THE PSYCHONEUROSES AND NEUROSES
The words neurosis, psychosis and psychoneurosis are of obscure origin
and have had a varied significance from time to time. Murray[332]
defines psychosis as a psychological term indicating "a change in
the psychic state; an activity or movement of the psychic organism,
as distinguished from neurosis" which he speaks of as a "change in
the nerve-cells of the brain prior to, and resulting in, psychic
activity." Huxley in discussing this subject in 1871 made the
following differentiation: "In all intellectual operations we have to
distinguish two sets of successive changes—one in the physical basis
of consciousness and the other in consciousness itself; one set which
may, and doubtless will, in course of time, be followed through all its
complexities by the anatomist and the physicist, and one of which only
the man can have immediate knowledge. As it is very necessary to keep
a clear distinction between these two processes, let the one be called
neurosis and the other psychosis."
Von Feuchtersleben used the latter word in its present psychiatric
significance in his "Lehrbuch der Aertzlichen Seelenkunde" in 1845.
Its repeated appearance in the first volume of the _Allgemeine a
Zeitschrift für Psychiatrie_ in 1844 would strongly suggest a frequent
use of the term in the German psychiatry of that day. It was unknown
in English works until quite recently, although the word is found in
Maudsley's "Responsibility in Mental Diseases" (1874)—"No wonder that
the criminal psychosis which is the mental side of the neurosis,
is for the most part an intractable malady, punishment being of no
avail to produce reformation." Lewes, in "The Problems of Life and
Mind" published after his death in 1879, makes a very significant
remark: "Pathologists call it a psychosis, as if it were a lesion of
the unknown psyche." Clouston's 1911 edition makes no reference to
psychoneuroses as such.
The word neurosis has been much more extensively employed in medical
literature. William Cullen, a well-known professor in the University
of Edinburgh, in his "First Lines of the Practice of Physic" in
1774, said: "I propose to comprehend, under the title of neuroses,
all those preternatural affections of sense or motion which are
without pyrexia, as a part of the primary disease." In his "Synopsis
Nosologicae Medicae" in 1785 he divided diseases into four general
classes: Pyrexia or febrile diseases; neuroses or nervous diseases, as
epilepsy; cachexiae or diseases resulting from bad habit of the body,
as scurvy; and locales, or local disease, as cancer. Brachet,[333] who
was one of the earlier writers on the subject of hysteria, defined that
disease in the following words in 1847: "Hysteria is a neurosis of the
cerebral nervous system, which manifests itself more or less brusquely
by crises of general chronic convulsions and by the sensation of a
globe ascending in the course of the oesophagus, at the upper extremity
of which it becomes fixed, causing there a menace of suffocation."
Briquet, another French writer, expressed somewhat similar views
in 1859. The word neurosis as now used may be said to refer to a
functional disturbance of the nervous system, which, if directly due to
etiological mental factors, is spoken of as a psychoneuroses.
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.
"4. The hysterical symptom is the realization of an unconscious fancy
serving as a wish fulfilment.
"5. The hysterical symptom serves as a sexual gratification, and
represents a part of the sexual life of the individual (corresponding
to one of the components of his sexual impulse).
"6. The hysterical symptom, in a fashion, corresponds to the return of
the sexual gratification which was real in infantile life but had been
repressed since then.
"7. The hysterical symptom results as a compromise between two
opposing affects or impulse incitements, one of which strives to
bring to realization a partial impulse, or a component of the sexual
constitution, while the other strives to suppress the same.
"8. The hysterical symptom may undertake the representation of diverse
unconscious nonsexual incitements, but can not lack the sexual
significance."
The practical application of these theories of Freud is illustrated
by the line of treatment suggested. By his method of "catharsis" the
repressed and forgotten painful idea is restored to the conscious
sphere of the mind and a normal reaction brought about by "affording
an outlet to the strangulated affect through speech." To accomplish
this result it is obviously necessary to find out what the psychic
trauma was that originally caused the repression. For this purpose he
uses psychoanalysis, hypnosis and the study of dreams. Psychoanalysis
is nothing more or less, as Campbell says, than a sort of "scientific
confessional", a complete analysis of the mental mechanisms of the
individual in a search for the buried complexes. It has largely been
preferred by Freud to hypnosis, the latter often being impracticable
for various reasons. The association test of Sommer was very
successfully adapted to the determination and explanation of buried
complexes by Jung. Freud's views as to the analysis of dreams in
the unravelling of mental mechanisms are set forth in full in his
"Traumdeutung" (1900). He describes a dream as being "the more or less
disguised fulfilment of a suppressed wish." Owing to the activities of
the psychic censor we may have either manifest or latent dreams. The
former are recalled on waking; the latter are distorted or forgotten
and indicate the repressed wish. He classifies dreams as, those which
represent an unexpressed wish as being fulfilled, those which represent
the realization of the wish in some entirely concealed form and those
which represent it in a form insufficiently or partly concealed.
