FOOTNOTE:

[16] The principle of reserve energy was developed independently by my friend, William James, and myself.

[CHAPTER XXXIV]
DYNAMIC ENERGY

Whenever the dynamic energy is exhausted and the levels of reserve energy are reached, the individual affected begins to feel restless, and if there is no access to the levels of reserve energy, the individual gets scared. The fear instinct becomes awakened, giving rise, after repeated unavailing attempts, to the states of psychopathic neurosis. In states of depression, such as hypochondria and more especially in states of melancholia, the fear instinct is potent. The fear instinct is brought about in the darkness of the night, when the individual is fatigued from his day’s labor, when the external stimuli are at a minimum, and reserve energy is not available. The fear instinct rises from the subconscious regions to the surface of conscious activities.

Convalescent states as well as exhaustion from pain and disease, such as fever or a shock from some accident, war-shock, shell-shock, surgical shock predispose to the manifestation of the fear instinct. Hence the caution of surgeons in the preparation of the patient for a serious operation. For the result may be a shock to the system due to the subconscious activities of the fear instinct present in subconscious mental life, no longer protected by the guardianship of the upper consciousness. And it may also be shown, both by experiment and observation, that during the subconscious states when the lower strata of dynamic energy are reached, such as hypnoidal, hypnoid states, and sleep, that the individual is more subject to fear than during the waking states. We know how a sudden noise, a flash of light during drowsy states or sleep startles one, and the same holds true of any stimulus. I have observed the same condition of fright during hypnoidal states.

We must agree with the French psychologist, Ribot, when he comes to the conclusion that “every lowering of vitality, whether permanent or temporary, predisposes to fear; the physiological conditions which engender or accompany it, are all ready; in a weakened organism fear is always in a nascent condition.”

The fear instinct becomes morbid when the individual has to draw on his reserve energy, and finds he is unable to do it. The cure consists in the release of the reserve energy which has become inaccessible. This can be done by various methods, but the best is the method of induction of the hypnoidal state under the control of a competent psychopathologist. The whole process consists in the restitution of the levels of dynamic energy and the building up of the patient’s active personality.

From our point of view, fear is not necessarily due to pain previously experienced, it may be purely instinctive. The fear instinct may be aroused directly, such for instance is the fear of young children who have never before experienced a fall. In fact we claim that the fear instinct and the restlessness which expresses it antedate and precede pain. The fear of pain is but one of the forms under which the fear instinct is manifested. The fear instinct appears long before pain and pleasure come into existence. This holds true not only of the lower animal life, but also of the vague fear found in many a case of neurasthenia and functional neurosis and psychosis. Ribot also calls attention to pantophobia. “This is a state in which the patient fears everything, where anxiety instead of being riveted on one object, floats as a dream, and only becomes fixed for an instant at a time, passing from one object to another, as circumstances may determine.”

It is probably best to classify fears as antecedent and subsequent to experience, or fears as undifferentiated and differentiated.

When the dynamic energy is used up in the course of life adaptations, and reserve energy is drawn upon, there may be danger that the energy may be used up until the static energy is reached, and neuropathic conditions are manifested. These conditions are preceded by psychopathic disturbances. Associative life becomes disturbed, and emotional reactions become morbid. There is a degeneration or reversion to earlier and lower forms of mental activity, and to lower instinctive life. The primitive instincts, the impulse of self-preservation and the fear instinct, come to the foreground, giving rise to the various forms of psychopathic affections.

This process of degeneration and simplification is characteristic of all forms of psychopathic conditions, though it may be more prominent in some cases than in others. The type of mental life becomes lowered and there is a reversion, a sort of atavism, to simpler and more childish experiences, memories, reactions of earlier and less complex forms of mental life. I have laid special stress on this feature of psychopathic reactions in all my works on the subject. What I emphasize in my present work is the fact that psychopathic reactions are dominated by self and fear, which are laid bare by the process of degeneration.

The patient in psychopathic states is tortured by his fears, he is obsessed by wishes which are entirely due to his fear and deranged impulse of self-preservation.

