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But now, an inquisition into these types of cases shows that in many important respects they differ from the phobias described above. The patient with a true hysterical phobia certainly recognises the fact that in certain situations he or she may feel vaguely uncomfortable and may be anxious to change such situations and to keep away from them in future, but they are not worried, still less are they ill, with this recognition; unless the condition has been carefully fostered and elaborated by defective environment, my experience of these people is that they are very little disturbed by what they consider a 'constitutional' peculiarity. On the other hand, patients of the second group are definitely ill with their fear; it is always present and they manifest strangeness of behaviour in endeavouring to avoid specific objects and situations in which such objects are likely to be encountered. Also, whereas the true hysterical phobia is always associated with primary instinctive conation, the second group of cases is not so associated; often enough the conation is intensely complex and ingenious. Again, the hysterical phobia is to all intents and purposes constant, and only occurs in certain conditions, the patient remaining mentally placid otherwise; patients of the second class are constantly annoyed by their fear, and their behaviour towards it is liable to vary from day to day in accordance with the circumstances of the environment.

In other words, behaviour, loosely characterised as dependent upon a 'phobia,' is divisible into two groups; one of which originates as a result of psychical dissociation and is truly hysterical; it is perpetuated as a habit; it does not worry the patient and is only present in certain well-defined and primitive environments; its manifestation is either flight or recoil, or the desire to run away or to avoid. The other is never the result of psychical dissociation and is therefore never hysterical; it is associated with constant misery and efforts to modify a normal environment; the patients are depressed and uncontrolled in contrast to the former group in which they are placid. The former type of case is not dealt with logically by psycho-analysis whereas the latter is; the latter group is probably the larger of the two.

The modus operandi of the hysterical phobia has already been discussed; it is, so to speak, the perpetuation and reinforcement of primitive conative activity at the expense of a psychical registration in memory of an incident encountered in early life by the process of psychical dissociation. As regards the second variety, the non-hysterical, the mechanism is perhaps rather more obscure; in another place1 I have endeavoured to explain it on the principle of "amnesia by relative inattention."

1 Core, Functional Nervous Disorders, John Wright and Co., Bristol, 1922.

According to this theory an experience, not in itself at the time of its occurrence necessarily terrifying, is intimately associated after its registration in memory with terrifying attributes. The strength of the secondary emotion tends to perpetuate in memory these attributes at the expense of the memorisation of the initial experience, which sinks into oblivion; but which, having been psychically registered at the time of its occurrence, is therefore theoretically recoverable.

As an illustrative case I may perhaps quote the following1: A child, which is developing in surroundings conducive perhaps to the stressing of emotional control, in playing with a pea, slips it up his nostril and immediately runs off to his mother to tell her about its disappearance. He is not at this time frightened; his mother however is horrified and after a somewhat disagreeable series of manipulations the pea is re covered. The child is then elaborately informed about the potential dangers of his performance; unpleasant information is imparted as to the liability of the pea growing into a 'tree' in his nose; the possibilities of 'ulcers' and 'discharges' are dwelled upon and he is made to realise the narrowness of the escape he has had from these dangers.

This deliberate inculcation of fright has the effect of emotionalising and therefore perpetuating the elements of the warning at the expense of the initial incident in memory. Both for a time pass out of consciousness, but of the two, the terror-laden secondary attributes of the initial experience are the more liable to make themselves felt in proportion to the greater degree of emotionalism attached to them in comparison with the initial incident. In the event at any future time of the emotional control of the individual being lowered, he will be liable to develop obsessive fears in the spheres of peas, his nose, nasal discharges and so forth; he will have no voluntary memory of the initial experience. Careful analysis however is capable of unearthing this experience, in that it has been registered in memory at one time, and the proper presentation of this experience in relation to the elements of the 'phobia' will resolve the trouble and will fulfil the ideal of a resolution in the patient's own consciousness, and, therefore is liable to effect an academically perfect

cure.

Now, for this mechanism to be operative in the production of a 'phobia' it is essential that the superimposition of fear by means of the subsequent lecture, on the initial incident, should succeed that incident by a very short interval of time; the lecture should so to speak, form a periphery for the experience. Given that a period of time be allowed to

1 Loc. cit.

elapse between the registration in memory of the initial incident and the secondary warnings, then, in accordance with the number of 'interim' memory registrations, the warning, when it does occur will not bring about a relative inattention for the original experience; the child will have a healthy disinclination to insert peas into his nose, but he will not develop an amnesia for the specific incident and a subsequent phobia is not likely to be built upon it.

These non-hysterical phobias are essentially dependent upon memory and therefore fall into the mnemoneurotic group of the progressive neuroses. Their actual manifestation in behaviour would appear to be associated with an impairment of emotional control in adult life, an impairment which is increased by the consciousness of an inexplicable dread, which in turn is reinforced by the progressive diminution of the control.

