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THE SIGNIFICANCE OF THE IDEA OF DEATH

IN THE NEUROTIC MIND1

By E. H. CONNELL.

THIS paper is based on clinical observation of persons suffering from Psychoneuroses and Psychoses, and since the terminology in medical Psychology is somewhat chaotic at the present time, it will be useful to define certain terms and to indicate the sense in which they are used in the following pages.

The term Libido is avoided and the expression "instinct interest" is used, this being the affective and conative elements in instinct experience, which give meaning to that experience and influence the reactions. The notion advanced by C. Spearman in his book on The Nature of Intelligence, that conation can and does control the intensity of cognition, is adopted and extended. The view of J. Drever, that it is the affect in the instinct experience of an animal organism that gives primary meaning to that experience, and that a secondary meaning is added by cognitive elaboration, is adopted. The term "Regression" is freely used to express a common phenomenon in Psychopathology and refers to the passing back from a higher to a lower level of Mental function, that is to say, from complex, rational, noesis, to the less complex, non-rational and more affective function operating in children and primitive people; or, further back, to the simple reflex instinctive behaviour level. In psychopathological regression, cognition is weakened and there is abundance of phantasy. This may proceed to failure of cognition, absence of the time and space conceptions, and uncontrolled impulsive actions. The term "Narcissism" is used to mean that state of mental function exhibited by the young child, in which the affect is attached to the self, to the body, and to phantasies of the self, which occurs in development before the stage of transcendence of the self to the conception of the not-self. Narcissism is characterised by self-love rather than self-interest, pleasurefeeling rather than personal advantage. The only other terms used which may be unfamiliar or have other implications than those intended here are the Reality Principle and the Pleasure Principle. These are terms

1 Read before the Scottish Branch of the British Psychological Society at Edinburgh on Feb. 2nd, 1924.

freely used by Freudian psychoanalysts; where used in this paper the Reality Principle refers to a mode of mental function which neglects, postpones or suppresses affective ends and directs itself to purposive ends or objects; the Pleasure Principle, on the other hand, is the more primitive mode of function which neglects purposive ends in favour of pleasurable affect.

Let us now consider the Significance of the idea of Death in the Neurotic mind. It is striking to notice the absence of this idea in the minds of those physically ill, and the frequent presence of it in the minds of neurotics. The writer assisted in the bacteriological and microscopical examination of 2600 dysentery stools of soldiers in the 3rd British General Hospital on the Shat al Arab in 1915, 1916 and 1917, and personally visited and talked with nearly all of these patients: it was part of his duty to get answers to a questionnaire, the main objects of which were to ascertain the source of infection, to detect the carriers, and to prevent the spread of dysentery, so that the talk was more than a cursory question, but in no case did a patient mention death or show any conscious preoccupation with it, although many were extremely ill and some died in the hospital. Amongst those 2600 patients there were some neurotics, but it appeared as though physiological preoccupation in resisting organic disease diverted attention from the idea of Death.

In melancholia there is an impulse to self-inflicted death, so that melancholics have to be sequestered and guarded for their own protection. It has been frequently noted that the mental state of the melancholic is greatly improved by the occurrence of physical disease. When suffering from bacterial invasion, or severe injury, the melancholic who has been monotonously and with agitation accusing himself of being a sinful, unworthy man, ceases to do so and may soon recover completely; it is as though the occupation of energy in physiological resistance to disease relieved a psychic tension. The death idea in melancholia seems to be associated with self-hatred or loathing, and we have now to enquire whether this is a real hatred or an affective tension 'rationalised' by the melancholic as personal unworthiness.

Freud explains the impulse to death in Melancholia in these words: "As with Paranoia, so also with Melancholia (under which, by the way, very different clinical types are classified) it has been possible to obtain a glimpse into the inner structure of the disorder. We have perceived that the self-reproaches with which these sufferers torment themselves so mercilessly actually relate to another person, to the sexual object they have lost or whom they have ceased to value on account of some fault.

From this we concluded that the melancholic has indeed withdrawn his Libido from the object, but that by a process, which we must call 'narcissistic identification' he has set up the object within the Ego itself, projected it on to the Ego.... The Ego itself is then treated as if it were the abandoned object; it suffers all the revengeful and aggressive treatment which is designed for the object. The suicidal impulses of melancholics also become more intelligible on the supposition that the bitterness felt by the diseased mind concerns the Ego itself at the same time as, and equally with, the loved and hated object. In Melancholia, as in the other narcissistic disorders...ambivalence comes markedly to the fore; by this we mean a directing of antithetical feelings (affectionate and hostile) towards the same person1." Freud then would explain the death impulse in Melancholia as the result of three processes.

1. Abandonment of the sexual object.

2. Regression of the mind to narcissism.

3. Projection of hatred from the abandoned object on to the self, resulting from identification of the self with the object.

The Freudian interpretation of the death impulse in melancholia is attractive as a simplification by analogy with paranoid mechanisms, but the fact that melancholics recover is against the supposition that projection of hatred on to the Ego occurs; and an even more weighty psychological reason for the rejection of the Freudian interpretation is that such projection does not achieve psychic ease or comfort for the melancholic. He is agitated, restless, self-accusatory or stuporose, and continues to experience impulses of self-destruction. It may make this point, as to whether projection occurs in melancholia, clearer if the series of psychic events in paranoia and melancholia are compared.

