III.
In both cases thus far considered the defense of the unbearable idea was brought about by the separation of the same from its affect; the idea though weakened and isolated remained in consciousness. There exists, however, a far more energetic and more successful form of defense wherein the ego misplaces the unbearable idea with its affect, and behaves as though the unbearable idea had never approached the ego. But at the moment when this is brought about the person suffers from a psychosis which can only be classified as an “hallucinatory confusion.” A single example will explain this assertion. A young girl gives her first impulsive love to a man who she firmly believed reciprocated her love. As a matter of fact she was mistaken; the young man had other motives for visiting her. It was not long before she was disappointed; at first she defended herself against it by converting hysterically the corresponding experience, and thus came to believe that he would come some day to ask her in marriage; but in consequence of the imperfect conversion and the constant pressure of new painful impressions, she felt unhappy and ill. She finally expects him with the greatest tension on a definite day, it is the day of a family reunion. The day passes but he does not come. After all the trains on which he could have come have passed she suddenly merged into an hallucinatory confusion. She thought that he did come, she heard his voice in the garden, and hastened down in her night gown to receive him. For two months after she lived in a happy dream, the content of which was that he was there, that he was always with her, and that everything was as before (before the time of the painfully defended disappointment). The hysteria and depression were thus conquered; during her sickness she never mentioned anything about the last period of doubt and suffering; she was happy as long as she was left undisturbed, and frenzied only when a regulation of her environment prevented her from accomplishing something which she thought quite natural as a result of her blissful dream. This psychosis, unintelligible as it was in its time, was revealed ten years later through hypnotic analysis.
The fact to which I call attention is this: That the content of such an hallucinatory psychosis consists in directly bringing into prominence that idea which was threatened by the motive of the disease. One is therefore justified in saying that through its flight into the psychosis the ego defended the unbearable idea; the process through which this has been brought about withdraws itself from self perception as well as from the psychological-clinical analysis. It is to be considered as the expression of a higher grade of pathological disposition, and can perhaps be explained as follows: The ego tears itself away from the unbearable idea, but as it hangs inseparably together with a part of reality, the ego while accomplishing this performance also detaches itself wholly or partially from reality. The latter is, in my opinion the condition under which hallucinatory vividness is decreed to particular ideas, and hence after very successful defense the person finds himself in a hallucinatory confusion.
I have but very few analyses of such psychoses at my disposal; but I believe that we deal with a very frequently employed type of psychic illness. For analogous examples such as the mother who becoming sick after the loss of her child continues to rock in her arms a piece of wood, or the jilted bride who in full dress expects her bridegroom, can be seen in every insane asylum.
It will perhaps not be superfluous to mention that the three forms of defense here considered, and hence the three forms of disease to which this defense leads may be united in the same person. The simultaneous occurrence of phobias and hysterical symptoms, so frequently observed in praxis, really belongs to those moments which impede a pure separation of hysteria from other neuroses and urge the formation of the “mixed neuroses.” To be sure the hallucinatory confusion is not frequently compatible with the continuation of hysteria and not as a rule with obsessions; but on the other hand it is not rare that a defense psychosis should episodically break through the course of a hysteria or mixed neurosis.
In conclusion I will mention in few words the subsidiary idea of which I have made use in this discussion of the defense neuroses. It is the idea that there is something to distinguish in all psychic functions (amount of affect, sum of excitement), that all qualities have a quantity though we have no means to measure the same—it is something that can be increased, diminished, displaced, and discharged, and that extends over the memory traces of the ideas perhaps like an electric charge over the surface of the body.
This hypothesis, which also underlies our theory of “ab-reaction” (“Preliminary Communication”), can be used in the same sense as the physicist uses the assumption of the current of electric fluid. It is preliminarily justified through its usefulness in the comprehension and elucidation of diverse psychic states.
CHAPTER VI.
On the Right to Separate from Neurasthenia a Definite Symptom-complex as “Anxiety Neurosis”
(Angstneurose).
It is difficult to assert anything of general validity concerning neurasthenia as long as this term is allowed to express all that for which Beard used it. I believe that neuropathology can only gain by an attempt to separate from the actual neurosis all those neurotic disturbances the symptoms of which are on the one hand more firmly connected among themselves than to the typical neurasthenic symptoms, such as headache, spinal irritation, dyspepsia with flatulence and constipation, and which on the other hand show essential differences from the typical neurasthenic neurosis in their etiology and mechanism. If we accept this plan we will soon gain quite a uniform picture of neurasthenia. We will soon be able to differentiate—sharper than we have hitherto succeeded—from the real neurasthenia the different pseudoneurasthenias, such as the organically determined nasal reflex neurosis, the neurotic disturbances of cachexias and arteriosclerosis, the early stages of progressive paralysis, and of some psychoses. Furthermore, following the proposition of Moebius, some status nervosi of hereditary degenerates will be set aside and we will also find reasons for ascribing some of the neuroses which are now called neurasthenia to melancholia, especially those of an intermittent or periodic nature. But we force the way into the most marked changes if we decide to separate from neurasthenia that symptom-complex which I shall hereafter describe and which especially fulfills the conditions formulated above. The symptoms of this complex are clinically more related to one another than to the real neurasthenic symptoms, that is, they frequently appear together and substitute one another in the course of the disease, and both the etiology as well as the mechanism of this neurosis differs basically from the etiology and the mechanism of the real neurasthenia which remains after such a separation.
I call this symptom-complex “anxiety neurosis” (Angstneurose) because the sum of its components can be grouped around the main symptom of anxiety, because each individual symptom shows a definite relation to anxiety. I believed that I was original in this conception of the symptoms of anxiety neurosis until an interesting lecture by E. Hecker[[41]] fell into my hands. In this lecture I found the description of the same interpretation with all the desired clearness and completeness. To be sure, Hecker does not separate the equivalents or rudiments of the attack of anxiety from neurasthenia as I intend to do; but this is apparently due to the fact that neither here nor there has he taken into account the diversity of the etiological determinants. With the knowledge of the latter difference every obligation to designate the anxiety neurosis by the same name as the real neurasthenia disappears, for the only object of arbitrary naming is to facilitate the formulation of general assertions.