FOOTNOTES:

Now, on approaching the field of war the readjustment necessary is one of the more difficult ones experienced in life, although it is by no means so difficult as can arise in various situations appertainingto the field of sex. It is an adjustment which practice shews is possible to the large majority of men, but there is no doubt that the success with which it is carried out is extremely variable in different people; and it probably varies in the same person from time to time for either internal reasons or for external reasons relating to the precise environment at the moment, to the precise war experiences through which they may be passing. It is further clear that the readjustment is likely to vary in its success almost entirely with the success with which the earlier adjustments were made during the development of the individual. This statement is meant to carry more than its obvious meaning that the more stable a man is the more surely can he meet the problems and difficulties of warfare; it has a deeper implication. Namely, there is an important relationship between the two phases of difficult adjustment, the current one and the older one. Fundamentally it is the same difficulty, the same conflict; it is only the form that is different. Let us suppose, for instance, that the original difficulty in adjustment was over the matter of cruelty, that in childhood the conflict between strong tendencies of this kind and perhaps specially strong ideals of the contrary sort was an exceptionally sharp one, so that it was never very satisfactorily resolved, though a working equilibrium may have been established on the basis of powerful reaction-formations and various protective devices for avoiding in every possible way contact with the subject of cruelty. Such a man may well have unusual difficulty in adapting himself to the cruel aspects of war, which really means that his long-buried and quite unconscious impulses to cruelty, impulses the very possibility of whose existence he would repudiate with horror, are stimulated afresh by the unavoidable sights and deeds of war. In bayonet practice, for instance, the man is taught how best to inflict horrible injuries, and he is encouraged to indulge in activities of this order from the very thought of which he has all his life been trying to escape. He now has to deal afresh with the old internal conflict between the two sides of his nature, with the added complication that there has to take place an extensive revaluation of his previous standards, and in important respects an actual reversal of them. He has to formulate new rules of conduct, to adopt new attitudes of mind, and to accustom himself to the idea that tendencies of which he had previously disapproved with the whole strength of his ego-ideal are now permissible and laudatory under certain conditions. One would get a very erroneous view of the picture I am trying to draw if one imagined that the process of readjustment in question goes on in the person’s consciousness. This is never entirely true, and often not atall true; the most important part of the readjustment, and often the whole of it, is quite unconscious. We thus see that to obtain a proper understanding of the problems of an individual case, and to be able to deal with them practically in therapeutics, it is often necessary to appreciate the relation between a current conflict and an older one, for the real strength and importance of the current one is often due to the fact that it has aroused buried and imperfectly controlled older ones.

I have taken the one instance of cruelty, but there are many others in connection with warfare. It may, indeed, be said in general that the process of re-adaptation in regard to war consists of two distinct sides: on the one hand, war effects an extensive release of previously tabooed tendencies, a release shewn in endless ways—for instance, even in the language of camps; and on the other hand the acquiring of a strict discipline and self-control along lines widely different from those of peace-times. The one is a correlative of the other, and we have perhaps in these considerations a psychological explanation of the feature of military life that is so puzzling to most civilians—namely, the extraordinary punctiliousness that a rigid discipline attaches to matters which to the outsider appear so trivial. An indisciplined army has always been the bane of commanders, and perhaps the risks attaching to indiscipline are related to the release of imperfectly controlled impulses that war deliberately effects.

The way in which a relative failure in war adaptation may lead to a neurosis can be illustrated by a parallel drawn from the more familiar problems of peace neuroses. Imagine a young woman who has never been able to reconcile the sexual sides of her nature with her ego ideal, and whose only way of dealing with that aspect of life has been to keep it at as great a distance from her consciousness as possible. If now she gets married, it may happen that she will find it impossible to effect the necessary reconciliation, and that, being deprived of themodus vivendi—namely, the keeping sexuality at a distance—which previously made it possible to maintain a mental equilibrium, she develops a neurosis in which the repressed sexual desires achieve a symbolic and disguised expression. Similarly in a war neurosis when the old adjustment between the ego-ideal and the repressed impulses is taken away, it may prove impossible to establish a fresh one on the new conditions, and then the repressed impulses will find expression in some form of neurotic symptom.

