Karl Abraham

“ I think personally that behind this influence there are still deeper factors at work of a more individual order, derived essentially from hereditary tendencies and the earliest relation of the child to its parents. However this may be, it is certain that every one has such ideals, though he may not describe them under this name, and that in the course of development he insensibly builds up a series of standards of which his ego approves—and which I therefore propose to refer to by Freud’s term of the “ego ideal”—together with a contrasting series of which his ego disapproves. ”

“ For my own part I have the utmost difficulty in believing that a current wish, however strong that is half conscious and sometimes fully conscious can ever in itself produce a neurosis, for it contradicts all one’s knowledge concerning the nature of neuroses, as well as my experience, such as it is, of war neuroses themselves. ”

“ However, we cannot spare neurologists the reproach of having so long disregarded the pioneer researches of Breuer and Freud concerning the psychical determination of many nervous disturbances, and of having required the terrible experiences of the war to set them right in this respect. And yet a science—psycho-analysis—has existed for more than twenty years to which many investigators had devoted the whole of their efforts, and which had helped us to unexpected and important knowledge of the mechanisms of mental life and its disturbances. ”

“ 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. ”

“ I have learnt for a long time now to estimate the dreams of my war neurotic patients as an attempt at self-healing, especially in the psycho-cathartic sense. I never give drugs for the dreams of anxiety, terror and rage. I am glad of the cooperation of the patient, I learn by listening to his dreams his own tendency to cure, then I get him to continue the dream under hypnosis where it has stopped the previous night, or, this I have several times found successful, I cause the patient to continue in his dreams at night from where the hypnosis has left off. ”

“ Freud considers that there are probably always three factors in the causation of any neurosis: a specific hereditary predisposition, secondly an unresolved infantile conflict which means that the person has not satisfactorily developed past a given stage of individual evolution—in other words, that he has been subjected to what is called an “infantile fixation” at a given point in development, and thirdly the current difficulty. There is a reciprocal relationship between these three factors, so that if any one is especially pronounced the others may be correspondingly less important. ”

“ That a neurosis, which after all is a disorder of the unconscious imagination, should arise from a conflict between two states of mind that are fully in contact with reality would be something entirely contradictory of our past experience, as would also a neurosis arising from a conflict between two tendencies both belonging to the ego. ”

“ The soldier who would like to escape from shell fire is, so far as moral values are concerned, in the same position as a man in peace-time who will not venture his life to save a drowning child. Indeed, the conflict cannot be as sharp in the case of the soldier, for he would find very widespread and thorough sympathy for his quite comprehensible desire, and there would be much less social blame or guilt attaching to him than to the man in the other situation mentioned. ”

“ We thus see that only one half of the psycho-analytical theory has so far been confirmed by the observations of war neuroses. According to this theory, there are typically two sets of wishes concerned in the production of any neurosis. One of these, the “primary gain of illness”, a current one, alien to the conscious ego ideal, and therefore half repressed and only half conscious—if that—has not only been demonstrated by a number of observers, but has been shewn to be of tremendous importance, and certainly the effects of treatment largely turn on the way in which it is dealt with. ”

“ The passivity is expressed then not only in the sphere of the ego impulses, but likewise in that of the sexual impulses. The narcissism breaks out. The capability of the transference of the sexual hunger (libido) dies away as well as the capacity of self-sacrifice in favour of the community. On the contrary, we now have a patient before us who himself needs care and consideration on the part of others, who in a typically narcissistic manner is in constant anxiety about his life and health. The obtrusiveness of the symptoms (tremors, attacks, etc.) is also narcissistic. ”

“ In the smallest loss of consciousness, the shock effects of terror, up to the severe fainting attacks and the long continued loss of consciousness after being buried, we see the self-conscious of the personality more or less obliterated and the way opened to the unconscious. Here undoubtedly at the commencement are operating those teleological mechanisms which constitute the foundation of the neuroses and their formation of symptoms. Consciousness refuses to take up ideas or to assimilate at the moment those things which are too horrible in their reality to be consciously tolerated. ”

“ The functions of the unconscious are the deciding factor in the formation and building up of the war neuroses, also the frequently observed instances of the forgetting of events accompanied by feelings hostile to the ego, even when these events are very recent, permits us to recognise from the outside alone the submergence and repression of ideas and affects of a painful nature. It is comprehensible that under the pressure of years of discipline, which limits the personality and thereby prevents every individual reaction to events, the disposition to repression is extraordinarily favoured. ”

