Table of Contents
SOMOPSYCHOSIS AND PSYCHONEUROSIS
FROM a clinical standpoint the various psychopathic disturbances may be reduced to two main types: Somopsychosis and Psychoneurosis.
In somopsychosis the somatic symptoms predominate such as paralysis, contractures, convulsions, or anaesthesia, hyperaesthesia of the various organs, glands, and tissues. The somatic psychoses or neuroses may be further divided according to the symptoms into motor, sensory, or glandular. The somatic neuroses would comprise the various manifestations of what is at present described in literature as hysteria and neurasthenia, as well as the milder forms of hypochondriasis. In all such diseases the physical symptoms form the prominent elements of the mental malady. The patient remains unaware of the underlying mental grounds. So much is this the case that the patient is offended if his trouble is regarded as purely mental in character. The psychic elements, although of the utmost consequence in the causation of the disease, remain unknown to the patient. The mental side of the malady is submerged subconsciously.
In the other psychopathic affections, the psychoneuroses, or neuropsychoses, the physical symptoms are, on the contrary, few or none at all, while the predominating symptoms are entirely of a mental character. The patient ignores his physical condition, even if any exists, and his whole mind is occupied by mental troubles. Such conditions are to be found in all obsessions, fixed ideas, imperative impulses, and other allied mental states. Thus, one patient is in agony over the unrighteousness of his conduct; another suffers tortures over the unanswerable question of “What am I?”; another is obsessed by a fear of some mysterious agency, or by a fear of women, or by agonies of suspicions of criminality in her husband, or by religious and moral fears of not having lived up to the proper duties of life.
The two forms of psychopathies are in strong contrast with each other. In the somatic psychopathies or somopsychoses the patient brings before the physician physical symptoms,—stomach trouble, intestinal pains, soreness of the abdomen, contractures of limbs, headaches, anaesthetic spots of various shapes, or paresis and paralysis of various organs. Hence it is for the physician to discover the underlying psychic states.
In the purely mental forms, the psychoneuroses, on the other hand, the patient entirely omits to describe his physical condition and tells little of it even when he is pressed for it. He usually states that he has always been physically well, and some patients even assert they are sure that they will always be physically well, that the whole trouble is purely mental. The patient, in fact, takes special care and time to bring out this point to the physician. “I have no physical trouble,” he tells the physician, “all my troubles are mental. If you could cure me of my mental suffering, I would be perfectly happy.
"I am as strong and tough as a bull; my physical condition is perfect. I rarely have as much as a cold. I can be exposed to any conditions of life and feel all the better for it, but my mind is hell.”
The psychosomatic patient lays stress on his physical symptoms and is offended when they are declared to be mental; the psychoneurotic, on the contrary, insists on his mental symptoms and becomes impatient when the physician pays attention to physical symptoms or bodily functions. This difference between the somopsychoses and neuropsychoses or psychoneuroses is a fundamental one, and is of the utmost clinical importance, both in diagnosis and in treatment.
The somopsychoses simulate physical and organic nervous troubles. Thus, many “hysterical” forms simulate tabes, or paralysis agitans, hemiplegia, paraplegia, or epilepsy, while many of the neurasthenic, hypochondriacal, and their allied states simulate tumor or cancer of the stomach, intestinal obstructions and glandular derangements, cardiac, laryngeal, pneumonic, hepatic, splanchnic, ovarian, tubal, uterine, renal, and hundreds of other bodily afflictions. The neuropsychoses or psychoneuroses simulate all forms of mental disease, beginning with melancholia and mania, and ending with general paresis.
The psychosomatic patient is in constant terror of being afflicted by some incurable physical disease, such as heart trouble, tuberculosis, kidney trouble, or of becoming a helpless invalid, or of suffering from an incurable, fatal, bodily malady. The psychoneurotic, on the contrary, ignores physical diseases, but he is in terror of insanity.
Thus many of my psychosomatic patients are delighted, for a short period of course, when, after a physical examination, I tell them that they have no angina pectoris, or no valvular trouble, or after a urinary examination that there is no sugar in the urine and no diabetes, or that there is no albumin in the urine and no Bright’s disease, which was so much dreaded.
The psychosomatic must be assured that he is not an invalid. The psychoneurotic must be constantly assured that he is not crazy. The psychosomatic must be assured that he has no fatal malady. The psychoneurotic must be assured that there is no fear of his becoming insane, and that he need not dread that his “head will give way,” and that he will have to be confined the rest of his life in a sanitarium or be committed to an insane asylum.