So far as I can judge, the specific problems characteristic of the war neuroses are to be found in connection with two broad groups of mental processes. One of these relates to the question of war adapttation considered above, the other to that of fear. The latter is hardly to be regarded as a sub-group of the former, inasmuch as there is no readjustment or transvaluation of values concerned, as there typically is with the former. The moral attitude towards fear, and the conflicts arising in connection with it, remain the same in war as in peace. In both cases it is considered a moral weakness to display or be influenced by fear, and especially to give in to it at the cost of not doing one’s duty. The soldier who would like to escape from shell fire is, so far as moral values are concerned, in the same position as a man in peace-time who will not venture his life to save a drowning child. Indeed, the conflict cannot be as sharp in the case of the soldier, for he would find very widespread and thorough sympathy for his quite comprehensible desire, and there would be much less social blame or guilt attaching to him than to the man in the other situation mentioned. So that the problem of fear, which we all agree plays a central part in connection with the typical war neuroses, seems to be apart from that of war adaptation in general as expounded above.

Before discussing the problem of fear, however, I should like at this point to review the position and see how far we have got in the attempt to approximate the facts of war neuroses to the psycho-analytical theory. This theory of the neuroses is a very elaborate one, including many problems of unconscious mechanisms, distinctions between the predispositions and mechanisms characteristic of the different neuroses, and so on, but it is possible to formulate the main principles of it along fairly simple lines, and I now propose to do this in a series of statements.

(1) The first principle in Freud’s theory of neurotic symptoms is that they are of volitional origin. This principle, long suspected by both the medical and the lay public, and the real reason why in the past they have been so confounded with malingering, would be at once evident were it not for the fact that it is not true of volition in the ordinary sense of conscious deliberate voluntary purpose. In other words, it is not true of the will as a whole, but only of a part of it—namely, a part that the patient is not aware of. Thus, neuroses are not diseases or accidents that happen to a person, as the French school of psychopathology maintains, but are phenomena produced and brought about by some tendency in the person’s mind, and for specific purposes. Freud distinguishes three classes of motives that operate in this way, one essential, the other two not. The indispensable one is an unconscious desire to obtain pleasure by gratifying in the imagination some repressed and dissociated impulse, a motive, therefore, arising in the part of the mind that is notin harmony with the ego-ideal. A second motive is to achieve some end in the outer world; for instance sympathy from an unkind husband, which the person finds easier to do by means of a neurosis than in other ways. The third set of motives has the same purpose as the last, but may be distinguished from it in that they concern the making use of an already existing neurosis rather than the helping to bring one about. Both the latter sets are usually, but not always, unconscious: more strictly, they are preconscious—that is, they do not relate to deeply buried tendencies, and so are correspondingly easy to reveal; Freud terms them the primary and secondary “gain of illness” respectively. Now I take it that this principle of volitional origin is no longer very widely questioned by modern psychopathologists, and in the case of war neuroses the main motives are visible and comprehensible enough—namely, the desire to find some good reason for escaping from the horrors of warfare.

(2) The second principle is that all neurotic symptoms are the product of an intrapsychical conflict which the person has failed satisfactorily to resolve, and that they constitute a compromise formation between the two conflicting forces. Here, again, I think that those who have been investigating the psychology of war neuroses will agree with this principle. MacCurdy,12in particular, has described in great detail the conflict that arises in soldiers between, on the one hand, the motives actuating to continuance at duty and concealment of growing sense of incapacity and apprehension, and, on the other, the awful sense of failure accompanying the sometimes almost overwhelming desire to escape from the horrors of their position. The neurosis offers a way out of this dilemma, the only way that the particular person is able to find, and the actual symptoms, which are often grossly incapacitating, such as blindness, represent the fulfilment of the desire against which the man has been fighting. We reach, therefore, the wish-fulfilment part of Freud’s theory.

(3) The third principle is that the operative wish that leads to the creation of the neurosis is an unconscious one. Freud means this in the full sense of the word, and in this sense the principle has not yet been confirmed from the experience of the war neuroses. There are, however, different degrees of unconsciousness of a mental process, and the important point to Freud is not so much the degree of the unawareness in itself—this being largely an index of the repression—as the repression or dissociation that has led to the unawareness. What he maintains is that the wish producing the neurosis is one that is not in harmony with the ego-ideal, and which is thereforekept at as great a distance as possible from it. Anyone who has read the touching accounts given by MacCurdy or Rivers13of the shame that soldiers feel at their increasing sense of fear, and the efforts they make to fight against it, to conceal it from others, and if possible from themselves, will recognise that the wish in question is one alien to the ego-ideal and is well on in the first stages of repression, even if it is half-avowed.

