Psychopathology

“ They are essentially problems of psychogenesis—the development of the various mental reactions and tendencies of which individual character and temperament are built up. It is readily discernible that a growing emphasis is laid in psychopathology upon the determining if not conditioning rôle of psychogenic factors in a variety of conditions, ranging from hysteria to the manic-depressive group; though the scientific development of methods, or their application to the study of normal mental reaction types, has been largely conspicuous in absence. ”

“ Those who still believe in an exclusively materialistic theory of mental disorder must find it extremely difficult to maintain their doctrine in the face of the many incontrovertible facts brought to light through modern research in the field of psychopathology. ”

“ Bizarre as these cases must seem, they are actually typical of a widespread malady that causes an amount of suffering only appreciable by the sufferers themselves. In every land there are thousands of men and women afflicted with obsessions equally strange and equally distressing, yet amenable to treatment by the methods of psychopathology. ”

“ Since psychology primarily deals with the laws of psycho-physiological functions, it will be admitted that the more important and valuable method is the one that has for its subject matter the changes going on directly in the material under investigation. The investigations, however, of changes or disturbances of mental function itself are really a study of the abnormal, researches into the domain of mental pathology. In psychology, as in many other sciences, especially those of the biological order to which psychology naturally belongs, the pathological method is by far the most important. ”

“ When the symptoms are disposed of in a reverse manner—that is, when they appear in the most important individual and social activities in a manner to disturb the functions of nourishment and sexual relations, professional and social life—such disposition is found in the severe cases of neuroses, and is perhaps more characteristic of the latter than the multiformity or vividness of the morbid manifestations. ”

“ As in every scheme of a pathological kind we can distinguish between the conditions or causes of the morbid process and the mechanisms by which these conditions produce the manifestations or symptoms of disease. In the heat engendered by differences of opinion concerning the conditions of psycho-neurosis, the pathological mechanisms had been neglected and had aroused little interest, a neglect which is readily intelligible, for few will find it worth while to study the details of a structure resting on foundations they reject. ”

“ In proportion as the neurotic attacks keep on recurring the formed pathological system is gaining in energy and in ease of manifestation. The psychopathic attacks with their symptoms emerge [148] at an ever diminishing intensity of stimulation. The resistance of healthy normal associations is ever on the decrease until a point is reached when all power of resistance is lost. The conscious and subconscious groups which enter into the psychopathic system, forming the neurosis, get control over the patient’s life, and become an uncontrollable, psychopathic obsession. ”

“ The events of the last hundred years include more particularly the delimitation and complete differentiation of general paresis, the rise and fall of the paranoia concept, the description of the traumatic psychoses, the establishment of the alcoholic insanities as clinical entities, a study of the mental diseases due to endogenous and exogenous toxins, the recognition of the neuroses and psychoneuroses in their modern sense, the addition of the psychopathic personalities to our classification and the definition of manic-depressive insanity, dementia praecox and involutional melancholia. ”

“ In other types of psychopathic affections the patient is entirely unaware of the whole situation, he is engrossed by the symptoms which he regards as the sum and substance of his trouble; the fear is entirely subconscious. Frights, scares, dread of sickness, instructions associated with fear of the mysterious and unseen, injunctions with fear of punishment or failure in moral standards, enforcement of social customs with dread of failure and degradation,—all go to the cultivation of the fear instinct which in later life becomes manifested as functional psychosis or neurosis. ”

“ Psychiatry, which engages in the exploration of the mind, stands ever at the door seeking in vain to weigh and measure as in the other departments of science. We have long known that we have to do with a definite organ, the brain; but only beyond the brain, beyond the morphological basis do we reach what is important for us—the mind; as indefinable as it ever was, still eluding any explanation, no matter how ingenious. Former ages, endowing the mind with substance, and personifying every incomprehensible occurrence in nature, regarded mental disorder as the work of evil spirits ”

“ To-day we can say that the pathological images dominate the interests of the patient so completely, because they are simply derivatives of the most important questions that used to occupy the person when normal—what in insanity is now an incomprehensible maze of symptoms, used to be fields of vital interest to the former personality. I will cite as an example a patient who was twenty years in the asylum. She was always a puzzle to the physicians, for the absurdity of her delusions exceeded anything that the boldest imagination could create. ”

“ This difference in type is the first great obstacle which stands in the way of an understanding concerning fundamental conceptions of our psychology. A second objection arises from the circumstance that the constructive method, faithful to itself, must adapt itself to the lines of the delusion. The direction along which the patient develops his morbid thoughts has to be accepted seriously, and followed out to its end; the investigator thus places himself at the standpoint of the psychosis. ”

“ Whether or not there are any psychogenic diseases, whether or not purely psychical events can be proved to produce the group of symptoms known as neurasthenia, psychasthenia, or hysteria, or whether there are physical causes contributing to produce the symptoms, this at any rate may be said with confidence: that if we are to root out the patient's trouble, if we are to bring about anything approaching a radical cure, we must attack the mental symptoms directly and upon their own grounds, that is, by mental means, chiefly by reëducation. ”

“ However, you are not unknown to me. I have heard you well-spoken of; and I remember that, when you were a student in Paris, you were mentioned with honor by the college, for an able paper read before the open section upon the very subject to [13] which I now propose to direct your attention,—mental disease," he added, after a moment's hesitation.
"A case of insanity?" bluntly asked the doctor.
"Heaven forbid! And yet I must not conceal from you that I fear it."
"Give me some of the symptoms. Insanity in strong development, or aberration of faculties, or hallucination?" ”

