A SURVEY THE DEVELOPMENT OF THE PSYCHO-ANALYTICAL THEORY OF THE PSYCHOSES1 § 2. Defence mechanisms, 1894 (p. 271). Hallucinatory confusion and projection, 1894-1896 (p. 271). Hysteria and dementia praecox compared, 1906 (pp. 273–275). § 3. The Schreber case, 1911 (pp. 278–286). The mechanism of paranoia, 1911 (pp. 281-283). § 4. The manic-depressive disorders, 1911 (pp. 286-289). § 6. Narcissism. PART II §7. The modification of the feeling of omnipotence. § 8. The developmental stages of the libido. § 9. Melancholia. § 10. The super-ego (ego-ideal). § 11. The death instincts. PART III § 12. The ego and the id. § 13. The sense of reality. § 14. Anxiety. § 15. Classification of the neuroses, psycho-neuroses and psychoses. 16. Miscellaneous. Some psycho-analytic psychiatric hypotheses and opinions: on the early stages of psychotic conditions; on decomposition; on depersonalization; on the wish to get well; on remissions; on a diagnostic technique; on organspeech, etc.; some brief descriptions by way of approach to definition. Conclusion § 17. Bibliography. 1 This paper is based on one read before the Medical Section of the British Psychological Society on December 17th, 1924. INTRODUCTION § 1. The contributions of psycho-analysts to psychiatry may be divided into three groups which fall roughly into three periods. The first period ranges from 1893 to 1914, the second from 1914 to 1923, the third from 1923 till the present. The first group is characterized by a simplicity not found in later work, and may be summarized by saying that the psychoses were viewed from the aspect of libido development; stress is laid on fixation points, on defence mechanisms, on the aims of the sexual instinct and on object cathexis. The second group, while rejecting nothing in the work already done, makes additions which give rather a different orientation, the psychoses are viewed from the aspect of ego development; the economic factor is introduced, the subdivision of the ego into super-ego and real ego, cathexis of the ego, the castration complex and the types of object-relationship are brought to the foreground. These divisions into groups may serve for a brief exposition, but it must be confessed that they do violence to the chronological sequence of the contributions. There is no harm in this if the reader is aware of the fact that psycho-analytical psychiatry is only a part-and a small part of psycho-analysis, and that he must add to his study of the part by an examination of the whole, preferably by a careful chronological study. The most that this paper can do is to give an account of selected contributions that will assist in the larger work of a systematic, chronological examination of the literature. PART I § 2. In his first psycho-analytical papers, published in the early nineties, Freud calls attention to the mechanism of psychosis1. He contrasts two cases with obsessions in which the defence against an unbearable idea is effected by detachment of the affect (the idea itself remaining in consciousness, although weakened and isolated) with a case of 'hallucinatory confusion' in which a much more energetic and successful kind of defence exists; "the ego rejects the unbearable idea together with its associated affect and behaves as if the idea had never occurred to the person at all. But, as soon as this process has been successfully carried through, the person in question will have developed a psychosis, and his state can only be described as one of 'hallucinatory confusion.' ."" The content of the symptoms consists in the accentuation of the very idea (Vorstellung) which was menaced by the experience which caused the outbreak of the illness. "One is therefore justified in saying that the ego has averted the unbearable idea by a flight into psychosis, and the process by which this result is obtained again withdraws itself out of range of selfperception as well as of psychological-clinical analysis.... The ego has broken away from the unbearable idea; but, the latter being inseparably bound up with a part of reality, in so far as the ego achieves this result, it has also cut itself loose from reality, totally or in part." After thirty years Freud returned to this formulation2, in the meantime he had provided a number of working hypotheses to account for the outbreak and symptoms of hysteria, the obsessional neurosis, paranoia, dementia praecox, and melancholia. His first 2 Freud, Collected Papers, II, p. 277. 1 Freud, Collected Papers, 1, p. 72. formulation now seems rather commonplace, but it bears repetition because it fits into a wider scheme of psycho-pathology. 