(4) The fourth principle is that current repressed wishes cannot directly produce a neurosis, but do so only by reviving and reinforcing the wishes that have been repressed in older unresolved conflicts. According to Freud, a pathogenetic disappointment or difficulty in readjustment leads first to an introversion or turning inwards of feeling, and the wish that has been baulked seeks some other mode of gratification. It tends to regress back to an older period of life, and thus to become associated with similarly baulked and repressed wishes belonging to older conflicts. It is the combination of these two, the present and the old, that is the characteristic mark of the pathogenesis of neurotic disorders as distinct from other modes of reaction to the difficulties of life.

Freud considers that there are probably always three factors in the causation of any neurosis: a specific hereditary predisposition, secondly an unresolved infantile conflict which means that the person has not satisfactorily developed past a given stage of individual evolution—in other words, that he has been subjected to what is called an “infantile fixation” at a given point in development, and thirdly the current difficulty. There is a reciprocal relationship between these three factors, so that if any one is especially pronounced the others may be correspondingly less important. For instance, if the hereditary factor is very pronounced then a person may become neurotic from the quite ordinary experiences of childhood and adult life, for he is incapable of dealing adequately with them. In the case of war neuroses it is evident that the current factor is of the greatest importance, being, indeed, the only one that so far has attracted attention. The only traces of infantile factors I have seen noted have been the instances where the localisation of hysterical symptoms seems to have been determined in part by the site of old injuries, and in a general way the many traits of childhood, such as sensitiveness to slights, self-centredment, and desire to be guarded, protected, and helped, which are sometimes very evident in the cases of war neurosis.

We thus see that only one half of the psycho-analytical theory has so far been confirmed by the observations of war neuroses. According to this theory, there are typically two sets of wishes concerned in the production of any neurosis. One of these, the “primary gain of illness”, a current one, alien to the conscious ego ideal, and therefore half repressed and only half conscious—if that—has not only been demonstrated by a number of observers, but has been shewn to be of tremendous importance, and certainly the effects of treatment largely turn on the way in which it is dealt with. The other factor, the infantile and altogether repressed and unconscious one, which, according to psycho-analysis, is also essential to the production of a neurosis, has not been systematically sought for, though I have found it in the few cases of which I have been able to make a full study. Its presence or absence is a matter of greater theoretical importance than might perhaps appear, even though its practical importance may often not be great. For my own part I have the utmost difficulty in believing that a current wish, however strong that is half conscious and sometimes fully conscious can ever in itself produce a neurosis, for it contradicts all one’s knowledge concerning the nature of neuroses, as well as my experience, such as it is, of war neuroses themselves. I would therefore urge that no conclusion is possible on the matter one way or the other until adequate investigations have been carried out. That it has its practical side also will be pointed out when we come to consider the chronic cases where war neuroses pass over into peace ones.

(5) The principle of the psycho-analytical theory that has aroused the strongest opposition is that the primary repressed wish ultimately responsible for the neurosis is always of a sexual nature, so that the conflict is between the two groups of instincts that go to make up the whole personality, those concerned respectively with preservation of the self and of the species. Dr. MacCurdy has suggested to me that this is so only because, apart from war, there is no instinct that comes into such strong conflict with the ego-ideal as does the sexual one, but that in war the conflict between the instinct for self-preservation and the ego-ideal is enough to lead to a neurosis. This may seem very plausible, but I shall be surprised if it is confirmed by future research. That a neurosis, which after all is a disorder of the unconscious imagination, should arise from a conflict between two states of mind that are fully in contact with reality would be something entirely contradictory of our past experience, as would also a neurosis arising from a conflict between two tendencies both belonging to the ego. I shall venture to put forward an alternative hypothesispresently when discussing the subject of fear, which we have next to consider.

Freud states14that from one point of view all psychoneurotic symptoms may be regarded as having been constructed in order to prevent the development of fear—another point of contact between his theory and the observers of war neuroses, who would surely agree that fear is the central problem they have to deal with. By fear is here meant rather the mental state of dread and apprehension, increasing even into terror, and accompanied by well-marked bodily manifestations, a state for which psychopathologists have agreed to use the term “morbid anxiety” (or, shortly, “anxiety”) in a special technical sense as being the nearest equivalent of the German wordAngst.

