions are divided into nervous exhaustion (neurasthenia), the dread neuroses, induced insanity, the paranoid conditions of the deaf, the traumatic neuroses, the prison and the "querulant" psychoses. Hysteria now appears separately. Under the constitutional psychopathic disorders he discusses nervousness, compulsion neuroses, impulsive insanity and the sexual perversions. In view of these varying conceptions which are fairly representative of the literature of the day, we are certainly on safe ground in confining a consideration of the psychoneuroses to hysteria, neurasthenia, psychasthenia and various other conditions characterized by anxiety and fears.
Hysteria has long been a subject of interest and controversy. It has been a topic of discussion since the time of Esquirol and even Sydenham. It was studied exhaustively by Brachet in 1847. Briquet in 1859 defined hysteria as "an encephalic neurosis whose apparent phenomena consist principally in the perturbation of the vital actions which serve to manifest the affective sensations and passions." Lasègue wrote an elaborate treatise on the subject in 1864. It was discussed in detail later by Möbius, Charcot and many others. To Möbius hysteria was "a congenital morbid mental state where diseased bodily conditions are produced by ideas." During the last twenty or thirty years many new and interesting theories have been advanced. Binet sees in hysteria a condition of double consciousness, the two states almost entirely independent and separated by periods of amnesia. Janet's[335]interesting conception of the disease is covered in full in his definition: "Hysteria is amental disease belonging to the large group of the diseases due to weakness, to cerebral exhaustion; it has only rather vague physical symptoms, consisting especially in a general diminution of nutrition; it is above all characterized by moral symptoms, the principal one being a weakness of the faculty of psychological synthesis, an abulia, a contraction of the field of consciousness manifesting itself in a particular way; a certain number of elementary phenomena, sensations and images, cease to be perceived and appear suppressed by the personal perception; the result is a tendency to a complete and permanent division of the personality, to the formation of several groups independent of each other; these systems of psychological factors alternate, some in the wake of others, or coexist; in fine, this lack of synthesis favors the formation of certain parasitic ideas which develop completely and in isolation under the shelter of the control of the personal consciousness and which manifest themselves by the most varied disturbances, apparently only physical." He summarized this as a complete doubling (dédoublement—literally undoubling, as translated by Corson) of the personality. On analysis there is fundamentally much in this view strongly suggestive of the theories of Breuer and Freud.
Babinski interprets hysteria as a purely psychic functional disturbance due to suggestion. He would eliminate from this field all symptoms which cannot be induced by suggestion and relieved by methods of persuasion. The ordinary physical manifestations of the disease, such as anesthesia, hyperesthesia, paralyses, convulsions, etc., Babinski describes as stigmata. His theories lead him to suggest "pithiatism" as the correct name for hysteria.
A revolutionary and epochmaking contribution to the literature of this important subject was the publication of their "Studien über Hysterie" by Breuer and Freud in 1895. The latter has made various further expositionsof his views more recently. What the ultimate outcome of the hysteria problem may be, only time can determine. No consideration of the subject, however, is complete, nor should any definite conclusions be attempted, without a thorough understanding of theories which have a material bearing on the mental mechanisms involved in all of the psychoneuroses. Breuer and Freud advanced the suggestion that hysteria is always the result of a psychic trauma. The mechanisms involved may be very briefly summarized. Studies of everyday life show that the peculiar amnesia often observed for certain names and events does not mean usually in the average individual a mere fading of memory with the lapse of time. Freud found that the inability to recall things in such cases is largely due to the fact that they are for some reason or other unpleasant in nature and therefore not desirable to remember. They are accordingly pushed into the background as it were, by burying them in the subconscious strata of the mind and intentionally obliterating them from memory. When the ordinary well balanced individual is confronted with an unpleasant situation he meets it as best he can, by the exhibition of normal reactions of various sorts. He treats the matter lightly, dismisses it as a joke or "laughs it off." His dignity may be maintained by a display of anger or resentment. The mental equilibrium