Neither psychoneurotic nor psychosomatic patients are aware of the real character of their malady. To understand their trouble the physician must investigate their subconscious life. Both psychoneurosis and somopsychosis are diseases of the subconsciousness. In the one the mental, in the other the physical, symptoms predominate.
Both groups of patients are completely unaware of the rich subconsciousness that forms the soil of their psychopathic states. Both are ignorant of the underlying, subconscious psychosis. The only difference between the two is that, while the psychoneurotic is at least aware that he suffers from a mental malady, the psychosomatic is even ignorant of that fact,—he is convinced all along that his trouble is purely physical, and is even offended when the psychic origin of his symptoms is suggested to him.
The characteristic of both forms of functional psychosis is the presence of subconscious, pathological nuclei around which clusters the symptom-complex of the disease. It is this nucleus of sets of subconscious systems that nourishes, guides, and controls the course and manifestations of the total symptom-complex. Unless this nucleus of the set of subconscious systems is reached and disintegrated, the patient cannot be regarded as cured. The psychopathologist must look carefully, like the operating surgeon, for the subconscious, pathological nucleus which forms the root of the malady.
In both forms of functional psychosis, somopsychosis and psychoneurosis, the pathological nucleus is subconscious, and this means that the root of the trouble escapes the patient’s consciousness. The pathological focus is dissociated from the rest of the patient's life. In somopsychosis the dissociation is so complete that the patient is not only ignorant of the origin of the symptoms, but he is even unaware of the character of the trouble; he may think, for instance, that he suffers from cardiac trouble and go to heart specialists, when the real trouble is some subconscious emotion, referring to some former experience of the patient’s life.
In psychoneurosis the patient may be aware that his trouble is mental, but the nature and root of the trouble escape him as much as they do the psychosomatic patient. The pathological nucleus in both types remains subconscious and dissociated from the patient’s conscious life activity. Dissociation is pathognomonic of functional psychosis in both its varieties, somopsychosis and psychoneurosis.
In the somopsychoses the line of cleavage in the dissociation runs along the psychic and the physical, the physical symptoms alone being in consciousness, the psychic systems being subconscious. In psychoneurosis the line of cleavage runs along the line of mental states. Emotional states, a few fragmentary ideas persist in consciousness, while the root of the whole process is hidden in the soil of the subconscious.
The psychosomatic patient is not only deprived of access to the subconscious elements of his malady, but he does not even suspect that such subconscious systems are at the root of his affliction. In fact, so sure is he that everything is well known to him that at first he is surprised at the efforts made to get hold of his subconscious activities and trace the roots of his mental affection. The psychoneurotic patient, however, is harder to handle than is the psychosomatic, inasmuch as the latter has no preconceived ideas about the mental nature of his malady.
The psychosomatic patient has, psychopathologically or clinically regarded, a somewhat different attitude from that found in one who is actually affected with a physical malady. In the first place, the character is affected; the patient becomes at times irritable and at other times quite indifferent to what is going on around him. In the second place, the symptoms become accentuated after concentration of attention on them, and tend to lapse when the attention slackens. In the third place, the symptoms form a well-connected system, a kind of a well-told story.
The symptoms do not follow any physiological or psychological connection, but rather a connection characteristic of the logical order of an external event. They come periodically, depending in their appearance on definite stimuli and a determined series of external events. Finally, the psychosomatic patient has a proclivity, without understanding the real reason, for mental treatment of all kinds. It is the psychosomatic patient who feeds the mental scientist, the Christian Scientist and testifies to the miracles professed by these sects.
This hankering after mental treatment and faith-cures should be taken to mean that, although the psychosomatic patient is unaware of the psychic origin of his disease, he, nevertheless, subconsciously recognizes the real source of his malady, testifying to it by his credulity in faith-cure.
It is from the ranks of the psychosomatics that recruits are drawn that fill the armies of the mental healers and “faith curists,” and overflow the offices of the clerical doctors. The testimony of the psychosomatic patient is sincere,—his symptoms are somatic, with a subconscious psychosis. The psychosis is the important factor. A patient is psychosomatic, not because he suffers from actual physical troubles, but because physical symptoms stand out mainly in his consciousness.
