In connection with this I would suggest that there are two aspects to be considered. First, what is the standard according to which we are to judge them? Secondly, to what extent are the reactions of the patient abnormal in kind to the driving stimulus? They may perhaps be reckoned abnormal in degree, but, to what extent, if at all, are they abnormal in kind?
It may be readily admitted that the behavior of those suffering from mental illness offends against conventional usages and is anti-social. It must also be recognized that amongst human beings living in aggregates some conventional usages must be evolved and insisted on in order to insure the greatest good of the greatest number. These usages are regarded not merely as protective measures for the body corporate, but they are also supposed to indicate a beneficial standard for the individual. But such a standard being adopted, observation is liable to be limited so much to results without sufficient attention being given to the causes which had led to those results.
By the recent advances in scientific knowledge and in methods of investigation we have been led to see that the conditions under consideration cannot be understood without a study of the mechanisms on which mental activity depends and without discovering the psychic and physical causes, arising from without and from within, which have disturbed the function of these mechanisms. We have learned that these illnesses do not arise from one cause alone and that they are the result of influences to which we all may be subject to some degree.
The originator of these modern methods, Prof. Freud, has stimulated us to regard the ordinary symptoms of mental illnesses as directing posts indicating lines to be investigated, and he and others have suggested various methods which may usefully be employed.
It is essential that we carefully distinguish what are primary from what are secondary symptoms. Two thousand years ago a physician, Areteus, pointed out that mania frequently commenced as melancholia, and he drew attention to the extreme frequency of an initial depression in cases of mental illnesses. But he did not offer any explanation of this initial state.
Such an initial state may perhaps be, to a certain extent, understood if we assume that the first evidences of mental disturbance consist in some difficulty in carrying out ordinary mental processes, some difficulty in exercise of the function of perceiving, thinking, feeling, judging, and acting, and that any disturbance of the harmonious activity of these functions must give rise to an emotional condition of anxiety and depression. Some such disharmony will, by adequate investigation, be found in a large number of cases to exist in the early states of the illness and will be appreciated by the patient before there occur any obvious signs, any outward manifestations of disability.
But in any disharmony which may occur it must be recognized that the mental mechanisms affected are those with which the patient was originally endowed, which he has gradually trained throughout his past experience and which he has employed more or less successfully up to the time the illness commenced. There is no new mechanism introduced to produce a mental illness, but a putting out of gear of those common to the race and their disturbance is the result of the action of influences which may befall any one of us, unbearable ideas with which some intense emotional state is intimately associated. The normal function of these mechanisms, simple at first and remaining fundamentally unaltered, although possibly much modified gradually by added experiences from within and without, depends on the maintenance of a harmonious balance between stimuli received and emotional reaction and motor response to those stimuli so that the feeling of well-being may arise.
If from any cause there occurs a failure to appreciate the stimuli clearly, if the emotional reactivity be disturbed, if the sense of value becomes biassed in one direction or another so that the response is recognized by the patient as abnormal there will result a disharmony and a feeling of ill-being of the organism. Under these conditions the processes of facilitation along certain definite lines and inhibition of all other lines—processes which are essential to clear consciousness—will become difficult or perhaps impossible and a mental illness will develop. In the slighter degrees the disharmony may be known to the patient without there being any outward manifestation to betray the conflict going on within. In the severe degrees the mental activity of the patient may be under the control of some dominant emotional state so that it may be impossible for him to adapt himself to his surroundings in a normal manner although his behavior may not appear so irrational when we know the stimuli affecting him. Within these extremes we discover all degrees of disturbance, and all varieties of signs and symptoms may be encountered.
But the signs which become obvious to superficial observation are, to a large extent, secondary products. The primary symptoms are felt by the patient as a disturbance of the capacity to perceive, to think, to feel, to judge, and to act, and with these disabilities there will be associated a certain degree of confusion and anxiety which cannot fail to appear as the result of such alterations of function.
The obvious signs may represent merely a more intense degree of the primary affection, disturbed capacity together with some confusion and anxiety; or they may represent efforts on the part of the patient to overcome or to escape from the disturbance or to explain it to himself. And now the total lack of knowledge of the processes on which mental activity depends, the altered standard of judgment due to some degree of dissociation, and the necessity of obtaining relief in some way or other will have much to do with determining the character of the symptoms with which we are all familiar. So many factors are concerned in the production of these secondary characters that it is difficult to assign to the symptoms their true value or to decide whether they possess much value at all with regard to the fundamental disturbance which constituted the primary illness. So often they appear to be mere rationalizations, mere false judgments on the part of the patient; they thus form subjects for investigation rather than fundamental constituents of the illness.