As the static energy is reached, and with lack of functional energy of the dynamic character, the energy habitually used in the ordinary relations of life, the patient experiences a monotony, a void in his life activity. He has a feeling of distress, as if something is haunting him, and possibly something terrible is going to happen to him or his family. He may have a feeling of some depression, and may suffer from a constant unquenchable craving for new stimulations, run after new impressions and excitements which pale in a short time on his fagged mind. He is restless, demanding new amusements and distractions. He is distracted with fear, conscious and more often subconscious,—which he is unable to dispel or shake off. He seems to stand over a fearful precipice, and he is often ready to do anything to avoid this terrible gap in his life. Life is empty, devoid of all interest; he talks of ennui and even of suicide; he is of a pessimistic, gloomy disposition, his state of mind approaching a state of melancholia. He asks for new sensations, new pleasures, new enjoyments which soon tire him. He is in the condition of a leaking barrel which never can be filled.

Psychopathic individuals are in a state of the wicked “who are like the ocean which never rests.” This misery of ever forming wishes and attempting to assuage the inner suffering, this craving for new pleasures and excitements, in order to still uneasiness, distress, and the pangs of the fear instinct with its gnawing, agonizing anxieties, brings the patient to a state in which he is ready to drink and use narcotics. The patient seeks ways to relieve his misery. The patient has used up all his available dynamic energy, and being unable to reach the stores of reserve energy looks for a key or stimulant to release his locked up reserve energies. The patient is unable to respond to the stimuli of life, so he attempts then the use of his static energy. This can only result in producing psychopathic and neuropathic symptoms.

The patient needs to be lifted out of the misery of monotony and ennui of life, he needs to be raised from his low level of vitality, to be saved from the listlessness into which he has fallen. The low level of energy makes him feel like a physical, nervous, and mental bankrupt. This bankruptcy is unbearable to him. He is in a state of distraction, distracted with the agony of fear. Something must be done to free himself from the depression of low spirits and from the low level of energy which keeps him in a state devoid of all interest in life, accompanied by physical, mental and moral fatigue. He is like a prisoner doomed to a life long term.

This constant craving for stimulation of energy, this reaction to the anxiety of the morbid fear instinct is the expression of exhaustion of available dynamic energy for the purpose of normal life activity. The patient attempts to draw on his latent reserve energy. Since this form of energy is not accessible to the stimulations of common life, he tries to release the energy by means of artificial stimulations, be it morphine, alcohol, mysticism, Freudism, sexual and religious “at-one-ments” or by other stimuli of exciting character. Unable to release energy by fair means the patient is driven to the employment of foul means for the stimulation of new sources of energy. The psychopathic patient is driven by fear, by fears of life and death.

The morbid fear instinct in all cases is brought about by exhaustion of energy, whether sudden or gradual. Fear is due to exhaustion of lower levels of dynamic energy and to the inability of liberation of stored up reserve energy. The more intense this incapacity of utilization of reserve stores of energy be, the more intense is the fear. When this condition is prolonged the psychopathic symptoms become unendurable.

The experienced, thinking surgeon has learned the danger of this condition in his operating room. Thus it is told of Porta, the great surgeon of Pavia, when his patients died under an operation, he used to throw his knife and instruments contemptuously to the ground, and shout in a tone of reproach to the corpse: “Cowards die of fear.”

The great physiologist Mosso gives a graphic description of the effects of fear in a pathetic case that has come under his personal observation: “As army surgeon, I had once to be present at the execution of some brigands. It was a summary judgment. A major of the besaglieri put a few questions to one or two, then turning to the captain said simply: ‘Shoot them.’ I remember one lad, of scarcely twenty years of age, who mumbled replies to a few questions, then remained silent, in the position of a man warding off a fatal blow, with lifted arms, extended palms, the neck drawn between the shoulders, the head held sideways, the body bent and drawn backwards. When he heard the dreadful words he emitted a shrill, heart-rending cry of despair, looked around him, as though eagerly seeking something, then turned to flee, and rushed with outspread arms against a wall of the court, writhing and scratching it as though trying to force an entrance between the stones, like a polyp clinging to a rock. After a few screams and contortions, he suddenly sank to the ground, powerless and helpless like a log. He was pale and trembled as I have never seen anyone tremble since. It seemed as though the muscles had been turned to a jelly which was shaken in all directions.”