The psychoneurotic person, in contradistinction to the psychosomatic, is not so apt to fall a prey to quacks. This is no doubt due to the fact that he himself is aware of the character of his malady, and the attending physician is not so apt to commit a blunder in his case, and has him referred in time to the neurologist, psychiatrist, and psychopathologist.
The psychoneurotic is characterized by his introspection, by the close analysis of mental states that rise on the fringe of his consciousness. He has in him the making of a good psychologist. His introspection is keen. In this respect his depression widely differs from the depression of the melancholic, whose mental life is laboring under strong inhibition. The mind of the psychoneurotic is in a state of conflict; he is constantly engaged in an inner, subjective battle royal with his tormenting obsessions.
It is on this account that he is an excellent subject for psychological, introspective accounts.
States of inner struggle are absent in the psychosomatic, whose attention is fixed on his somatic symptoms without the least comprehension of his psychopathic condition. The introspection of the psychosomatic is entirely occupied with physical symptoms. The introspection of the psychoneurotic is mental, moral, or religious, and is full of mental distress.
The psychosomatic cases should, therefore, be investigated through their subconscious life activities, while the psychoneurotics should be studied both through their upper and lower consciousness or subconsciousness.
Psychopathic affections can be differentiated from the various forms of insanity by the following important symptom: Readiness of the patient to get an insight into his trouble. The psychosomatic and the psychoneurotic are characterized by the fact that they are anxious to learn the nature and causation of their trouble. They are eager to learn the psychogenesis of their affection, and will do everything in their power to help the physician in his examination and study of their case. Even in the cases where the idea is fixed, the obsession intense, and the impulse uncontrollable, they are anxious to listen to views different from their own, and, in fact, are always on the lookout for some help to get rid of the insistent, mental states.
No matter how fixed the mental state may be, it will temporarily give way to suggestion and persuasion. No matter how deep and intense may be the emotional state of the psychoneurotic and psychosomatic, it can be distracted and dissipated by the personal touch of some firm and trusted friend, or by the influence of the confidential physician who has an insight into the nature of the malady. Neither the emotions nor the ideas are immovably fixed,—they are always ready to give way to other associations.
Moreover, the psychoneurotic is always ready to receive such associations, and welcomes them with all his might and main. There is a great amount of optimism in the psychosomatic and psychoneurotic. This is clearly revealed in the various religious and mental cults which often delight the heart of the psychopathic patient.
Throughout my experience and study of functional psychosis,—both somopsychosis and psychoneurosis,--I have noticed two important factors which help in bringing about the pathological mental condition, viz., emotional shocks and a predisposition to dissociative states.
In so far as the shocks are concerned, they must be of a character intimately related to the most important interests and emotions of the personality as a whole. The shock must affect the center, the nucleus of personality. Psychopathic states cannot be produced by shocks which do not affect this central nucleus of personal life.
The shock to be effective must threaten the very center of one’s individuality. The mother and father may become affected in regard to the children, the wife or husband with regard to each other, the lover in regard to his or her love, the ambitious man in regard to the object of his ambitions, the miser in regard to his treasured-up wealth, and the religious and highly moral person in regard to the objects of religion or moral life. The character of the shock that is capable of producing psychopathic states must be such as to affect the life existence of the individuality.
It is, of course, clear that this menace of the shock need not be a real one in the sense of a trauma actually having in itself the power of bringing about a mental shock. The event itself may be insignificant, but it is enough, if the person affected considers the event as sufficiently important to produce ill effects. So insignificant, in fact, may the event-producing shock be that the whole process may have occurred in a dream. I could adduce a number of cases in which the psychopathic condition was traceable to dreams. Such dreams, however, must have their origin in some actual event or in a series of events, often lapsed from the patient’s conscious memory.
The psychopathologist, however, who regards such a shock as the sum total of the causation of psychopathic states has not yet mastered the rudiments of psychopathology. The event that produces the shock is but the last link in a whole chain of similar shocks which can be traced far back into the dim lights of subconscious regions, leading back to early child life.
The psychopathic state is like a plant that has its roots deep in the soil of subconscious life activities; it has its beginning in the very germs of the patient’s individuality. A long series of shocks in childhood must first have shattered the individuality of the patient before the given particular shock can produce the psychopathic upheaval. Both somopsyehosis and psychoneurosis have a natural history, beginning in early childhood.
On the whole, in both somopsychosis and psychoneu-rosis, there must be a cumulative influence in order that the psychopathic state shall be brought about. Early childhood, subsequent education, and experiences in later life contribute to the final outburst of the psychopathic condition, apparently produced by some one event.
