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 primary hallucinatory 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 sexual perversions, 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 a mental 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 expositions of 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 is rejected 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" as follows:—
"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.