[CHAPTER XXXV]
FEAR VARIETIES

The great psychologist Ribot classifies fears into pain fears, and disgust fears. To quote from Ribot: “I propose to reduce them (fears) to two groups. The first is directly connected with fear and includes all manifestations, implying in any degree whatever the fear of pain, from that of a fall or the prick of a needle, to that of illness or death. The second is directly connected with disgust, and seems to me to include the forms which have sometimes been called pseudophobia (Gelineau). Such are the fear of contact, the horror of blood and of innocuous animals, and many strange and causeless aversions. Let us remark furthermore that fear and disgust have a common basis, being both instruments of protection or defense. The first is the defensive-conservative instinct of relative life, the second the defensive-conservative instinct of organic life. As both have a common basis of aversion, they show themselves in equivalent ways: fear of withdrawal, departure, flight, disgust by vomiting and nausea: The reflexes of disgust are the succedanea of flight; the organism cannot escape by movement in space from the repugnant object which it has taken into itself, and goes through a movement of expulsion instead.”

I hesitate to accept Ribot’s classification, inasmuch as we have pointed out that fear is prior to pain. In most lower animals it is hardly probable that not having representations that there is present a fear of pain in advance of the pain itself. Fear under such conditions can only be awakened by an actual sensory experience whether it be painful or not. In fact Ribot himself agrees to the fact that “There is a primary, instinctive, unreasoning fear preceding all individual experience, a hereditary fear.”

Perhaps a word may be said in regard to the factor of disgust as having a common basis with fear. It is only by a stretch of imagination, if not by a stretch of words, that fear and disgust can be identified. There may be fear where there is no disgust, and there may be disgust where there is no fear. The two are independent variables, and can hardly be referred to as one and the same fundamental reaction, such as withdrawal and flight. The object of disgust does not preclude approach. The avoidance or aversion, the nausea and vomiting are all subsequent phenomena. Disgust may even follow after an abuse of food, of pleasant or necessary objects of nutrition, such as satiety.

The reactions of the fear instinct run the contrary way, approach is precluded from the very start. Fear is not associated with useful objects or events, unless it be in morbid states of fear.

And still fear and disgust may become intimately associated when disgust and its objects awaken the fear instinct, and the fear becomes the fear of disgust or of the disgusting object. Disgust is more of a specialized character, and is associated with particular events or specific objects, while fear, in its primitive form at least, is more of a generalized character.

In the higher forms of life disgust may be so intimately related to fear that the two become synthesized, so to say, and are felt like one emotional state, the state becoming one of fear disgust. In such cases the fear instinct, fear disgust, is a determining factor of the morbid state. This is confirmed by clinical experience of the various cases of psychopathic functional neurosis and psychosis.

In the various morbid states of the depressive types fear is awakened long before any pain is actually suffered, or any particular cause is found by the patient to account for the terror that dominates his mental life. The fear comes first while the representative cause is assigned by the sufferer as the cause of the fear.

Similarly in the functional psychosis and neurosis the object, experience, event, may be quite ordinary without any suggestion of pain or distress in it. In fact, the experience may be indifferent or even pleasant, but when associated with the fear instinct may become the nucleus of a very distressing pathological state. The experience is the occasion, while the fear instinct, the intimate companion of the impulse of self-preservation, is the only cause of functional psychopathic maladies.

The fear instinct in its primitive state is anterior to all experiences of danger, pain, and suffering, as is the case in most of the lower animals. In the higher animals where memory is developed, the fear instinct is associated with some form of representation, however vague, and then fear becomes posterior to experience. In man both forms of fear are present. The anterior form is specially found in children, while in adults the posterior form is, under normal conditions, predominating. The primitive anterior type of the fear instinct is by no means absent, in fact, it is more overpowering, its effects are overwhelming when it comes forth from the subconscious regions to which it is confined, and is manifested under conditions of lowered vitality.

When the strata of dynamic energies are passed and the strata of reserve energies are reached, the reserve energy not being accessible, the fear instinct is elemental, fundamental, while the fear of pain and of some definite representation of danger, or of suffering is a secondary consequence. People may suffer from pain, disease, and even danger, and still have no fear, while others may have never experienced the pain or disease, and still be obsessed by intense pangs of fear. Fear is sui generis, it is at the foundation of animal life.

