Psycho-Analysis and the War Neuroses · Sándor Ferenczi
SYMPOSIUM
Many investigators, including non-psycho-analysts, came to the conclusion from these and similar observations, that these disturbances are not the direct effects of the trauma, but psychical reactions to it and act in the service of the instinct of self-preservation against the repetition of the unpleasant occurrence. We know that also the normal organism has at its disposal such protective measures. The symptoms of the terror, such as the immovable legs, the tremblings, the hesitating speech, seem to be useful automatisms; one is reminded by them of certain animals which simulate being dead when danger threatens. And if Bonhoeffer looks upon these traumatic disturbances as fixations of the means of expression of the terrible emotion which has been suffered, Nonne goes further and discovers that “the hysterical symptoms represent partly a reminiscence of inborn guard and defence mechanisms, the suppression of which in those individuals whom we call hysterical has not taken place in the normal degree or not at all”. According to Hamburger the most frequently occurring type of disturbances of standing, walking and speech associated with shaking tremors represents a “complex of ideas of feebleness, weakness, refusal and exhaustion”, and Gaupp sees in the same symptoms the lapse into infantile and puerile states of obvious helplessness. Some authors actually speak of the “fixation” in the traumatic posture of the body and innervation.
It cannot escape the notice of anyone with a knowledge of psycho-analysis how near these authors, without knowing it, are to psycho-analysis. The “expressions of fixations of movements” described by them are in reality only paraphrases of the Breuer-Freudian hysterical conversion, and the lapse into atavistic and infantile methods of reaction is nothing more nor less than what Freud called special attention to as the regressive character of the neurotic symptoms, all of which according to him only signify reversions into ontogenetic and phylogenetic stages of development already overcome. At any rate we have definite proof that neurologists have now decided to _interpret_ certain nervous symptoms, that is to say, refer them to unconscious psychical contents, which would never have occurred to anyone to do before the introduction of psycho-analysis. I will now speak of the few authors who occupy themselves with the war neuroses from the psycho-analytical points of view.
Stern has published a work on the psycho-analytical treatment of the war neuroses in war hospitals. I have not been able to see the work in the original, but I learn from the abstracts that the author proceeds from the point of view of repression and finds the situation of the serving soldier particularly suited to the production of neuroses in consequence of the suppression of affects which his service demands. Schuster admits that the investigations of Freud “however one may feel towards them” have thrown a ray of light on the psycho-genesis of the neuroses; they assist in revealing the hidden connection between symptom and psychical content which still exists though difficult to discover. Mohr treats the war neuroses by the cathartic method of Breuer and Freud, by getting the patients to live through the critical scenes again and brings about an abreaction of their affects by letting them re-experience the terrible emotion. Simmel is the only one up to the present who has occupied himself methodically with the psycho-catharsis of the war neuroses, and he will give his own report of his experiences to the Congress. Finally, I will mention my own investigations concerning the psychology of the war neuroses, in which I made the attempt to bring the traumatic forms of disorder into the category of psycho-analysis.
In this connection I will allude to a discussion which branches out in all directions on the question whether an affect can still act psycho-genetically when the person concerned immediately loses consciousness. Goldscheider and many others still maintain that a psychical effect is made impossible through swooning, and Aschaffenburg adheres to the view that loss of consciousness before falling ill guards against the neurosis. Nonne rightly opposes this view, and points out that unconscious mental streams could act psychically in spite of the loss of consciousness. L. Mann, relying on Breuer’s hypnoidal theory, puts forward the view that the loss of consciousness before falling ill does not protect but disposes to the appearance of the neurosis, by preventing the discharge of the affects. Orlovsky expresses himself the most rationally on this vexed question; he points out the possibility that the swooning itself can be a psychogenic symptom, a flight into unconsciousness, which would spare the person concerned the conscious experiencing of the painful situation and sensations. The possibility of the psychogenic formation of symptoms during a faint is quite comprehensible to those of us who are psycho-analysts. This problem could be started only by authors who take up a standpoint, obsolete to psycho-analysis, that equates mental with conscious. I do not know, ladies and gentlemen, whether you also have obtained the impression from all these quotations and references (which are only taken at random from the literature) that an advance, even though one that is not admitted, has taken place in the attitude of leading neurologists towards the teachings of psycho-analysis. Moreover, candid recognition is not lacking; for example, the expression of Nonne, that Freud’s experiences concerning the elaboration in the unconscious have received interesting illuminations and corroborations through the experiences of the war.