may be restored by a resort to profanity, tears, violence, or even physical flight. An emotional outlet in the form of hate or thoughts of revenge may be necessary to settle the question and finally dispose of it by "getting it off the mind." There are unpleasant situations which for various reasons cannot be met and treated in this ordinary way. The mental shock of the "psychic trauma" may, for instance, be the result of an occurrence which is so distasteful and repulsive as to be incompatible with the present existence. There being no other escape from such a difficulty, it isrejected by the psychic censor, to use Freud's expression, and repressed or forced into the subconscious. This is the inadequate reaction which takes place in hysteria and leads to a dissociation and rudimentary splitting of the consciousness. Freud finds that in practically every instance the repressed and painful idea is due to a psychic trauma resulting from some incident of a sexual nature; furthermore, that it usually dates back to the time of childhood. These buried sexual complexes are completely disposed of by what Freud speaks of as the process of "conversion," the associated affect being radiated, as it were, into the physical sphere where it is converted into a memory symbol in the form of an hysterical symptom. The mental symptoms of the disease he explains as the results of the elaboration and development of hypnoid states or erotic day-dreams of the individual. Freud[336]summarized his views in a series of formulae "which strive to progressively exhaust the nature of hysteria" asfollows:—
"1. The hysterical symptom is the memory symbol of certain efficacious (traumatic) impressions and experience.
"2. The hysterical symptom is the compensation by conversion for the associative return of the traumatic experience.
"3. The hysterical symptom—like all other psychic formations—is the expression of a wish realization.
"4. The hysterical symptom is the realization of an unconscious fancy serving as a wish fulfilment.
"5. The hysterical symptom serves as a sexual gratification, and represents a part of the sexual life of the individual (corresponding to one of the components of his sexual impulse).
"6. The hysterical symptom, in a fashion, corresponds to the return of the sexual gratification which was real in infantile life but had been repressed since then.
"7. The hysterical symptom results as a compromise between two opposing affects or impulse incitements, one of which strives to bring to realization a partial impulse, or a component of the sexual constitution, while the other strives to suppress the same.
"8. The hysterical symptom may undertake the representation of diverse unconscious nonsexual incitements, but can not lack the sexual significance."
The practical application of these theories of Freud is illustrated by the line of treatment suggested. By his method of "catharsis" the repressed and forgotten painful idea is restored to the conscious sphere of the mind and a normal reaction brought about by "affording an outlet to the strangulated affect through speech." To accomplish this result it is obviously necessary to find out what the psychic trauma was that originally caused the repression. For this purpose he uses psychoanalysis, hypnosis and the study of dreams. Psychoanalysis is nothing more or less, as Campbell says, than a sort of "scientific confessional", a complete analysis of the mental mechanisms of the individual in a search for the buried complexes. It has largely been preferred by Freud to hypnosis, the latter often being impracticable for various reasons. The association test of Sommer was very successfully adapted to the determination and explanation of buried complexes by Jung. Freud's views as to the analysis of dreams in the unravelling of mental mechanisms are set forth in full in his "Traumdeutung" (1900). He describes a dream as being "the more or less disguised fulfilment of a suppressed wish." Owing to the activities of the psychic censor we may have either manifest or latent dreams. The former are recalled on waking; the latter are distorted or forgotten and indicate therepressed wish. He classifies dreams as, those which represent an unexpressed wish as being fulfilled, those which represent the realization of the wish in some entirely concealed form and those which represent it in a form insufficiently or partly concealed. Freud justified his emphasis of the sexual element in his studies of the psychoneuroses by the publication of his "Drei Abhandlungen zur Sexualtheorie." In this he calls attention to the neglected importance of sexual factors in the developing mentality of the child and shows that these influences are manifested long before the age of puberty. He even maintains that the normal child is homosexual as well as incestuous at a certain stage. These erotic impulses are largely unconscious and become submerged, playing an important part later in the development of the neuroses.