“ The modern trend in psychiatry is distinctly in the opposite direction. We no longer today insist upon material changes in cells and tissues for every psychotic phenomenon, but rather endeavor to investigate mental life, be it normal or abnormal, from the biologic point of view. We are being constantly confronted with the undeniable fact that whatever may be the physical substratum of mental disorder, it does not aid us in understanding the peculiar expression which a given psychosis chooses to assume. ”

“ Anything which arouses the fear instinct in the inhibitory or paralyzing stages will necessarily give rise to psychopathic functional psychosis or neurosis. The fear instinct and the impulse of self-preservation, inherent in all life, are the alpha and omega of psychopathic maladies. ”

“ Nevertheless, the range of maladies susceptible of cure by psychopathological processes is marvelously wide, and it is no exaggeration to say that the discovery of the influence exercised by the subconscious in the causation of disease is one of the most vitally significant ever made in the history of medicine.
The truth of this may readily be shown by citing a few cases illustrating some of the manifold [236] ways in which dissociation works havoc in the human organism, and the extreme ingenuity displayed by the skilled psychopathologist in overcoming its ravages. ”

“ A person, we will say, has acquired—owing to no matter what psychogenetic factor—a recurrent fear. This fear, or, in less obtrusive form, anxiety, or apprehension, is, we will say, of disease—heart disease or insanity or fainting or cancer or epilepsy or what not. It recurs from time to time when awakened by some thought or stimulus from the environment. At once there is an outburst of physiological, i.e., functional disturbances, in the form of an “attack.” ”

“ We shall be able from the very outset to recognize that a disorder, in all appearance slight and which is not deeply set, presents a bad prognosis, and we shall be able to foresee a serious and deep psychosis in the future. ”

“ Each psychosis repeats in itself, in tendency form at least, the essential stages in the evolution of consciousness. Every psychosis rises from the pure pleasure-pain as the lowest level of mentality like a wave, and like a wave falls back into it again. Every wave of consciousness, whether it rises slowly or rapidly, whether it subsides gradually or violently, rises from pure subjectivity and comes back to it again. ”

“ The type of behavior disorder, the social reactions, the trends of interests, etc., which psychopathic personalities may show give special features to many cases, e.g., criminal traits, moral deficiency, tramp life, sexual perversions and various temperamental peculiarities. ”

“ To sum up: in round figures a quarter of our insane patients show more or less clearly extensive changes and destruction of the brain, while three-fourths have a brain which seems to be generally unimpaired or at most exhibit such changes as give no explanation of the psychological disturbance.
These figures offer the best possible proof that the purely morphological view-point of modern psychiatry leads only very indirectly, if at all, to the understanding of the mental disorder, which is our aim. ”

“ One became especially convinced of the potency of mental factors in the production of mental disease from the observation and study of the psychoses of criminals. Here the conflicts which lead an individual to seek in mental disorder a satisfactory compromise are so concrete as to leave no doubt concerning cause and effect. ”

“ The pronounced mental disturbances or psychoses which develop in psychopathic personalities and bring about their commitment are varied in their clinical form and are usually of an episodic character. Most frequent are attacks of irritability, excitement, depression, paranoid episodes, transient confused states, etc. ”

“ Naturally, these psychoses, being, as they are, psychologically motived, are extremely variable in their manifestations, but at the root they are all alike and impress the observer as something entirely different from the pure endogenous mental disorders. ”

“ The latter, if experienced in such psycho-neuroses, can often from his knowledge of the phenomena of emotion anticipate the facts and in a large degree foretell to the patient the list of symptoms from which he suffers. By those who lack familiarity with these functional disturbances mistakes in diagnosis are frequently made. Disease of the heart, or of the stomach, or of the nervous system is frequently diagnosed when the symptoms are simply the product of emotion. ”

“ The term neurosis is now generally used synonymously with psychoneurosis, although it has been applied to certain disorders in which, while the symptoms are both mental and physical, the primary cause is thought to be essentially physical. In most instances, however, both psychogenic and physical causes are operative and we can assign only a relative weight to the one or the other. ”

“ Comparative and animal psychology and the study of the reactions of children, of primitive races, and of the mentally disordered give us a splendid opportunity for studying it and unravelling the meaning of the many somatic and psychic manifestations which are exhibited to us in the psychoneuroses and psychoses and in tracing out the racial history of man. Is it not plain that an understanding of the genesis and meaning of tics opens the gateway to the elucidation of the origin and significance of the psychoneuroses and functional psychoses—of reaction types of various kinds? ”

“ Periodical recurrence of the act under identical circumstances, and an impulsive manner in carrying it out, give rise to weighty presumptions that it is of pathological significance. The decision, however, must follow after referring the act to its psychological motive (abnormalities of thought and feeling) , and after showing this elementary anomaly to be but one symptom of a general neuropathic condition,—either an arrest of mental development, or a condition of psychical degeneration, or a psychosis. ”

“ Again, an answer will, no doubt, be demanded by some people to the question—How does that which, objectively considered, is neurosis become subjectively felt as psychosis? Is not the identification of neurosis and psychosis a begging of the question, unless the how, the modus operandi, is explained? ”

“ The two major divisions of mental disease—psychosis and psychoneurosis—are not always readily differentiated. In the psychotic, the personality is usually distorted, whereas in the psychoneurotic the personality remains normal in relation to the realities of the world and social life. The psychotic is the more [Pg 63] obviously deranged, the psychoneurotic usually passes for almost normal. ”