The fear instinct may be awakened directly by a sensory stimulus, when, for instance, one finds himself in darkness and feels some creeping, slimy thing, or when attacked suddenly with a club or a knife. The fear instinct may again be aroused by an expectation, by something to which his dynamic energies cannot respond adequately, while the reserve energies are in abeyance, such for instance as the expectation of some threatening event either to himself or to the objects bound up with his life existence. When one is threatened with some misfortune, with torture, death, or with a mortal disease, or with a serious operation, or when confronted with great danger against which his energies prove inadequate, in such cases the fear is ideational. These types of fear may in turn be either conscious or subconscious.

We may thus classify the fears as follows:

{ Conscious
I.Sensory{
{ Subconscious
{ Conscious
II.Ideational{
{ Subconscious

The fear of the etherized or chloroformed patient is entirely of the subconscious type. It is the arousing of subconscious fear which, from the nature of the case, cannot be reached and alleviated that gives rise to functional psychosis and neurosis.

From this standpoint it may be said that psychopathic diseases are subconscious fear states, in other words functional psychosis or neurosis is essentially a disease of subconscious activities. This is, in fact, confirmed by my clinical experience and by my psychopathological research work.

Dr. L. J. Pollock, professor of nervous diseases at Northwestern University Medical School, made an extremely interesting “Analysis of a Number of Cases of War Neurosis.” This analysis fully conforms to the results obtained by me in my work on functional psychosis and neurosis carried on for a great number of years. It fully confirms the results of my studies, clinical and psychopathological, that the causation, or etiology of functional psychopathic states depends on fluctuations of the levels of neuron energy, or physical exhaustion, fatigue, hunger and thirst, or shock to the system, and more especially on the ravages of the fear instinct, aroused during the dangers and horrors of war.

“Of several hundred cases which I observed in base hospitals in France, copies of about 350 records were available. From these 200 of the more detailed ones were selected to determine the relative frequency of some of the factors.... From the numerical group has been excluded cases of emotional instability, timorousness, hospital neuroses occurring as an aftermath of an illness or a wound, the phobic reactions of gassed patients and constitutional neuroses, and those not directly related to the war.

“Heredity as a factor plays but a small part, and the incidence of neuropathic taint constituted little over 4 per cent.

“Of these 43 per cent followed shell fire, 36 per cent after concussion as described by the soldier.... A definite history of fatigue and hunger was obtained in 30.5 per cent. Both probably occurred in a greater percentage, but were frequently masked by other symptoms which occupied the patient’s attention to a greater extent. Fatigue and hunger are important factors, not only because they prepare the ground for an ensuing neurosis by breaking down the defensive reactions, but also in that when the patient is more sensitive and impressionable, the natural physical consequences of fatigue are misinterpreted by him as an evidence of an illness, and give rise to apprehension and fear.

“As frequently as fear is seen in some form or other in the neuroses of civil life, so does it manifest itself in the war neuroses. Fifty per cent of the cases admitted considerable fear under shell fire. Concussion was the immediate precipitating cause of the neuroses in 31 per cent of the cases. The symptoms of the neuroses could be divided into those of the reactions of fear and fatigue.”

These results corroborate my work on neurosis as due to exhaustion of Neuron Energy and Self-Fear.

In fact, in one of my works written at the beginning of the war, I predicted the wide occurrence of what is known as shell shock, war shock or war neurosis. The prediction was fully corroborated by the facts.

Fear, Self, Reserve Energy, and Fatigue are the main factors in the formation of the psychopathic or neurotic condition. Janet, in a recent article of his, lays stress on the fear states in psychopathic affections and refers these conditions to the levels of vital energy. There is no doubt that Janet lays his finger on the very heart of the psychopathic diathesis.

In my work I come to a similar conclusion only I lay more stress on the fear states, being referred to the fundamental instinct present in all animal life as a primordial condition of existence. This instinct is intensified and extended in the psychopathic diathesis.

The level of energy and the fear instinct are vitally interdependent. A low level of energy, especially a dissociation or inhibition of the store of reserve energy, arouses an excess of reaction of the fear instinct, and vice versa the excessive reaction of the fear instinct locks up the stores of reserve energy, thus intensifying and extending the psychopathic states with their fear-fatigue conditions. Janet refers indirectly to the impulse of self-preservation which is of the utmost consequence in psychopathic affections. On the whole, I may say that my work and clinical experience are in accord with that of the great French psychopathologist.