Kraepelin has devoted one hundred and sixty pages of his work on psychiatry to a consideration of the subject of hysteria. The mental symptoms of the disease are all described as being definitely associated with twilight or dream states (Dämmerzustände). These he refers to as including somnambulisms, definite excitements, attacks assuming a characteristic silly or "puerile" form, confusions, deliria of various kinds, the Ganser complex, prison stupors and double personalities (retrograde amnesia). He does not accept Freud's views as to the influence of the sexual life in the etiology of hysteria.
Neurasthenia was first described by Beard of New York in 1880. As has already been shown, it was referred to by Kraepelin as one of the psychogenic neuroses. Freud is much inclined to question the existence of such an entity as the classic neurasthenia described by Beard. He feels that most of the cases can be traced to a definite association with some other psychosis. Hedoes, however, recognize a neurasthenic complex which is entirely sexual in origin and attributes it to the excessive masturbation of adult life. The symptoms, according to Freud, are a result of the inadequate sexual relief afforded by the habit, and are those of nervous exhaustion, a sense of pressure or fulness in the head, spinal irritation, hyperesthesias, paresthesias, diminished sexual power, and occasionally a mild form of emotional depression. He would also differentiate another psychoneurosis of sexual origin—the anxiety neurosis (Angstneurose). He mentions an increased irritability as a prominent symptom often in the form of an oversensitiveness to noises. The characteristic feature, however, is a state of anxious expectation. This may manifest itself in a mere uneasiness and general tendency towards pessimism or may approach a state of hypochondriasis with paresthesia and annoying somatic sensations. Fear of sudden death may be experienced. There may be physical symptoms such as disturbed heart action (palpitation or tachycardia), disturbance of respiration (dyspnea or asthmatic attacks), profuse perspiration, periods of trembling, dizziness, attacks of inordinate appetite, diarrhea, etc. Nocturnal frights are common. The symptoms as outlined above are accompanied by a marked anxiety. He finds anxious psychoses usually in women, in the form of virginal fears in adults, the anxiety of the newly married, similar states occurring in widows or intentional abstainers, and fears occurring at the climacterium. This condition in women he believes to be due as a rule to coitus interruptus or ejaculatio praecox. Similar anxieties in men, according to Freud, are due to abstinence, frustrated sexual excitement, coitus interruptus or senile conditions. Masturbation may also be a factor. He also admits that there are causes other than sexual, in the form of overwork, serious illnesses, etc. The mentalmechanism involved is a "deviation of the somatic sexual excitement from the psychic, and in the abnormal utilization of this excitement occasioned by the former."
In 1903 Janet formulated his conception of psychasthenia, describing it as a clinical entity. In this grouping he included the obsessions of doubt, phobias, imperative ideas, impulsive obsessions, compulsions and other conditions described by various authors. The essential mechanism to be considered, according to Janet, is a "lowering of the psychological tension." This results, as White expresses it, in an inadequate perception of the realities of the outside world. Meyer has spoken of psychasthenia as "a lowering of general interest and tendency to rumination over what is accessible to the patient in his memory, but is not squarely met, and where the normal reaction is replaced by rumination, substitutive acts and panics." These conditions are described by Freud as belonging to the "Zwangsneurose" or compulsion neuroses. The obsessing ideas force themselves into the consciousness of the individual, who is perfectly clear as to their inconsistency but cannot escape them. These he also looks upon as being of sexual origin and due to repression as in hysteria. After the unpleasant idea is repressed, however, the mechanism is different. Instead of converting the concept into a bodily symbol, a defense reaction displaces the affect from the painful thought, connecting it with some entirely disinterested and innocuous idea. This process he spoke of as substitution. This transference, as in hysteria, takes place in the subconscious and is not recognized by the patient as having anything to do with his peculiar symptoms. Compulsive ideas prevent the recurrence in thought, of the repressed etiological factor. It must be conceded that these mechanisms are exceedingly interesting from a psychological point of view. Freud's theories have, however, met with a great deal of opposition, due apparently to the fact thatall of his conceptions are based almost exclusively on the influence of the sexual life on the human mind. The characteristic and entirely consistent Freudian answer to this objection is that it is a "defense reaction." Without attempting to determine the exact basis of the psychoneuroses the fact remains that their importance from a psychiatric point of view cannot be questioned. They constitute in a large measure the field of observation covered by the out-patient clinics and psychopathic hospitals. They played an exceedingly important part in the psychiatry of the late war.
