“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.