Where the fear instinct, self, and inhibition of reserve energy are present, then any emotion, even that of love, and devotion, will give rise to psychopathic states. This psychopathic state is not produced, because of the intensity or repression of the emotion, but because of the underlying subconscious predisposition to fear-instinct, self-preservation, and inhibition of reserve energy.

The feelings of inhibited reserve energy produced by fear and self, make the individual hesitate in decision, in action, and finally demoralize and terrorize him. These conditions take away from him all assurance and security of life and action, and hold him in a perpetual state of anxiety until he becomes completely incapacitated for all kinds of action and reaction.

Events that threaten the impulse of self-preservation of the individual, such as misfortunes, shocks, losses, tend to bring about psychopathic states, on account of the aroused fear instinct, on account of the impulse of self-preservation, and sudden inhibition of the stores of reserve energy. Events that may lead to dissolution of personality are, hence, attended with intense anxiety.

As we have seen, an intense state of fear, conscious or subconscious, produces a state of aboulia, a state of indecision, a state of incompletion of action, a state of insufficiency, a paralysis of will power, and a sense of unreality, all of which are intimately interrelated. For the fear instinct, when intense, inhibits and arrests the will and paralyzes action. The patient fears, not because he is inactive, but he is inactive, because he fears.

The impulse of self-preservation, the fear instinct, and the principle of subconscious reserve energy give an insight into the multiform symptomatology of the psychopathic diathesis.

The following classes of people are subject to psychopathic affections:

(I) Childless people.

(II) People who had been afflicted with various diseases in childhood.

(III) Children of sickly, nervous, psychopathic parents who have kept their progeny in a constant state of anxiety, full of terrors and troubles of life.

(IV) People who had been affected by a series of shocks and fears in childhood and youth.

(V) People whose parents suffered long from various systemic diseases, especially cardiac and tubercular troubles.

(VI) In a large family of children the first, or last child, or sickly child of psychopathic parents.

(VII) The only child, or sickly child, especially of a widowed parent who is of a psychopathic diathesis.

In all these cases the psychopathic state is due to early cultivation of the fear instinct, self-impulse, and low level or dissociated state of vital reserve energy.

[CHAPTER XXXVI]
CONTROL OF THE NEUROTIC[17]

The first thing in the examination and treatment of neurosis is the elimination of any physical trouble. It is only after such an elimination that one should resort to psychotherapeutic treatment.

In psychopathic or neurotic diseases one should take into consideration the fact that the patients are characterized by the tendency of formation of habits which are hard to break. The patients are apt to ask that the same thing be done again and again for the simple reason that it has been done several times before. In other words, psychopathic neurosis is characterized by automatism and routine. This tendency to recurrence is characteristic of all forms of primitive life as well as of mental activities which are on the decline,—it is the easiest way to get along.

Effort is abhorrent to the patient. He is afraid of change in the same way as the savage is afraid of any novelty or of any change in custom. Tradition is holy, and in a double sense, because it has been handed down by former generations, regarded as divine and superior, and because the new is strange and, therefore, may prove dangerous and of evil consequence. What has not been tried may prove harmful, pernicious, and even deadly. The old has been tried and approved by generations and the consequences are known, while the new may be in alliance with evil powers. This holds true in all cases obsessed by the impulse of self-preservation and the fear instinct. What the patients have tried several times and what has proved good and pleasant is demanded by the patient to be repeated; the new is not known and may be risky, dangerous. I have great difficulty in making changes in the life of advanced psychopathic cases, because of the fear of the new, neophobia. Once the change is made, and the patient becomes adapted to the new way, then the old way is shunned. In short, neophobia is an essential trait of psychopathic patients.

The physician must take this trait of neophobia into account, and as the patient begins to improve, he must gradually and slowly wean the patient of this phobia, inherent in the very nature of the malady. The patient must learn to do new things, and not simply follow mechanically a régime, laid out by the physician.