Morbid anxiety is certainly the commonest neurotic symptom, and the theory of its pathogenesis has been the occasion of a very great deal of investigation,15with, in my opinion, very fruitful results. We meet it in the form of a general apprehensiveness of impending danger and evil, as the anxiety-neurosis, and also in hysteria in the form both of apparently causeless attacks of dread and of innumerable specific phobias. In all its forms its most striking feature is the disproportion between its intensity and its apparent justification, so that it seems at first sight extremely difficult to correlate with the biological view of fear as a useful instinct that guards against danger. Practically all modern investigations into its pathogenesis agree that it stands in the closest relation with unsatisfied and repressed sexuality, and, in my judgment, the conclusion that morbid anxiety represents the discharge of repressed and unconscious sexual hunger is one of the most securely established in the whole of psychopathology; it is impossible here to consider the extensive evidence in support of this conclusion, and I can only refer to the published work on the subject16.

The next question is: What is the relation between morbid anxiety as seen in peace neuroses and real—i.e., objectively justified—fear, as seen in various situations of acute danger and so prominently in the war neuroses? The point of connection is the defensive character of the reaction. Morbid anxiety, as we are familiar with it in the peace neuroses, is a defensive reaction of the ego against the claims of unrecognised “sexual hunger” (Libido), which it projects on to the outsideworld—e.g., in the form of phobias—and treats as if it were an external object; it is, in a word, the ego’s fear of the unconscious. But there appears to be an important difference between it and “real” dread in that the latter concerns only the ego itself, arises only in connection with external danger to the ego, and has nothing to do with the desires of repressed sexual hunger. One is tempted to say that the latter (real dread) is a normal protective mechanism that has nothing to do with the abnormal mechanism of morbid anxiety. Here, however, as elsewhere, the line between normality and abnormality is not so absolute as might appear, and consideration of the matter leads one to examine more closely into the nature of real dread itself. We then see that this can be dissected into three components, and that the whole reaction is not appropriate and useful as is commonly assumed. The reaction to external danger consists normally of a mental state of fear, which will be examined further in a moment, and in various activities suited to the occasion—flight, concealment, defence by fighting, or even sometimes by attacking. On the affective side there is, to begin with, a state of anxious preparedness and watchfulness, with its sensorial attentiveness and its motor tension. This is clearly a useful mental state, but it often goes on further into a condition of developed dread or terror which is certainly the very reverse of useful, for it not only paralyses whatever action may be suitable, but even inhibits the functioning of the mind, so that the person cannot judge or decide what he ought best to do were he able to do it. The whole reaction of “real” fear is thus seen to consist of two useful components and one useless one, and it is just this useless one that most resembles in all its phenomena the condition of morbid anxiety. Further, there is seen to be a complete lack of relation between development of dread and the degree or imminence of danger, nor does it bear any relation to the useful defensive activities. Thus, one does not flee because one is frightened, but because one perceives danger; in situations of extreme danger men very often respond with suitable measures of flight, fight, or what not, when they are not in the least degree frightened; on the other hand, the neurotic can be extremely frightened when there is no external danger whatever. The inference from these considerations is that even in situations of real danger a state of developed dread is not part of the useful biological mechanism of defence, but is an abnormal response akin to the neurotic symptom of morbid anxiety.

In a recent publication17Freud has made the striking suggestion that the developed dread sometimes found in situations of real danger is derived, not from the repressed sexual hunger that is directed towards external objects, as is the case with morbid anxiety of the peace neuroses, but from the narcissistic part of the sexual hunger that is attached to the ego, and I venture to suggest that we may here have the key to the states of terror with which we are so familiar in the war neuroses. The psycho-analytic investigations of recent years have laid increasing stress on the distinction between “object-libido”, the sexual impulses that are directed outwards, and the “ego-libido”, the narcissistic portion that is directed inwards and constitutes self-love. There is good reason to suppose that the latter is the more primary of the two, and also the more extensive—though the least explored as yet—so that it constitutes, as it were, a well from which externally directed sexuality is but on overflow. The analogy naturally occurs to one of the protoplasmic outpourings in the pseudopodia of the amœba, and the reciprocal relation of these to the main body seems to be similar to that between love of others and self-love. It has been known for some time that there is a limit on the part of the organism to tolerate without suffering more than a given quantity of sexual hunger in its familiar sense of impulses directed outwards, and analytic study of the psychoses, notably of paraphrenia, has shewn that the same is even more profoundly true of the narcissistic sexual hunger. In both cases, before other symptoms are formed so as to deal with the energies in question and bind them, the first thing that happens is a discharge in the form of morbid anxiety, so that we reach the comforting conclusion that a normal man would be entirely free from dread in the presence of any danger, however imminent, that he would be as fearless as Siegfried; it is a gratifying thought that there seem to be many such in our Army to-day. It seems to me probable that the intolerance of narcissistic sexual hunger which leads to dread in the presence of real danger is to be correlated with the inhibition of the other manifestations of the fear instinct, with the accumulated tension characteristic of the mode of life in the trenches.

