symptoms may be regarded as having been constructed in order to prevent
the development of fear—another point of contact between his theory
and the observers of war neuroses, who would surely agree that fear
is the central problem they have to deal with. By fear is here meant
rather the mental state of dread and apprehension, increasing even
into terror, and accompanied by well-marked bodily manifestations, a
state for which psychopathologists have agreed to use the term “morbid
anxiety” (or, shortly, “anxiety”) in a special technical sense as being
the nearest equivalent of the German word _Angst_.
Morbid anxiety is certainly the commonest neurotic symptom, and the
theory of its pathogenesis has been the occasion of a very great deal
of investigation,[15] with, in my opinion, very fruitful results. We
meet it in the form of a general apprehensiveness of impending danger
and evil, as the anxiety-neurosis, and also in hysteria in the form
both of apparently causeless attacks of dread and of innumerable
specific phobias. In all its forms its most striking feature is the
disproportion between its intensity and its apparent justification,
so that it seems at first sight extremely difficult to correlate with
the biological view of fear as a useful instinct that guards against
danger. Practically all modern investigations into its pathogenesis
agree that it stands in the closest relation with unsatisfied and
repressed sexuality, and, in my judgment, the conclusion that morbid
anxiety represents the discharge of repressed and unconscious sexual
hunger is one of the most securely established in the whole of
psychopathology; it is impossible here to consider the extensive
evidence in support of this conclusion, and I can only refer to the
published work on the subject[16].
The next question is: What is the relation between morbid anxiety as
seen in peace neuroses and real—_i.e_., objectively justified—fear, as
seen in various situations of acute danger and so prominently in the
war neuroses? The point of connection is the defensive character of
the reaction. Morbid anxiety, as we are familiar with it in the peace
neuroses, is a defensive reaction of the ego against the claims of
unrecognised “sexual hunger” (_Libido_), which it projects on to the
outside world—e.g., in the form of phobias—and treats as if it were an
external object; it is, in a word, the ego’s fear of the unconscious.
But there appears to be an important difference between it and “real”
dread in that the latter concerns only the ego itself, arises only in
connection with external danger to the ego, and has nothing to do with
the desires of repressed sexual hunger. One is tempted to say that the
latter (real dread) is a normal protective mechanism that has nothing
to do with the abnormal mechanism of morbid anxiety. Here, however,
as elsewhere, the line between normality and abnormality is not so
absolute as might appear, and consideration of the matter leads one
to examine more closely into the nature of real dread itself. We then
see that this can be dissected into three components, and that the
whole reaction is not appropriate and useful as is commonly assumed.
The reaction to external danger consists normally of a mental state
of fear, which will be examined further in a moment, and in various
activities suited to the occasion—flight, concealment, defence by
fighting, or even sometimes by attacking. On the affective side there
is, to begin with, a state of anxious preparedness and watchfulness,
with its sensorial attentiveness and its motor tension. This is clearly
a useful mental state, but it often goes on further into a condition
of developed dread or terror which is certainly the very reverse of
useful, for it not only paralyses whatever action may be suitable, but
even inhibits the functioning of the mind, so that the person cannot
judge or decide what he ought best to do were he able to do it. The
whole reaction of “real” fear is thus seen to consist of two useful
components and one useless one, and it is just this useless one that
most resembles in all its phenomena the condition of morbid anxiety.
Further, there is seen to be a complete lack of relation between
development of dread and the degree or imminence of danger, nor does it
bear any relation to the useful defensive activities. Thus, one does
not flee because one is frightened, but because one perceives danger;
in situations of extreme danger men very often respond with suitable
measures of flight, fight, or what not, when they are not in the least
degree frightened; on the other hand, the neurotic can be extremely
frightened when there is no external danger whatever. The inference
from these considerations is that even in situations of real danger a
state of developed dread is not part of the useful biological mechanism
of defence, but is an abnormal response akin to the neurotic symptom of
morbid anxiety.
In a recent publication[17] Freud has made the striking suggestion
that the developed dread sometimes found in situations of real danger
is derived, not from the repressed sexual hunger that is directed
towards external objects, as is the case with morbid anxiety of the
peace neuroses, but from the narcissistic part of the sexual hunger
that is attached to the ego, and I venture to suggest that we may here
have the key to the states of terror with which we are so familiar in
the war neuroses. The psycho-analytic investigations of recent years
have laid increasing stress on the distinction between “object-libido”,
the sexual impulses that are directed outwards, and the “ego-libido”,
the narcissistic portion that is directed inwards and constitutes
self-love. There is good reason to suppose that the latter is the
more primary of the two, and also the more extensive—though the least
explored as yet—so that it constitutes, as it were, a well from which
externally directed sexuality is but on overflow. The analogy naturally
occurs to one of the protoplasmic outpourings in the pseudopodia of
the amœba, and the reciprocal relation of these to the main body
seems to be similar to that between love of others and self-love. It
has been known for some time that there is a limit on the part of the
organism to tolerate without suffering more than a given quantity of
sexual hunger in its familiar sense of impulses directed outwards, and
analytic study of the psychoses, notably of paraphrenia, has shewn
that the same is even more profoundly true of the narcissistic sexual
hunger. In both cases, before other symptoms are formed so as to deal
with the energies in question and bind them, the first thing that
happens is a discharge in the form of morbid anxiety, so that we reach
the comforting conclusion that a normal man would be entirely free from
dread in the presence of any danger, however imminent, that he would be
as fearless as Siegfried; it is a gratifying thought that there seem
to be many such in our Army to-day. It seems to me probable that the
intolerance of narcissistic sexual hunger which leads to dread in the
presence of real danger is to be correlated with the inhibition of the
other manifestations of the fear instinct, with the accumulated tension
characteristic of the mode of life in the trenches.
