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He enjoys himself immensely; for his exaggerated, unchecked, selfassertive impulse obtains intense gratification through the imagining of successes and triumphs of all sorts.
Just as the primary and fundamental affect of mania (namely elation) is apt to be complicated by anger; so the primary and fundamental affect of the depressive phase, namely self-abasement, is peculiarly liable to be complicated by fear. And this fact also is in harmony with the hypothesis. When we are dominated by the submissive impulse, we feel small and weak, and other powers seem vast and overwhelming; we cannot stand up against them. If, then, this impulse becomes morbidly intensified, it is natural that the imagination shall take a fearful turn. The patient feels himself weak and helpless, and in most cases guilty (and here of course any repressed ground of selfreproach may operate as a secondary factor)1. He imagines either various offences and shortcomings, or is content to claim that he has committed "the unpardonable sin" without having the vaguest notion what the nature of that sin may be. Then, logically enough, he imagines all sorts of punishments, especially those of the vaguer kind; fire and brimstone and so forth, if his early education has taught him to believe in the devil or other such retributive agents. These imaginings then fill him with terror which may inhibit all other activities and keep him cowering in bed or other place of retreat.
A striking feature of mania is the ceaseless activity of the patient, the tremendous output of energy which, though in some cases it renders the patient thin, sometimes is maintained for a long time without producing any signs of fatigue or exhaustion, in spite of shortened sleep. The medical man, contemplating a hypomanic patient is often inclined to envy him and to wish that he also might be permanently hypomanic. Whence comes this abnormally great flow of energy? How can we account for the continuance of this tremendous output of energy without exhaustion? There are two factors to be taken into account. First, we must recognise that in the normal man the constant reciprocal play of the impulses of self-assertion and submission, through which his sober balanced reasonable view of himself and of his relations to others is maintained, involves a considerable internal consumption of energy. The process, although it is entirely normal, is yet of the nature of internal conflict; and, like the morbid conflict of the neurasthenic, it consumes energy internally without any corresponding overt activity. In the manic state this conflict, so essential to the normal conduct of life, is in
1 No doubt sexual irregularities frequently play this part.
abeyance; the self-assertive impulse works freely without any such internal consumption of energy in inhibitory work1. It works freely with all brakes removed: whatever the nature of the inhibitory process, we may liken it to the application of brakes that involves consumption of energy without external output of work.
Secondly, there is some ground for believing that all instinctive activities draw upon a common supply or source of energy. If my old hypothesis of inhibition by drainage 2 is an approximation to the truth, it follows from the fact that any one instinctive activity tends to inhibit others, that the several modes of instinctive activity must be regarded as drawing upon a common supply of energy; that the several instinctive impulses do not represent specific forms of nervous energy; but rather that, just as we do not need to postulate specific energies of sensory nerves in order to explain the specific qualities of sensation, but may attribute those specific qualities to the specific constitutions of cerebral elements, so we may suppose the energy at work in the various modes of instinctive activity to be one in nature and origin, and to be given its peculiar mode of expression in each case by the instinctive disposition through which it finds expression.
The way in which one instinctive tendency, or a group of such tendencies organized in a sentiment, may for a time dominate the whole organism at the cost of all other modes of activity (as in the case of the young man in love) bears out this view. It is facts of the order here referred to which give colour and justification to Bergson's use of the term élan vital and to Jung's use of the word 'libido,' or better still the word 'hormé,' as denoting the sum of the vital or psycho-physical energies of the organism.
If it be true that all the instincts draw upon a common source of energy, then, when one instinct or sentiment acquires decided dominance over all others, that one may be regarded as enjoying a virtual monopoly of the vital energy and as giving it outlet or expression in a peculiarly effective and economical manner, just because it works without the rivalries and inhibitory expenditures inevitably involved in balanced self-controlled conduct.
I have attempted to elucidate the physiology of instinctive action
1 It would probably be truer to say that the energy thus consumed is expended in maintaining the muscular tensions through which the poise and balance of the normal man are expressed.
2 Cp. Brain, 1902, "The Nature of Inhibitory Processes in the Central Nervous System."
along these lines in an earlier publication1. Here I will add only a point in its support from the phenomena of the manic state. If the manic state were one of generally increased excitability and lack of control, one in which all instinctive urges are manifested with unusual intensity, we should expect to find manic patients liable to much sex excitement and apt to make violent sexual assaults. But that, I believe, is not commonly the case. The dominance of the one form of excitement seems to withdraw energy from the alternative channels.
Again, the rapid volatile thinking, the so-called flight of ideas, characteristic of mania, reveals no preoccupation with any one topic, no sustained interest in any one sphere of activity; and that is the peculiarity of the self-assertive impulse as a sustainer of mental activity; it can feed upon material of all kinds, can disport itself and acquire its gratifications in any field. Further, the absence of sustained thinking directed to any particular goal is entirely in harmony with the hypothesis. Sustained thinking implies doubt, uncertainty, hesitation, or suspension of judgment; and such suspension of judgment implies some balanced opposition of active tendencies 2. But in the manic state there is, according to the hypothesis, no balancing of opposed tendencies; the one abnormally dominant tendency to self-assertion, re-enforced by the anger impulse, bears all before it; there is no internal opposition, no criticism, no suspension of judgment or doubt, the patient leaps at once to his conclusions and passes on; the question of truth or reality cannot arise in his mind; hence "the flight of ideas." And this "flight of ideas” proceeds with a maximum economy of energy, just because it is a freely working process, a process without checks and inhibitions, doubts and questionings. The form of mental activity that fatigues and exhausts is the weighing of alternatives and the making of critical judgments; and all that is lacking in the thought processes of mania.