1896 The next paper which concerns us, "The Defence Neuropsychoses1," contains the analysis of a case of chronic paranoia. He found that this illness was a defence psychosis resulting from the repression of painful memories. Two important additions are now made to the theory, namely, that the form of the symptoms is determined by the content of the repressed memory, and that a special mechanism of repression, peculiar to paranoia, brings relief from the burden of the intolerable idea. Again making a contrast with the neuroses he saw that while in hysteria repression is effected by means of conversion into bodily innervation, and in obsessional neurosis by substitution, that is, by displacement of the affect along certain associated channels, in paranoia it is effected by projection. Here the patient erects his defences by directing his distrust against other people and thus becomes unable to recognize that he is himself the object of reproach; but while he thus guards against self-reproach he loses protection from the unbearable ideas which may come from without -they reappear in the delusions. The symptoms are to be described as manifestations of a return of the repressed and bear traces of a compromise which allows of their entry into consciousness. The return from repression is not possible without a disguise, or censorship, and having attained to consciousness they exhibit another peculiarity they absorb the thought processes of the ego until they finally come to be accepted without contradiction, that is to say, they alter the ego and by this means effect another or secondary stage of defence. The repressed content in this case of paranoia, as well as that in the cases of hysteria and obsessional neurosis analysed in the same paper, is a sexual experience in childhood. This, the first case of paranoia to be analysed, showed unmistakably that the defence was erected against intolerable homosexual ideas. The author does not comment on this point, but we note it now for later reference. 1900-1906 For about ten years after this paper on "The Defence Neuropsychoses was written, psycho-analysis was concerned with the neuroses and psychical mechanisms in general. For instance, in the "Interpretation of Dreams," the psychoses as such are not dealt with, and there are only sparing allusions to the formation of their symptoms. But we must note in passing one reference in it to the mechanism of hallucination. In the process of recollection the mind may follow a regressive path and allow the memory traces of past experiences to come up to consciousness in the form of visual images while the process of search for the desired experience is going on. The dream work employs this method when transforming latent thoughts into perceptual forms, this representation of thought by visual images is called 'regression.' During the day this process may be voluntary as we have seen, but sometimes is involuntary, in which case the patient has an hallucination. Our interest is centred first on the factors which cause the mind to follow this regressive path and 1 Freud, Collected Papers, 1, p. 169. In this paper the term 'psycho-analysis' is used for the first time and the term 'repression' is given its psycho-analytical significance. produce hallucinations, and secondly on the features which distinguish these from dreams. The theory to account for both states is that a high degree of cathexis must exist upon ideas which are separated from consciousness1 by repression, it is as though there is an excitation in the central part of the (psychical) reflex arc which cannot pass off by the motor end of the apparatus and so by reflux as it were excites the perceptory end. This can happen easily in sleep because the perceptory end of the apparatus is not in a state of excitement from external stimuli, but in the waking state it is otherwise. The external world is supplying stimuli which normally excite the usual afferent -central-efferent discharge, when there are hallucinations it seems as if the perceptory end of the apparatus is being stimulated from without and from within (memory-images) and that to produce the effect the latter have to be intense enough to overpower the external stimuli. This helps to explain the fact that hallucinations appear more frequently in the dusk and in semi-silence in those who are only slightly afflicted with hallucinatory symptoms. 1906 Jung's paper on "The Psychology of Dementia Praecox2" was written in 1906. Under the influence of the Word-Association tests he is dominated by the view that dementia praecox and hysteria are due to complexes, that is to say, to groups of associated mental elements having become separated from consciousness and influencing the conscious psychical levels, so that symptoms of various kinds are produced. He uses the term complex here to denote not only pathologically separated systems of mental associations but also ideational masses which may even function as parts or levels of the mind. For instance, "The ego-complex in the normal person is the highest psychical instance. By it we understand the ideational mass of the ego which we believe to be accompanied by the potent and ever-living feeling tone of our own body. The feeling tone is an affective state which is accompanied by bodily innervations. The ego is the psychological expression for the firmly associated union of all general bodily sensations3." He divides the effect of a complex into the two familiar categories, acute