The patient’s life must become personal. The patient should be made to change many of his ways, and above all he should learn to follow reason, rather than habit and routine. Everything, as much as possible, should be reasoned out,—he should be able to give a rational account of his habits and actions. Whatever appears to be a matter of routine, irrational and unaccountable habit, simply a matter of recurrence, of repetition of action, should be discarded, should be changed to actions and adaptations for which the patient could give a rational account.

We must remember that the patient lives in the condition of recurrent mental states, that his mental activity, as I have pointed out, follows the laws of recurrence, characteristic of the type of recurrent moment consciousness.[18] It is, therefore, the physician’s object to lift the patient out of this low form of mental activity to the higher types of rational, personal life in which the patient can rise above the perturbations of life, above the pettiness of existence with its worries and fears. This procedure is essential.

We can realize how pernicious are those schemes which physicians and many people in sanitariums lay out for the patients just to keep them busy for the time of their stay under special care. As soon as the patients leave, they are in the same predicament as before. The patients wish to have their lives conducted in the same mechanical, automatic routine. In this way they are really on the same low plane of mental life, on the plane of recurrent moment consciousness, a type which forms the pathological web and woof of the patient’s life.

Unless the patient is lifted out of this low, mean, and animal form of conscious activity, he cannot be regarded as cured. Instead of having the patient’s life saturated and controlled by the recurrent automatisms of the fear instinct, he should learn to be controlled by the light of reason. “A free man is he,” says Spinoza, “who lives under the guidance of reason, who is not led by fear.” Epicurus and the ancient Epicureans laid special stress on the necessity of getting rid of fear through reason, enlightenment, and education. Thus the great poet Lucretius:

“The whole of life is a struggle in the dark. For even as children are flurried and dread all things in the thick darkness, thus we in the daylight fear things not a whit more to be dreaded than those which the children shudder at in the dark and fancy future evils. This terror, therefore, and darkness of mind must be dispelled not by the rays of the sun and glittering shafts of day, but by knowledge of the aspect and law of nature.”

As Carlyle tersely puts it: “The first duty of a man is still that of subduing Fear. We must get rid of Fear; we cannot act at all till then. A man’s acts are slavish, not true but specious (we may add psychopathic); his very thoughts are false, he thinks too as a slave and coward, till he has got Fear under feet.... Now and always, the completeness of his victory over Fear will determine how much of a man he is.”

The patient complains of lack of confidence. This is a pathognomonic symptom of psychopathic states. At the same time there is confidence in the symptom complex which is often described by him with microscopic minuteness. The patient has no doubt about that. He is in search of some one who can overcome this symptom complex in a way which he specially approves. The patient matches his morbid self-will against the physician’s control. The physician is not to be subdued by the authority of the diseased personality, he should not let himself be controlled by the ruling symptoms of the patient’s life. Either the physician meets with opposition, and after some time, must give up the treatment of the case, or he is victimized by the patient’s demands, and must comply with them. In the latter case the patient may stick to the physician for some time. In both cases the patient is not really cured. It is only when the diseased self becomes subdued and falls under the physician’s control, it is only then that a cure is really possible, it is only then that the normal healthy self may come to the foreground.

The first and foremost characteristic of psychopathic states is the narrowing down of the patient’s life interests. He begins to lose interest in abstract problems, then in that of his own profession or occupation, then he loses interest in the welfare of his party or his country, and finally, in his family, wife, and children. Even in the case of love, the psychopathic patient seeks to utilize the person he loves for his own, neurotic benefit, namely, his neurotic comfort and health. He loves the person as a glutton likes his meal, or as a drunkard his liquor. The self becomes narrowed down to health, the key to his supposed spiritual life. Self-preservation and fear permeate the patient’s life.

We notice that the patient’s life activity, especially his mental functions, becomes narrowed down. His attention becomes circumscribed to a few subjects and objects. This is the limitation of the extent of attention. There is afterward a limitation of the temporal span of attention. The patient cannot keep his attention on any subject for any length of time. This span of attention becomes more and more limited with the growth and severity of the psychopathic malady. If the patient is educated and has had an interest in various subjects, the latter become more and more limited in scope. Finally the patient becomes reduced to the least amount of effort of the attention, and that only for a brief period of time. When the trouble reaches its climax, the patient loses all interest and capacity of reading and of studying. He cannot think, he becomes less and less original in his thoughts, he becomes even incapable of thinking. The patient’s whole mind becomes limited to himself and to the symptoms of his disease.