However, the same sentence of acknowledgement also contains a nihilistic opinion of Nonne concerning psycho-analysis; he states that Freud’s idea of the almost exclusively sexual foundation of hysteria has been conclusively disproved during the war. We can no longer leave this unanswered, which after all is only a partial denial of psycho-analysis: also we can very easily give the answer. The war neuroses, according to psycho-analysis, belong to a group of neuroses in which not only is the genital sexuality affected, as in ordinary hysteria, but also its precursor, the so-called narcissism, self-love, just as in dementia praecox and paranoia. I grant that the sexual foundation of these so-called narcissistic neuroses is less easily apparent, particularly to those who equate sexuality and genitality and have neglected to use the word “sexual” in the sense of the old platonic Eros. Psycho-analysis, however, returns to this extremely ancient standpoint when it treats all tender and sensual relations of the man to his own or to the opposite sex, emotional feelings towards friends, relatives and fellow-creatures generally, even the affective behaviour towards one’s own ego and body, partly under the rubric “erotism”, otherwise “sexuality”. It cannot be denied that those to whom this idea is strange cannot so easily be convinced of the correctness of Freud’s postulation of the sexual theory in a narcissistic neurosis in particular, for example, in the traumatic neurosis. We should like to advise them to examine themselves into the usual (non-traumatic) hysteria and obsessional neuroses also, and to keep strictly to the methods of free association, dream and symptom interpretation proposed by Freud; then they will be much more easily convinced of the correctness of the sexual theories of the neuroses, and agreement about the sexual background of the war neuroses will follow. At any rate the triumph concerning the overthrow of the sexual theories is somewhat premature.
The observation that I have made as regards the participation of sexual factors in the formation of symptoms in the traumatic neuroses also shows that in traumatic neurotics the genital sexual hunger (libido) and potency is generally greatly injured; in many cases it can even be entirely suspended and that for long periods. This condition which is a positive one is alone sufficient to demonstrate the rashness of Nonne’s conclusion[3]. Ladies and gentlemen: With what I have said I have discharged the chief task of my paper, which was the critical survey of the literature on the war neuroses from the standpoint of psycho-analysis. However, I will make use of this rare opportunity to tell you some of the observations I have made myself, and I will present points of view which may help to explain these conditions psycho-analytically.
In the psychical sphere of the traumatic neuroses there predominate such symptoms as hypochondriacal depression, terror, anxiousness, and a high degree of irritability with a tendency to outbursts of anger. Most of these symptoms can be traced back to _increased ego-sensitiveness_ (in particular the hypochondria and the incapability of tolerating physical or mental discomfort). This over-sensitiveness arises from the fact that in consequence of the shock, which has been experienced once or repeatedly, the interest and sexual hunger (libido) of the patients is withdrawn from the object into the ego. There thus comes about a damming-up of the sexual hunger (libido) in the ego, which is expressed in those abnormal hypochondriacal organic sensations and over-sensitiveness. Frequently this heightened ego-love degenerates into a kind of infantile narcissism: the patients would like to be pampered, cared for, and pitied like children. One can therefore speak of a reversion into the childish stage of self-love. This heightening corresponds to the diminution of object-love, often also of genital potency. A man who is already predisposed to narcissism will of course sooner fall a victim to a traumatic neurosis; still no one is entirely immune from it, since the stage of narcissism forms a significant fixation point in the development of the sexual hunger (libido) of every human being. The combination with other narcissistic neuroses, especially paranoia and dementia, frequently occurs.
The symptom of anxiety is the sign of the shock to the self-confidence occasioned by the trauma. This is most strikingly expressed in men who, in consequence of an explosion, have been knocked down, hurled over or blown up and have thereby permanently lost their self-confidence. The characteristic disturbances of walking (astasia-abasia with trembling) are protective measures against the repetition of the anxiety, therefore phobias in Freud’s sense. The cases in which these symptoms predominate are called anxiety-hysteria. Those symptoms, on the contrary, which simply express the situation at the moment of the explosion (innervation, position of the body) are conversion-hysterias in the psycho-analytical sense. Also in the anxiety there is naturally a constitutional predisposition; those persons more easily fall ill in this way who, in spite of real cowardice, are compelled from ambition to perform courageous deeds. The anxiety-hysterical disturbance in walking is at the same time a reversion to an infantile stage of not-being-able-to-walk or of learning-to-walk. Also the tendency to outbursts of rage and anger is a highly primitive method of reaction to a superior force; it can increase up to epileptic attacks, and represents more or less incoordinate discharges of affect analogous to those observed in the period of suckling. A milder variety of this loss of restraint is the lack of adaptation to discipline, which is practically never missing in the traumatic neuroses. The excessive need for love and the narcissism also give rise to this increased irritability.