“ The fact of the predisposition to neuroses is still a long way from being exhausted. The fact that in the midst of the self-same experiences one soldier remains well while another becomes a neurotic may, so far as my experience goes, be very well connected with the psycho-sexual constellation of the particular person. The systematic investigation of the dream-life of the soldier, even after the removal of the war neurotic symptoms, has indeed made it possible to recognise quite frequently threads that lead down to the primordial network of infantile sexuality. ”

“ The war affects and ideas which form the symptoms have, on the other hand, a certain intrinsic relation to sexuality inasmuch as they are closely bound with the most primitive instincts in man,—those connected with the self-preservation instinct. If the sexual affect in the last resort originates in the instinct which is directed towards the preservation of the species, the affects of anxiety, horror, rage, etc. ”

“ Thus in the case of primitive cruelty, a cruel child may develop into a person to whom the very idea of inflicting cruelty is alien and abhorrent, the original impulse having been quite split off from the ego into the unconscious, and its place taken in consciousness by the reaction-formation barrier of horror and sensitiveness to pain and suffering. ”

“ When we read in the more recent literature on the subject, of the ideas and views which have become so familiar,—abreaction, unconscious, psychic mechanisms, separation of the affect from its idea, etc.,—we might easily imagine ourselves to be in a circle of psycho-analysts, and yet it has never occurred to these investigators to ask themselves whether, after these experiences in the war neuroses, the psycho-analytical concepts cannot be made use of in the explanation of the usual neuroses and psychoses which were well known to us in peace times. ”

“ A door slammed, a thunder-clap, a distant shot, makes the patient break down, and his previously unconscious anxiety idea becomes over-weighted. Terror and dread of death here generally form the primary basis for the dissociation of the psyche and for the attack-like mastery of the conscious by the unconscious.
A soldier who has once been paralysed for a time through the emotion of terror in his conscious ego is in many ways no longer in the position to satisfy consciously the repression which the pressure of discipline demands. ”

“ 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. ”

“ The neurosis offers a way out of this dilemma, the only way that the particular person is able to find, and the actual symptoms, which are often grossly incapacitating, such as blindness, represent the fulfilment of the desire against which the man has been fighting. We reach, therefore, the wish-fulfilment part of Freud’s theory.
(3) The third principle is that the operative wish that leads to the creation of the neurosis is an unconscious one. Freud means this in the full sense of the word, and in this sense the principle has not yet been confirmed from the experience of the war neuroses. ”

“ The manhood of a nation is in war not only allowed, but encouraged and ordered to indulge in behaviour of a kind that is throughout abhorrent to the civilised mind, to commit deeds and witness sights that are profoundly revolting to our æsthetic and moral disposition. ”

“ The previous history of such people, and naturally, still more, a penetrating analysis, teaches us why the one in spite of the severest physical and mental influences of the war remains to all intents and purposes healthy, and why the other reacts to relatively trifling stimuli with a severe neurosis. It transpires with great regularity that the war neurotics already before the trauma were labile people—to designate it, to begin with, by a general expression—and especially so as regards their sexuality. ”

“ In the case of war neuroses it is evident that the current factor is of the greatest importance, being, indeed, the only one that so far has attracted attention. The only traces of infantile factors I have seen noted have been the instances where the localisation of hysterical symptoms seems to have been determined in part by the site of old injuries, and in a general way the many traits of childhood, such as sensitiveness to slights, self-centredment, and desire to be guarded, protected, and helped, which are sometimes very evident in the cases of war neurosis. ”

“ Gaupp accepts even explicitly a Freudian postulation, in that he describes the war neuroses as a flight from psychic conflicts into illness and, alluding to psycho-analysis, he says: “Much preferable is the postulate of the effects of the unconscious on consciousness and the physical system than a psychological theory which seeks by words taken from the sciences of anatomy and physiology to gloss over the fact that the path from the physical to the mental and vice versa is entirely unknown to us”. ”

“ 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. ”

“ The excessive importance which almost all the persons suffering from trauma attach to good food fits in with this picture. The slightest neglect in this respect may produce in them the most violent outbreaks of affect and even induce fits. Most of them are unwilling to work, they wish to be supported and provided for like a child.
It is here, therefore, not only a question, as Strümpell considers, of the production of illnesses on account of an actual gain (pension, compensation for injury, flight from the front) which are only secondary illness gains ”

“ The mind has the capacity of tolerating without harm a certain amount of stimulation from these internal impulses and desires that are not in unison with the ego, and when this limit is passed the energy derived from them flows over into neurotic manifestations. The mind has several methods for dealing with the energy of the anti-ego impulses successfully—that is to say, without the impairment of mental health—and it is only when these methods are inadequate to deal with the whole that neurosis ensues. ”