In paranoia a mental conflict has occurred between the self-regarding sentiment and an impulsive desire to do something inconsistent with that sentiment. This conflict is solved by repression of the desire, and the impulse and its affect are then attributed to another person; the paranoiac thus achieves freedom from self-blame and self-accusation, but at the expense of a delusion. But impulse and affect remain unsatisfied and they activate the delusional system; the paranoiac is rational apart from his delusion, but his self-regarding sentiment is eventually influenced by the delusion; he may injure, kill or flee from the person to whom he has projected his desire with its affect, but whatever he does the person "persecutes" him by unseen agency and countless imaginary devices. The impulse and affect are unsatisfied in reality and 1 S. Freud, Introductory Lectures on Psycho-Analysis (Eng. trans.), pp. 356–357. Med. Psych. IV

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when regression occurs within the delusion the paranoiac is inflated, as it were, by the withheld affect and the self-regarding sentiment is enhanced so that the delusion is now one of self-sufficient grandeur, power and importance. It must be noted that from first to last there is no impulse to self-destruction, and this is comprehensible from the nature of Projection.

Now the melancholic in some cases has experienced a real loss of money, position or love, but more often the situation is that there are infantile characteristics in his mental functioning and there is a disillusionment in his experience of life; he ceases to attend to reality and complains that everything seems flat, dull and "wanting in life," and he occupies himself with the "might have been." What is called by psychiatrists "depression," which is acute unpleasure, is the predominant affect; his attention is apparently devoted entirely to painful ideas; the continuation of this state of unpleasure feeling is accompanied by dreams usually of a fearful or accusatory character; the withheld affect unable to achieve real expression and unable to find occupation in phantasy by regression, is felt as a great and pressing emotion unpleasant in tone which now breaks into the self-regarding sentiment and the melancholic monotonously accuses himself of having sinned beyond redemption, and he blindly and desperately or sometimes cunningly seeks death; suddenly all is changed, he recovers completely, depression lifts, interest in the objects of perception is normal and as it was before the first insidious onset. He can tell of his experience only in terms of feeling, that it was all dreamlike, like the horror of nightmare, and that although he knew who he was and where he was and why he was under care, he felt cut off, hopeless and as though he never would be well again; he says the impulse to self-destruction was beyond his control, all he felt was he must end the "pain" and at once.

If we regard affect as instinct interest, which gives meaning to perception or to the objects of perception: if we accept the view that affect withheld from conative expression becomes emotion, and that emotion is bipolar, pleasurable in so far as it is moving towards its ends and objects, unpleasurable in so far as it is moving away from its ends and objects; then in paranoia by projection the way has been cleared for the affect to invest the Self and that Self is exalted by an enhancement of the self-regarding sentiment, so that the affect reaches an object, although it is one that has been substituted for the real object. In melancholia the affect remains unpleasurable because it is dammed back from expression in Reality and does not succeed except in chronic cases in getting

dispersed in phantasy; it remains as a tension, and this produces the impulse to death.

In a regressive psychosis such as dementia praecox, there is a stage when the death impulse is compulsive. This stage occurs only in some cases, and as a rule early in the development of the psychosis. The psychoanalytic interpretation of this phenomenon is that cases of dementia praecox disposed to suicide are individuals who have developed to the object love stage, at least to the stage of taking their parents as love objects; their instinct interest adheres to the parent object, but at puberty when there is an increase of libido they fail to invest objects other than the parents with instinct interest. This involves such cases in so many real difficulties that intrapsychic regression occurs, but because there has been investment of real objects, namely the parents, with instinct interest, this withdrawal of affect from the parents by repression produces temporarily the same feeling of unpleasurable tension as is seen in melancholia, and sudden impulses to self-destruction.

In other cases, and much more commonly, the instinct interest regresses to phantasy and the sphere of the Pleasure Principle, and this repression reaches a degradation of psychic function in which even primary meaning disappears from the objects of perception. In such cases there is no tension from withheld affect and no impulse to self-destruction. The interpretation of the extraordinary fact maintained here that the idea of death is absent from the mind of the individual physically ill but present as an impulse in the melancholic and precocious dement is that it is due to intrapsychic tension from affect withheld from conative expression, and unable to attach itself by regression to imaginative phantasy. The excitement is suspended, as it were, between the two psychic realms of Reality and Pleasure Pain, between the Reality Principle function and the Pleasure Principle function. According to the amount, which really is equivalent to the intensity, of the affective tension or excitement, there is present, the idea of death, a tendency to death, or an impulse to death.

The impulse to death in melancholia and dementia praecox has been discussed, and we have now to examine the significance of ideas of death and tendencies to death in the psychoneuroses.

There is a tendency to death in anxiety hysteria. This psychoneurosis is characterised by an affective state of dread by unreasonable anxiety, not about real problems or dangers but about the ordinary affairs of life-that from the midst of a blue sky a bolt is about to fall. Anxious hysterics think they are ill, have headaches and pains in the

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