Many persons may experience shocks of an intense character and yet not become psychopathic. This should not be taken to mean that shocks per se are not capable of producing psychopathic states, or, in other words, that shocks are not regarded as causes of functional psychosis. It only means that the shock is a contributory cause. The shock requires previous conditions and preparations to bring about a functional trouble of psychopathic character. Rain calls forth no growth from rocks, stones, and pebbles,—seeds and soil are requisite. People do not become psychopathic through the agency of one shock. Subconsciously the ground and seeds are prepared, and the last shock is but the proximate cause, calling forth to life what has been there before.
The last event need not necessarily result immediately in some functional disturbance. There may elapse some time,—a period which may be one of brooding of a subconscious character. In short, the disease may set in slowly, almost imperceptibly; or, the disease may be latent, so to speak, and then be brought out by some slight stimulus of a common-place character, a stimulus with which the patient is fully familiar, and which he would otherwise ignore. Psychopathic states have a long history of development, reaching in the subconscious far back to early childhood.
The other factor in somopsychosis and psychoneurosis is dissociation. The psychopathic individual has a predisposition to dissociative states. It is true that early experiences and the training of early childhood enter largely into the formation of such a predisposition. Still there is no doubt that heredity has its share. A sensitive nervous system is required,—a sensitive brain highly susceptible to special stimuli of the external environment.
This, of course, does not mean that the brain must suffer from stigmata of degeneration. On the contrary, it is quite possible, and in many patients we actually find it to be so, that the psychopathic individual may even be of a superior organization. It is the sensitivity and the delicacy of nervous organization that make the system susceptible to injurious stimulations, to which a lower form of organization could be subjected with impunity. An ordinary clock can be handled roughly without disturbance of its internal workings, but the delicate and complicated mechanism of a chronometer requires careful handling and special, favorable conditions for its normal functioning.
Unfavorable conditions are more apt to affect a highly complex mechanism than a roughly made instrument. It is quite probable that it is the superior minds and highly complex mental and nervous organizations that are subject to psychopathic states or to states of dissociation.
Of course, unstable minds are also subject to dissociative states, but we must never forget the fact that highly organized brains, on account of their very complexity, are apt to become unstable under unfavorable conditions. A predisposition to dissociation may occur either in degenerative minds or in minds superior to the average. Functional psychosis requires a long history of dissociated, subconscious shocks, given to a highly or lowly organized nervous system, dating back to early childhood.
As Mosso puts it: “The vivid impression of a strong emotion may produce the same effects as a blow on the head or some physical shock.” We may, however, say that no functional psychosis, whether somopsychosis or psychoneurosis, can ever be produced simply by physical shocks. In all functional psychoses there must be a mental background, and it is the mental background alone that produces the psychosis, and determines the character of the psychopathic state.
Thus, one of my patients gives the following account: “The nervous trouble (feeling of lassitude, fear of vague evil, fear of shadows fading into darkness, intense depression, loss of appetite and flesh, insomnia, headaches, and visceral disturbances) began in a rudimentary way about a year and a half ago, although I had already been nervous, and was gradually getting more so. At first it would be just what I call ‘painful thought,’ that is, if I read something that was a story of misfortune or suffering of any kind, or heard of a real case of a similar nature, I could feel how the person must have suffered, felt it as if it were myself. What if that had been me? I shuddered and was afraid. I would go through the most painful of all the sorrowful things I had ever read or known of. It would seem that I was going through the whole experience myself, and then I would hear myself tell the story of suffering, and it was I who had suffered all these experiences. I would begin to believe the story. When the end would come I would go off into a shivering horror that would end in a chill, which would sometimes last for three hours. When the horror would come on I would go out and walk until I was tired and come home and go to bed without any dinner and sleep the sleep of reaction and complete exhaustion. I slept apparently a dreamless sleep, which sometimes lasted about nine hours. Then I seemed to get better in the daytime, but would begin to dream the whole thing at night, and wake up in a blind, shivering terror.”
The dreams terrorized the patient, who, finally, sank into a deep physical and mental depression. As in many other cases, the patient presents a sensitive organization subject to a series of shocks dating back to early childhood. The terrorizing dreams are hallucinations formed by the play of associations out of fragments of actual former experiences, lived through during the period of trauma.*
*I shall revert to this subject in my forthcoming work “The Causation and Treatment of Psychopathic Diseases.”