and chronic. In the acute stage the ego-complex is threatened by danger, and danger excites fear; in the condition of fear bodily changes are produced which alter the attention-tone of the ego, and it is compelled to give way to the stronger sensations of the new complex, so that the ego-complex is impoverished. If the danger passes rapidly the disturbing complexes soon lose their attention-tone and the ego resumes its normal characteristics, yet the affect continues to oscillate for a long time in its physical and hence in its psychical components. Thus strong affects (new complexes) leave behind extensive complexes, which may manifest themselves as disturbances of the bodily organs or of sleep, etc. The patient will for a long time be in a condition of 'complex-sensitiveness.' This leads him to the consideration of the chronic effects of the complex, which he summarized as either a prolongation of complex-sensitiveness, or else a state in which the affect is in a continuous state of provocation. The complex in these two cases is less at the disposal of the ego 1 Freud, Traumdeutung, 6th ed. pp. 406 and 407, Ges. Schr. Bd. 11. 465–466. 2 Jung, Über die Psychologie der Dementia praecox. 3 Jung, op. cit. p. 38, authorized translation by Peterson and Brill. But there is no reason to suppose that Jung is here referring to a part of the ego being unconscious as Freud does in Das Ich und das Es. [The Ego and the Id translated.] Med. Psych. VI 18 complex, the affects are out of control, and he found the clinical conditions typical of both hysteria and dementia praecox1. Jung draws several parallels between the two conditions, they are alike in that they show an affective state without adequate ideational content, and may show either the apparent indifference of catatonia or the belle indifférence of the hysteric, and in both conditions explosive affects are met with. "The affects in dementia praecox are probably not extinguished but only peculiarly transposed and blocked, as we see on rare occasions when we obtain a complete catamnestic view of the disease....If a catatonic is constantly occupied by hallucinatory scenes, which crowd themselves into his consciousness with elemental force and with a much stronger tone than the external reality, we can then without any further explanations readily understand that he is unable adequately to react to the questions of the physician. Furthermore, if the patient, as described by Schreber2, perceives other persons in his environment as fleeting shadows of men, we can again understand that he is unable to react adequately to the stimuli of reality, that is, he reacts adequately, but in his own ways." Jung does not explain why persons are perceived as fleeting shadows or why the catatonic is constantly occupied with hallucinations that had to wait for two or three years till further researches threw new light on the libidinal disturbances in the psychoses. He was concerned with the concept of ideational groupings and not so much with cathexis, the 'charge' of energy, which makes this or that group of presentations (Vorstellungen) significant. Turning to the characterological aspects of the two disorders, he says that hysteria does not create a typical character but only exaggerates the already existing qualities; in dementia praecox, on the other hand, he found ‘embellishments' of character, mannerisms, affection, etc. In this case the disease takes over the mechanism from hysteria. He instances the use of powerwords' which elevate and garnish the personality: "I grand duke Mephisto will have you treated with blood-revenge for Orang-Outang-representance." Jung is here, of course, straining the boundary of hysteria too far, for such a sentence could not come from an hysteric and is not the exaggeration of an hysterical mechanism. He observed and stated with greater clearness than had been done before the similarities between dementia praecox and hysteria, but he let this emphasis on similarities obscure their essential difference, and this clouds his otherwise fine perception over and over again. He believed that the anomalities of consciousness, attention, orientation, hallucinations, stereotypies and even delusions of reference are common to both. He summarizes the situation by saying, "Hysteria contains in its innermost essence a complex which could never be totally overcome; in a measure the psyche is brought to a standstill since it is unable to rid itself of the complex.... In dementia praecox we find likewise one or more complexes which become tenaciously fixed. Here, too, we have complexes which can no longer be conquered. Whereas in hysteria there exists an unmistakable causal relation between the complex and the disease (a predisposition is presupposed), we are not at all clear about this in dementia praecox4." The last remark suggests that Jung was prepared to attribute this disease 1 Jung, op. cit. pp. 39-49. The patient whose case will be referred to at length in a later paragraph. 3 Jung, op. cit. pp. 72, 73. Jung, op. cit. p. 97. |