The entire personality of most of the victims of trauma corresponds therefore to the child who is fretting, whimpering, unrestrained and naughty in consequence of a fright. 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 primary motive for the illness is the pleasure itself of remaining in the secure retreat of the childish situation once so unwillingly left behind. Both these narcissistic and apprehensive manifestations of illness have their atavistic prototype; it is even possible that the neurosis often reverts to methods of reaction which play no part at all in the individual development (feigning of death by animals, methods of progress and protection of the young of animals in the ancestral series). It is as though an over-strong affect could no longer be compensated along normal paths, but had to regress to previously abandoned but virtually existent mechanisms of reaction. I do not doubt that many other pathological reactions will yet be revealed as recapitulations of overcome methods of adaptation.
As symptoms of the traumatic neuroses which are less appreciated, I might mention the over-sensitiveness of all the senses (shunning of light, hyperacusis, extreme ticklishness) and the anxiety dreams. The real terrors that have been experienced, or things similar to them, are lived through again and again in these dreams. I am following a hint of Freud’s when I look upon these terrors and anxiety dreams, as well as the state of terror by day, as spontaneous attempts of cure on the part of the patient. They serve to bring piecemeal to conscious abreaction the shock, which in its totality was intolerable and unintelligible and was therefore converted into symptoms, and to contribute to the adjustment of the disturbed equilibrium in the psychical economy. Ladies and gentlemen, I hope these few remarks of mine may serve as proof that the psycho-analytical conception discloses points of view where the rest of neurology leaves us in the lurch. From the methodical psycho-analysis of many cases we ought to expect the full explanation of these morbid conditions and perhaps also their radical cure.
While this article was in the press, I read the interesting work of Prof. E. Moro, the childrens’ specialist of Heidelberg, on “the first Trimenon”, _i. e._ the peculiarities of the first three months of the infant’s life. He says: “If one lays a young infant on a pillow on a table and strikes the pillow on either side with the hands, then there results a peculiar reflex action. Both arms are thrown up symmetrically apart and then come together again in a curve with easy tonic movements. A similar movement is carried out simultaneously by the legs”. We would say: Moro has here artificially produced a little shock (or traumatic) neurosis. The remarkable thing in this action is that this reflex to the shock in the young infant of less than three months old shows signs of the natural reflexes of clasping, which characterise the “carried offspring”, _i. e_. the young of animals (monkeys) which are compelled with the help of a pronounced clasping reflex to hold fast with the fingers to the mother’s fur while she climbs about the trees. We would say: Atavistic reversion of the method of reaction in sudden terror[4]. 2. DR. KARL ABRAHAM, Berlin. During the war academic neurologists have come round more and more to regard the aetiology of the traumatic neuroses from psychological points of view. However, in spite of the approach towards our views, mentioned by Ferenczi, their ideas differ from ours in two respects, namely, they for the most part only take into consideration the reactions of the ego impulses to the trauma, and they keep entirely to the manifest expressions of the neurosis. In the following remarks, besides those factors which we do not dispute, I intend to deal with the unconscious and sexual ones.
When in peace times psycho-analysis upheld the sexual aetiology of the neuroses it was often pointed out as a contrary argument that this could not hold good for the traumatic neuroses. Similarly now the opinion is expressed that the genesis of the war neuroses contravenes our ideas. Terror, anxiety lest the dangerous situation be repeated, seeking for a pension, and some vague idea of disposition are supposed to be adequate explanations of the illness; in the mass of the neuroses which have broken out during the war the unimportance of the sexual aetiology is thought to be clearly shown. My investigations of the traumatic neuroses in peace time had for a long time led me to conclude the importance of sexuality in them similar to that in the other neuroses, but they have not yet been sufficiently numerous and conclusive enough for publication. I might mention the case of a young girl who met with a slight tram accident when she was in the throes of a serious erotic conflict. The analysis showed that the accident in a certain measure gave a pretext for the outbreak of the neurosis. The symptoms were in connection with the conflict in question; the importance of the trauma receded quite into the background. I might also add that some litigious cases of traumatic neurosis which I observed in greater detail all suffered from impotence; this disturbance was produced by the accident, but seemed to have its real basis in old and unconscious sexual resistances.
The investigation of war neurotics has fully confirmed my surmises connected with such observations. Moreover, the recurrence of certain definite symptoms in war neurotics, which were familiar to me not only in the traumatic neuroses of peace time, but also in the non-traumatic cases, seems to me worth noting. I refer particularly to the complex of symptoms which we could so often observe during the war in the anxiety cases with trembling, such as trembling, agitation, irritability, sensitiveness, sleeplessness, headaches, anxiety, depression of spirits and feelings of incompetency. Two neurotic types with the same symptoms—although these do not appear so prominently as in the war—would be the impotent man and the frigid woman. A similarity which is so marked in external phenomena leads one to expect a similarity also in internal processes. All my experience fully coincides with that which Ferenczi has just communicated. The trauma acts on the sexuality of many persons in the sense that it gives the impulse to a regressive alteration which endeavours to reach narcissism. I might add that we both arrived at this idea without having previously even mentioned it to one another. The trauma, however, has this effect only in a portion of those participating in the war, hence we are unable to dispense with the assumption of an individual disposition, but we are in the position to define it far more accurately than the prevailing school of neurology. A couple of examples will make the problem before us clearer.