Throughout all the above argument it will be noticed that the factor of emotional control is constantly under discussion. It is to all intents and purposes absent in the infant; it is formed during childhood and is maintained and developed during adolescence and adult life; it disintegrates with the onset of the involutionary processes of old age. It is liable to diminution temporarily as a result of physical and psychical stress and strain at any time.

As regards the neuroses, it may be imperfectly formed during childhood, and provided the defect be sufficiently great, clinical hysteria in early adult life may be manifested. Its formation may be defective as regards its reaction on the two groups of emotionalism; that is there may be a wrongful balance of control in relation to these two groups, and this carries with it the liability to neuroses of the progressive group in later life, especially if there be a general impairment resulting from the stresses and strains mentioned above. A marked defect in the formation of control in childhood admits the operation of psychical dissociation and hysterical behaviour; a less severe defect results in behaviour, not in itself hysterical in that psychical dissociation is absent, but conforming superficially to such behaviour. Therefore in the secondary impairment of emotional control which is associated with the progressive neuroses there may be in the course of time behaviour which has certain points of resemblance to hysteria, but which is not hysterical in that it is not dependent upon psychical dissociation. Needless to say, the severe loss of control that is sometimes met with in the involutionary phases of life

can never give rise to hysterical behaviour owing to the organic lesions which underlie it.

A degree of emotional control which is less than that which is the average for the community in which the individual lives may for convenience be called 'hyperthymia,' and the hyperthymic state is therefore of all degrees of intensity. Hyperthymia may be primary or secondary; an intense primary hyperthymia constitutes the base of hysteria. A less intense primary hyperthymia leads to an undue emotional reaction to the surroundings combined with behaviour otherwise normal. Such people are commonly labelled 'hysterical' in general practice. Secondary hyperthymia may result from different physical stresses and strains and may also supervene on the course of any of the progressive neuroses. In the latter case there is a risk of the essential progressiveness of the disorder being masked by these secondary hysteria-like behaviour manifestations and in some cases the symptomatology may be complex.

Hysteria being a condition dependent upon defective education in the broad sense of the word is a condition which may reasonably be expected to disappear with an increase in knowledge of dealing with the developing child, though of course all of us will show traces for all time of its underlying mechanism in that all of us are born emotionally uncontrolled. But such traces will be confined to the sphere of the formation of useful habits and will not be found as clinical symptoms. On the other hand, the elimination of the progressive neuroses would appear to be a very much more difficult problem for the future, for it would seem to necessitate an elimination of the factors of worry and dread from everyday life, and in the present state of society it is difficult to see how this may be brought about. At the same time the trend of modern civilisation and enlightened thought is in this direction, and it is not only possible but probable that in the ultimate future these factors may be so greatly lessened as to become, to all intents and purposes, inoperative.

To summarise, we may say then that from the standpoint of clinical medicine emotionalism falls into two groups, centripetal and centrifugal respectively, and that the recognition of this duality is of utility in the classification of functional nervous disorders. It is of equal importance to realise that in the formation of such disorders emotional control would appear to play the most important role, and that abnormality of such control is an essential associate of these conditions. Functional nervous disorders would appear to arise out of an abnormal relationship between the emotionalism of an individual and his control; abnormal as considered in the light of the average for the community in which he is born and develops.

Defective formation of emotional control in the first few years of life, if sufficient in degree, conduces to hysteria in adolescence and to the perpetuation of certain symptoms as habitual action in later life in the event of the hysterical symptoms not receiving proper treatment. Hysteria therefore is a regressive condition.

A defective balance of control between the two groups of emotionalism is associated with functional disorders of the progressive order; the defect may consist of an overstraining of centrifugal control or an overdevelopment of a centripetal; the results in each case are clinically recognisable though in civil life the degree of invalidation may not be very great.

The occurrence of dread, independently or in the course of the above abnormal states, will, if it be allowed to persist, bring about definite and increasing invalidism. Prominent symptoms of such invalidism are pain and a rising blood-pressure, and this phase ultimately ends in organic disease through the supervention of vascular involutionary changes.

In the event of the emotional control being badly treated during childhood, in the direction of overdevelopment and overstrain, the elements of an obsessive neurosis in later life may be implanted through the possible mechanism of "amnesia by relative inattention," a neurosis which also in the course of time is liable to pass into the organic stage through the occurrence of dread.

These latter types of disorders, in that they depend upon the presence of emotional control and 'pictorial' memory, must be looked upon as exclusively human and therefore as being progressive.

The above conclusions have been arrived at as a result of clinical observation; it is therefore of considerable interest to find that Professor Jastrow1 writing on "The Neurological Concept of Behaviour," has come to similar conclusions on a purely psychological basis.

1 1 Psychological Review, vol. xxxi, No. 3.

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