Leaving out of consideration the mental mechanisms involved, the American Psychiatric Association has endeavored to collect statistical data relating to the various psychoneuroses generally recognized, as is shown by the suggestions regarding their delimitation, in themanual:—
"The psychoneurosis group includes those disorders in which mental forces or ideas of which the subject is either aware (conscious) or unaware (unconscious) bring about various mental and physical symptoms; in other words these disorders are essentially psychogenic in nature.
"The term neurosis is now generally used synonymously with psychoneurosis, although it has been applied to certain disorders in which, while the symptoms are both mental and physical, the primary cause is thought to be essentially physical. In most instances, however, both psychogenic and physical causes are operative and we can assign only a relative weight to the one or the other.
"The following types are sufficiently well defined clinically to be specified:
"(a) Hysterical type: Episodic mental attacks in the form of delirium, stupor or dream states during which repressed wishes, mental conflicts or emotional experiencesdetached from ordinary consciousness break through and temporarily dominate the mind. The attack is followed by partial or complete amnesia. Various physical disturbances (sensory and motor) occur in hysteria, and these represent a conversion of the affect of the repressed disturbing complexes into bodily symptoms or, according to another formulation, there is a dissociation of consciousness relating to some physical function.
"(b) Psychasthenic type: This includes the compulsive and obsessional neuroses of some writers. The main clinical characteristics are phobias, obsessions, morbid doubts and impulsions, feelings of insufficiency, nervous tension and anxiety. Episodes of marked depression and agitation may occur. There is no disturbance of consciousness or amnesia as in hysteria.
"(c) Neurasthenic type: This should designate the fatigue neuroses in which physical as well as mental causes evidently figure; characterized essentially by mental and motor fatigability and irritability; also various hyperesthesias and paresthesias; hypochondriasis and varying degrees of depression.
"(d) Anxiety neuroses: A clinical type in which morbid anxiety or fear is the most prominent feature. A general nervous irritability (or excitability) is regularly associated with the anxious expectation or dread; in addition there are numerous physical symptoms which may be regarded as the bodily accompaniments of fear, particularly cardiac and vasomotor disturbances; the heart's action is increased, often there is irregularity and palpitation; there may be sweating, nausea, vomiting, diarrhea, suffocative feelings, dizziness, trembling, shaking, difficulty in locomotion, etc. Fluctuations occur in the intensity of the symptoms, and acute exacerbations constituting the "anxiety attack."
"(e) Other types."
The psychoneuroses occur very infrequently in institutions for mental diseases. In 49,640 first admissions to the New York state hospitals during a period of eight years, only 671 cases were reported as neuroses or psychoneuroses, constituting 1.35 per cent of the total. Of this number 29.97 per cent were of the hysterical type, 37.35 of the psychasthenic, 30.27 of the neurasthenic form, and 2.41 per cent were anxiety psychoses. In the Massachusetts hospitals during the year 1919, thirty-six, or 1.19 per cent, of the 3,011 admissions reported were neuroses or psychoneuroses. Of these, 44.83 per cent were of the hysterical, 24.14 of the psychasthenic, and 18.39 per cent of the neurasthenic forms. On analyzing 18,336 admissions to twenty-one hospitals in other states we find 297 cases of neurosis or psychoneuroses, 1.63 per cent of the total. Of these, 44.11 per cent were cases of hysteria, 28.28 of psychasthenia, 22.90 of neurasthenia and 4.71 per cent of anxiety psychoses. The neuroses or psychoneuroses constituted 1.42 per cent of over seventy thousand admissions to all institutions. Of the 1,048 psychoneuroses reported, 35.20 per cent were cases of hysteria, 33.68 of psychasthenia, 29.19 of neurasthenia, and 3.91 per cent of anxiety psychoses.