I would suggest, therefore, that investigations be undertaken from this point of view with cases of war neurosis, especially the anxiety cases. Many of the features noted by MacCurdy18, for instance, accord well with the picture of wounded self-love: thus, the lack of sociability, the sexual impotence and lack of affection for relatives and friends, the feeling that their personality has been neglected, or slighted, that their importance is not sufficiently recognised, and so on. Perhaps a new light may also be thrown in this way on the attitude of such patients towards death. I understand that a great part of the war neurotic symptoms, and the battle dreams in particular, havebeen widely interpreted as symbolising the desire to die so as to escape from the horrors of life, an interpretation that does not accord well with the equally widespread view that the fundamental cause of such neuroses is a fear of death. I greatly doubt, on the contrary, whether the fundamental attitude is either a fear of death in the literal sense or a desire for death. The conscious mind has difficulty enough in encompassing in the imagination the conception of absolute annihilation, and there is every reason to think that the unconscious mind is totally incapable of such an idea. When the idea of death reaches the unconscious mind it is at once interpreted in one of two ways: either as a reduction of essential vital activity, of which castration is a typical form, or as a state of nirvana in which the ego survives, but freed from the disturbances of the outer world.

A word in conclusion as to the therapeutic aspects of psycho-analysis in the war neuroses. Even if it were possible, I see no reason whatever why a psycho-analysis should be undertaken in the majority of the cases, for they can be cured in much shorter ways. But I consider that a training in psycho-analysis is of the very highest value in treating such cases, from the understanding it gives of such matters as the symbolism of symptoms, the mechanisms of internal conflict, the nature of the forces at work, and so on, and there is certainly a considerable class of cases where psycho-analysis holds out the best, and sometimes the only, prospect of relief—namely, in those chronic cases where the war neurosis proper has, by association of current with older conflicts, passed over into a peace neurosis and become consolidated as such.

1I shall only here take into consideration the most important publications out of the enormous amount of neurological literature of the war, and only in so far as this refers to psycho-analysis. I am indebted to Dr. M. Eitingon and Prof. Dr. A. v. Sarbó for access to the necessary authorities.

2One of Oppenheim’s critics has suggested that these words so difficult to pronounce might be used as test words in the examination of paralytic disturbances of speech, so that they might at least be of some good.

3These facts have been confirmed in the course of the conference by all taking part in the discussions.

4(“Münchner Mediz. Wochenschrift”. 1918, No. 42, P. 1150.)

5The hallucinations, which those persons who having had an amputation experience, that that part of the body which has been taken away is still there, might find an explanation from this source.

6The intention of the medical department of the Prussian War Ministry in regard to the organisation of psycho-analytical treatment stations was not carried out in consequence of the altered political situation, which took place soon after the Congress.

7Read before the Royal Society of Medicine, Section of Psychiatry, April 9, 1918. Published in the Proceedings, Vol. XI. Reprinted in “Papers on Psycho-Analysis”: Jones, 2nd. Ed. 1918, Ch. XXXIII, p. 564. (Baillière, Tindall & Cox.).

8By Freud,“Allgemeine Neurosenlehre”, 1917, S. 286.

9Eder, “War Shock,” 1917.

10MacCurdy, “War Neuroses”,Psychiatric Bull., July, 1917, pp. 252, 253.

11Trotter, “Instincts of the Herd in Peace and War”, 1916.

12MacCurdy,op. cit.

13Rivers, “The Repression of War Experience”,Proceedings of the Royal Society of Medicine, 1918, xi (Sect. of Psych.), p. 1, Dec. 4, 1917.

14Freud,op. cit., S. 470.

15The latest discussion of the subject will be found in Freud’s “Allgemeine Neurosenlehre,” 1917, chapter xxv,“Die Angst”. See also his papers in“Sammlung kleiner Schriften zur Neurosenlehre,”1906, chapters v, vi, vii, and a general review of the subject in my “Papers on Psycho-Analysis,” 2nd ed., 1918, chapter xxvii, “The Pathology of Morbid Anxiety”.

16Seealso Stekel, “Angstzustände,” 2e. Aufl., 1912.

17Freud,op. cit., S. 502.

18MacCurdy,op. cit., pp. 269-272.

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