Freud justified his emphasis of the sexual element in his studies of
the psychoneuroses by the publication of his "Drei Abhandlungen zur
Sexualtheorie." In this he calls attention to the neglected importance
of sexual factors in the developing mentality of the child and shows
that these influences are manifested long before the age of puberty.
He even maintains that the normal child is homosexual as well as
incestuous at a certain stage. These erotic impulses are largely
unconscious and become submerged, playing an important part later in
the development of the neuroses.
Kraepelin has devoted one hundred and sixty pages of his work on
psychiatry to a consideration of the subject of hysteria. The mental
symptoms of the disease are all described as being definitely
associated with twilight or dream states (Dämmerzustände). These he
refers to as including somnambulisms, definite excitements, attacks
assuming a characteristic silly or "puerile" form, confusions, deliria
of various kinds, the Ganser complex, prison stupors and double
personalities (retrograde amnesia). He does not accept Freud's views as
to the influence of the sexual life in the etiology of hysteria.
Neurasthenia was first described by Beard of New York in 1880. As has
already been shown, it was referred to by Kraepelin as one of the
psychogenic neuroses. Freud is much inclined to question the existence
of such an entity as the classic neurasthenia described by Beard. He
feels that most of the cases can be traced to a definite association
with some other psychosis. He does, however, recognize a neurasthenic
complex which is entirely sexual in origin and attributes it to the
excessive masturbation of adult life. The symptoms, according to Freud,
are a result of the inadequate sexual relief afforded by the habit,
and are those of nervous exhaustion, a sense of pressure or fulness in
the head, spinal irritation, hyperesthesias, paresthesias, diminished
sexual power, and occasionally a mild form of emotional depression. He
would also differentiate another psychoneurosis of sexual origin—the
anxiety neurosis (Angstneurose). He mentions an increased irritability
as a prominent symptom often in the form of an oversensitiveness to
noises. The characteristic feature, however, is a state of anxious
expectation. This may manifest itself in a mere uneasiness and general
tendency towards pessimism or may approach a state of hypochondriasis
with paresthesia and annoying somatic sensations. Fear of sudden death
may be experienced. There may be physical symptoms such as disturbed
heart action (palpitation or tachycardia), disturbance of respiration
(dyspnea or asthmatic attacks), profuse perspiration, periods of
trembling, dizziness, attacks of inordinate appetite, diarrhea, etc.
Nocturnal frights are common. The symptoms as outlined above are
accompanied by a marked anxiety. He finds anxious psychoses usually
in women, in the form of virginal fears in adults, the anxiety of
the newly married, similar states occurring in widows or intentional
abstainers, and fears occurring at the climacterium. This condition
in women he believes to be due as a rule to coitus interruptus or
ejaculatio praecox. Similar anxieties in men, according to Freud, are
due to abstinence, frustrated sexual excitement, coitus interruptus or
senile conditions. Masturbation may also be a factor. He also admits
that there are causes other than sexual, in the form of overwork,
serious illnesses, etc. The mental mechanism involved is a "deviation
of the somatic sexual excitement from the psychic, and in the abnormal
utilization of this excitement occasioned by the former."
In 1903 Janet formulated his conception of psychasthenia, describing
it as a clinical entity. In this grouping he included the obsessions
of doubt, phobias, imperative ideas, impulsive obsessions, compulsions
and other conditions described by various authors. The essential
mechanism to be considered, according to Janet, is a "lowering of the
psychological tension." This results, as White expresses it, in an
inadequate perception of the realities of the outside world. Meyer has
spoken of psychasthenia as "a lowering of general interest and tendency
to rumination over what is accessible to the patient in his memory,
but is not squarely met, and where the normal reaction is replaced
by rumination, substitutive acts and panics." These conditions are
described by Freud as belonging to the "Zwangsneurose" or compulsion
neuroses. The obsessing ideas force themselves into the consciousness
of the individual, who is perfectly clear as to their inconsistency
but cannot escape them. These he also looks upon as being of sexual
origin and due to repression as in hysteria. After the unpleasant
idea is repressed, however, the mechanism is different. Instead of
converting the concept into a bodily symbol, a defense reaction
displaces the affect from the painful thought, connecting it with some
entirely disinterested and innocuous idea. This process he spoke of as
substitution. This transference, as in hysteria, takes place in the
subconscious and is not recognized by the patient as having anything to
do with his peculiar symptoms. Compulsive ideas prevent the recurrence
in thought, of the repressed etiological factor. It must be conceded
that these mechanisms are exceedingly interesting from a psychological
point of view. Freud's theories have, however, met with a great deal
of opposition, due apparently to the fact that all of his conceptions
are based almost exclusively on the influence of the sexual life on
the human mind. The characteristic and entirely consistent Freudian
answer to this objection is that it is a "defense reaction." Without
attempting to determine the exact basis of the psychoneuroses the
fact remains that their importance from a psychiatric point of view
cannot be questioned. They constitute in a large measure the field
of observation covered by the out-patient clinics and psychopathic
hospitals. They played an exceedingly important part in the psychiatry
of the late war.