We may perhaps add a third factor to this explanation of the great output of energy during mania. In some way that we do not understand, the pleasure or satisfaction of success promotes activity, seems to augment the amount of energy at the disposal of the organism at the moment. Now the manic patient is constantly enjoying such satisfactions or gratifications; in imagination, at least, he is constantly achieving great things; and, even when he is thwarted and breaks out into a furious display of anger, he smashes up the furniture or attacks his
1 "The Sources and Direction of Psycho-physical Energy," American Journal of Insanity, 1913.
2 Cp. my Outline of Psychology, sections on Judgment, Belief and Reality.
attendants with a singleness of aim, an absence of all inhibitions, that ensures him considerable successes and correspondingly intense gratifications. These, in accordance with a fundamental principle of our nature, sustain and augment his output of energy.
The development and due organization of the sentiment of selfregard is a long and delicate process. We may assume that it is not always effected with complete success. The circumstances of early life may be adverse, and may tend to prevent the attainment of harmonious integration of the sentiment; we might expect, then, to find that such a person would exhibit the cyclo-thymic peculiarities, and that any breakdown under emotional strain might take the form of the manicdepressive disorder. Something of this sort seems to be exemplified by the following case.
O'B. was a man of thirty years, of Irish descent; his family was Roman Catholic and of the lower middle class. He had intellectual capacity and ambitions and was studying law. As he boastfully remarked, he was the only member of his family and perhaps the first of his name to aspire to intellectual distinction. His father was a man of violent temper, who, though not devout, insisted upon the forms of the Roman Church. At an early age the son began to rebel against the prescriptions of the family's religion; but he continued to conform outwardly under the pressure of his father's authority. In the middle twenties he married a girl of a Protestant family, in defiance of his father. The girl was a typically modern, emancipated and up-to-date young person. She refused to have any children and regarded her husband as existing chiefly in order to supply her with the means to "have a good time," that is to say, to continue the round of gaiety to which she had become accustomed before marriage. She habitually exposed as much of her person as the law would permit, and regarded young men as necessary means to "a good time." Further she was entirely sceptical in all things, especially in respect of all moral and religious teachings; and she made fun of those religious beliefs which her husband continued to harbour, although he had ceased to be a practising Catholic. Here then was a train of circumstances which, if the hypothesis I am putting forward is sound, might be expected to lead to disorder of the manic-depressive type. Manic-depressive disorder of a mild type set in some few years after marriage and became gradually accentuated. Up to the time when he came into my hands he had escaped confinement in a hospital, except for one short period. The phases of exaltation and depression were of brief duration and com
monly were separated by weeks or months of normal or nearly normal mentality.
In the depressed phases he was full of fear whose objects were largely determined by his religious training: at these times he believed in hellfire and in the devil; and he felt that he was surrounded by spirits powerful to aid or to hurt: he looked upon himself as a miserable sinner who could not hope to escape the fate proper to a heretic and an apostate. His wife's sceptical pleasantries and jeers at the expense of religion in general and of Roman Catholicism in particular were terrible to him; and, when his fears were revealed to her, she lashed him with scorn and contempt before which he quailed miserably. Such jibes failed to stimulate him to any self-assertive reaction. What right had he, an ignorant creature of humble origin, to question the immense and ancient authority of the Church? What the Church taught was true; and there was no hope of salvation for him; he had had every chance to be a good Christian and had wilfully chosen the path of evil. In his exalted phases he was entirely sceptical of all religious teaching. His self-assertion largely took the form of seeking controversies with high authorities on moral and religious questions. He sought and obtained interviews with priests and distinguished theologians and professors. It was in this way that he came across my path; he thought my reputation sufficiently high to make me a foeman worthy of his steel; and he sought me out in order to argue sceptically and with the utmost dogmatism and selfconfidence against all religious and moral beliefs. At these times his wife's frivolous conduct gave rise to a furious jealousy that was completely lacking in the depressed phases.
Here then was a man in whom the sentiment of self-regard had developed under difficult and disturbing circumstances. Physically he was of well-marked Nordic type; he was introverted and introspective; and that his self-assertive tendency was strong is sufficiently proved by his intellectual ambitions and by his breaking away from the family traditions to take up a professional career1. A tyrannous father put a continual pressure upon him to conform to the family religion and to follow a calling of the kind traditional in the family. He grew up under circumstances that greatly accentuated the normal conflict between the
1 I have pointed out elsewhere (National Welfare and National Decay) that the Nordic type, by reason of its lack of docility, is unsuited to a religion of authority. I may add that it is in Saxony, where in anomalous fashion a largely Nordic population retains the Roman Catholic religion, that the Nordic tendency to suicide attains the highest recorded rate. There can be little doubt that this man, if he had been brought up in a Protestant family, might have escaped his disorder, which may well lead to suicide.