I would suggest, therefore, that investigations be undertaken from
this point of view with cases of war neurosis, especially the anxiety
cases. Many of the features noted by MacCurdy[18], for instance,
accord well with the picture of wounded self-love: thus, the lack of
sociability, the sexual impotence and lack of affection for relatives
and friends, the feeling that their personality has been neglected,
or slighted, that their importance is not sufficiently recognised,
and so on. Perhaps a new light may also be thrown in this way on the
attitude of such patients towards death. I understand that a great part
of the war neurotic symptoms, and the battle dreams in particular,
have been widely interpreted as symbolising the desire to die so as
to escape from the horrors of life, an interpretation that does not
accord well with the equally widespread view that the fundamental
cause of such neuroses is a fear of death. I greatly doubt, on the
contrary, whether the fundamental attitude is either a fear of death
in the literal sense or a desire for death. The conscious mind has
difficulty enough in encompassing in the imagination the conception
of absolute annihilation, and there is every reason to think that the
unconscious mind is totally incapable of such an idea. When the idea of
death reaches the unconscious mind it is at once interpreted in one of
two ways: either as a reduction of essential vital activity, of which
castration is a typical form, or as a state of nirvana in which the ego
survives, but freed from the disturbances of the outer world.
A word in conclusion as to the therapeutic aspects of psycho-analysis
in the war neuroses. Even if it were possible, I see no reason whatever
why a psycho-analysis should be undertaken in the majority of the
cases, for they can be cured in much shorter ways. But I consider that
a training in psycho-analysis is of the very highest value in treating
such cases, from the understanding it gives of such matters as the
symbolism of symptoms, the mechanisms of internal conflict, the nature
of the forces at work, and so on, and there is certainly a considerable
class of cases where psycho-analysis holds out the best, and sometimes
the only, prospect of relief—namely, in those chronic cases where
the war neurosis proper has, by association of current with older
conflicts, passed over into a peace neurosis and become consolidated as
such.
FOOTNOTES:
[1] I shall only here take into consideration the most important
publications out of the enormous amount of neurological literature of
the war, and only in so far as this refers to psycho-analysis. I am
indebted to Dr. M. Eitingon and Prof. Dr. A. v. Sarbó for access to the
necessary authorities.
[2] One of Oppenheim’s critics has suggested that these words so
difficult to pronounce might be used as test words in the examination
of paralytic disturbances of speech, so that they might at least be of
some good.
[3] These facts have been confirmed in the course of the conference by
all taking part in the discussions.
[4] (“_Münchner Mediz. Wochenschrift_”. 1918, No. 42, P. 1150.)
[5] The hallucinations, which those persons who having had an
amputation experience, that that part of the body which has been taken
away is still there, might find an explanation from this source.
[6] The intention of the medical department of the Prussian War
Ministry in regard to the organisation of psycho-analytical treatment
stations was not carried out in consequence of the altered political
situation, which took place soon after the Congress.
[7] Read before the Royal Society of Medicine, Section of Psychiatry,
April 9, 1918. Published in the Proceedings, Vol. XI. Reprinted in
“Papers on Psycho-Analysis”: Jones, 2nd. Ed. 1918, Ch. XXXIII, p. 564.
(Baillière, Tindall & Cox.).
[8] By Freud, “Allgemeine Neurosenlehre”, 1917, S. 286.
[9] Eder, “War Shock,” 1917.
[10] MacCurdy, “War Neuroses”, _Psychiatric Bull._, July, 1917, pp.
252, 253.
[11] Trotter, “Instincts of the Herd in Peace and War”, 1916.
[12] MacCurdy, _op. cit._
[13] Rivers, “The Repression of War Experience”, _Proceedings of the
Royal Society of Medicine_, 1918, xi (Sect. of Psych.), p. 1, Dec. 4,
1917.
[14] Freud, _op. cit._, S. 470.
[15] The latest discussion of the subject will be found in Freud’s
“Allgemeine Neurosenlehre,” 1917, chapter xxv, “Die Angst”. See also
his papers in “Sammlung kleiner Schriften zur Neurosenlehre,” 1906,
chapters v, vi, vii, and a general review of the subject in my “Papers
on Psycho-Analysis,” 2nd ed., 1918, chapter xxvii, “The Pathology of
Morbid Anxiety”.
[16] _See_ also Stekel, “Angstzustände,” 2e. Aufl., 1912.
[17] Freud, _op. cit._, S. 502.
[18] MacCurdy, _op. cit._, pp. 269-272.