Leaving out of consideration the mental mechanisms involved, the
American Psychiatric Association has endeavored to collect statistical
data relating to the various psychoneuroses generally recognized, as is
shown by the suggestions regarding their delimitation, in the manual:—
"The psychoneurosis group includes those disorders in which mental
forces or ideas of which the subject is either aware (conscious) or
unaware (unconscious) bring about various mental and physical symptoms;
in other words these disorders are essentially psychogenic in nature.
"The term neurosis is now generally used synonymously with
psychoneurosis, although it has been applied to certain disorders in
which, while the symptoms are both mental and physical, the primary
cause is thought to be essentially physical. In most instances,
however, both psychogenic and physical causes are operative and we can
assign only a relative weight to the one or the other.
"The following types are sufficiently well defined clinically to be
specified:
"(a) Hysterical type: Episodic mental attacks in the form of delirium,
stupor or dream states during which repressed wishes, mental conflicts
or emotional experiences detached from ordinary consciousness break
through and temporarily dominate the mind. The attack is followed by
partial or complete amnesia. Various physical disturbances (sensory
and motor) occur in hysteria, and these represent a conversion of the
affect of the repressed disturbing complexes into bodily symptoms
or, according to another formulation, there is a dissociation of
consciousness relating to some physical function.
"(b) Psychasthenic type: This includes the compulsive and obsessional
neuroses of some writers. The main clinical characteristics are
phobias, obsessions, morbid doubts and impulsions, feelings of
insufficiency, nervous tension and anxiety. Episodes of marked
depression and agitation may occur. There is no disturbance of
consciousness or amnesia as in hysteria.
"(c) Neurasthenic type: This should designate the fatigue neuroses in
which physical as well as mental causes evidently figure; characterized
essentially by mental and motor fatigability and irritability; also
various hyperesthesias and paresthesias; hypochondriasis and varying
degrees of depression.
"(d) Anxiety neuroses: A clinical type in which morbid anxiety or fear
is the most prominent feature. A general nervous irritability (or
excitability) is regularly associated with the anxious expectation or
dread; in addition there are numerous physical symptoms which may be
regarded as the bodily accompaniments of fear, particularly cardiac and
vasomotor disturbances; the heart's action is increased, often there is
irregularity and palpitation; there may be sweating, nausea, vomiting,
diarrhea, suffocative feelings, dizziness, trembling, shaking,
difficulty in locomotion, etc. Fluctuations occur in the intensity of
the symptoms, and acute exacerbations constituting the "anxiety attack."
"(e) Other types."
The psychoneuroses occur very infrequently in institutions for mental
diseases. In 49,640 first admissions to the New York state hospitals
during a period of eight years, only 671 cases were reported as
neuroses or psychoneuroses, constituting 1.35 per cent of the total.
Of this number 29.97 per cent were of the hysterical type, 37.35
of the psychasthenic, 30.27 of the neurasthenic form, and 2.41 per
cent were anxiety psychoses. In the Massachusetts hospitals during
the year 1919, thirty-six, or 1.19 per cent, of the 3,011 admissions
reported were neuroses or psychoneuroses. Of these, 44.83 per cent
were of the hysterical, 24.14 of the psychasthenic, and 18.39 per
cent of the neurasthenic forms. On analyzing 18,336 admissions to
twenty-one hospitals in other states we find 297 cases of neurosis or
psychoneuroses, 1.63 per cent of the total. Of these, 44.11 per cent
were cases of hysteria, 28.28 of psychasthenia, 22.90 of neurasthenia
and 4.71 per cent of anxiety psychoses. The neuroses or psychoneuroses
constituted 1.42 per cent of over seventy thousand admissions to all
institutions. Of the 1,048 psychoneuroses reported, 35.20 per cent were
cases of hysteria, 33.68 of psychasthenia, 29.19 of neurasthenia, and
3.91 per cent of anxiety psychoses.