Along with it the fear instinct grows in power, inhibiting all other activities. There is a limitation of the patient’s personal self. The personality becomes reduced to the lowest levels of existence, caring for his own selfish pains and small pleasures, which are exaggerated and magnified to an extraordinary degree. In other words, the personal life of the patient becomes more and more limited as the pathological process goes on. It becomes harder and harder for the patient to take an active interest in life.

It is clear that under such conditions the tendency of the patient is to rest and brood about himself, and keep indulging his limited interests, which get still more narrowed as the pathological process becomes more extensive and intensive. Under such conditions it is suicidal to indulge the patient and suggest to him a rest cure, a cure which lies along the line of the disease process, thus tending to intensify the disease. What the patient needs is to change his environment, and be put under conditions in which his interests of life can be aroused. His life activities should be stimulated to functioning on the right lines, laid out by physicians who understand the patient’s condition. Rest is harmful to the neurotic. What the patient needs is work, work, and work.

What we must remember in the treatment of psychopathic patients is the fact that we deal here with the aberrations of the impulse of self-preservation, the most powerful, the most fundamental, and the least controllable of animal impulses, accompanied with the fear instinct, which is the most primitive of all animal instincts. This morbid state of the impulse of self-preservation must be fully realized before any treatment is begun. The physician must also see and study closely the line on which the self-preservation impulse is tending, and comprehend the associations along which the impulse takes its course in the history of the patient and in the symptom complex.

What one must especially look after is the elusive feeling of self-pity which manifests itself under various garbs, and hides itself under all kinds of forms. As long as the patient is introspective and has the emotional side of self-pity present, so long is his condition psychopathic.

The extreme selfishness and the uniqueness with which psychopathic patients regard their own condition should be eradicated from their mind. It must be impressed on them that their case is quite common, and that there is nothing exceptional about them. It must be made clear to them that the whole trouble is a matter of mal-adjustment, that they have developed inordinately the impulse of self-preservation and the fear instinct until their mental life has become morbid and twisted. The whole personality has to be readjusted. It is the special tendency of psychopathic patients to regard themselves as unique, privileged above all other patients, they are a kind of geniuses among the afflicted, possibly on account of the special endowments possessed by them, gifts of quite exceptional and mysterious a character. “Have you ever met with a case like mine?” is the stereotyped phrase of the psychopathic, neurotic patient. As long as the patient entertains that conception of nobility, the impulse of self must still be regarded as morbid.

The neurotic must be made to understand clearly that there is no aristocracy in disease, and that there is no nobility of the specially elect in the world of morbid affections, any more than there is in the domain of physical maladies.

The egocentric character of the psychopathic patient puts him in the position of the savage who takes an animistic, a personal view of the world and of the objects that surround him. Natural forces are regarded as dealing with man and his fate, often conspiring against man. Magic is the remedy by which the savage tries to defend himself, and even to control the inimical or friendly natural forces or objects, animate and inanimate, with which he comes in contact. This same attitude, animistic and personal, of the primitive man is present in the psychopathic patient. The patient is afraid that something fearful may happen to him. Against such accidents he takes measures often of a defensive character which differ but little from the magic of the savage and the barbarian. That is why these patients are the victims of all kinds of fakes, schemes, panaceas of the wildest type, unscrupulous patent medicines, absurd régimes, mental and religious, whose silliness and absurdity are patent to the unprejudiced observer. The mental state of the psychopathic or neurotic patient is that of the savage with his anthropomorphic view of nature, with his fears based on the impulse of self-preservation. The psychopathic patient is in a state of primitive fear and of savage credulity with its faith in magic.

The emotional side of the impulse of self-preservation and of the fear instinct should always be kept in mind by the physician who undertakes the treatment of psychopathic cases. The physician must remember that the emotions in such cases are essentially of the instinctive type, that they therefore lie beyond the ken of the patient’s immediate control and action of the personal will. The physician should not, therefore, be impatient, but while protecting the invalid against the fears that assail the latter, he should gradually and slowly undermine the violence of the impulse of self-preservation and the anxiety of the fear instinct. For in all psychopathic maladies the main factors are the impulse of self-preservation and the fear instinct.