At the beginning of the war a soldier at the front was wounded on August, 12th, 1914. Before his wound was completely healed he secretly left the hospital and went again to the front, soon getting a second and after a few months a third wound. After repeated returns to the front he was one day blown up by a shell explosion and was unconscious for two days. After these four traumata he certainly presented the phenomena following upon shock, but no neurotic picture, being neither particularly anxious, depressed nor excited. Another man at the front during a night attack fell into a hole without injuring himself, but immediately developed neurotic trembling of a most severe kind, and presented the picture of a mental breakdown. How are such differences to be explained? 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. Many of these men were unable to carry out their tasks in practical life, others that were capable of doing this, however, showed little initiative and manifested little impelling energy. In all of them sexual activity was diminished, their sexual hunger (libido) being checked through fixations; in many of them already before the campaign potency was weak or they were only potent under certain conditions. Their attitude towards the female sex was more or less disturbed through partial fixation of the sexual hunger (libido) in the developmental stage of narcissism. Their sexual and social capacity of functioning was dependent on their making certain concessions to their narcissism.
In the war these men were placed under completely changed conditions and in the face of extraordinary demands. They had always to be prepared for unconditional self-sacrifice in favour of the mass. This signifies the renunciation of all narcissistic privileges. The healthy person is able to accomplish such a complete suppression of his narcissism: he loves according to the transference type, and so is capable of sacrificing his ego for the whole. In this respect those disposed to neuroses are inferior to healthy persons. It is not only demanded of these men in the field that they must tolerate dangerous situations—a purely passive performance—but there is a second demand which has been much too little considered, I allude to the aggressive acts for which the soldier must be hourly prepared, for besides the readiness to die, the readiness to kill is demanded of him. A further factor which operates on the labile sexuality of those disposed to neuroses is the almost exclusive association with men. The sexuality of the normal person takes no harm from this, but it is otherwise in men with strong narcissistic traits. The knowledge of the connection between homosexuality and narcissism enables us to understand this.
The previously unstable attitude towards women begins to waver under such conditions. If the lability of the attitude towards the other sex is very great then it does not need even a war trauma to cause a neurosis to break out in such men. For instance, I observed a man who on return from furlough at home had a convulsive attack and was brought into the hospital showing signs of anxiety and depression. The man had always been noted for his effeminate disposition, and in his married life was weakly potent and always inclined to jealousy. When he was home on leave he failed absolutely in the attempt to have sexual relations with his wife. His fears that his wife would be unfaithful to him reached a crisis, and soon after his departure from home he had his convulsive attack.
Such men with labile heterosexual impulses need a support for their sexuality. They frequently find this in their wife on whom their sexual hunger (libido) is completely dependent, or they have to defend themselves from their feelings of insecurity sexually by having constantly to convince themselves that they are potent by going with prostitutes. And so in war they constantly need a support for their wavering activity. Their military usefulness also is dependent upon conditions. They are frequently useful in rank and file, supporting their activity upon that of their comrades. A changed situation, and occurrence, which with a marked disposition needs only to be very trifling, upsets the balance, making the previously weakly-active man wholly passive. 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. Many of the patients show themselves completely female-passive in the surrender to their suffering. In their symptoms they are experiencing anew the situation which had caused the neurosis to break out, and soliciting the sympathy of other people.
At this juncture we must again refer to the previously mentioned circumstance that in our patients the anxiety as regards killing is of a similar significance to that of dying. The symptoms in part are only comprehensible in this sense. The case of a man who in the field suffered from a relapse of a neurosis which he had had six years previously is especially instructive. At that time he was taken with a tremor of his arm which arose in connection with a dream in which he murdered someone; a hand-to-hand fight in the field caused the old symptom to reappear. Hysterical convulsive attacks are not only produced through dangerous situations, terror, etc., but not infrequently an act of aggression which he has failed to carry out is expressed in them. Such an attack is especially often associated with an exchange of words with his superiors; the suppressed impulse to forcible activity finds in the expression its motor discharge. The complete instability of many war neurotics, their disconcerting depression, their propensity to thoughts of death, find a further explanation in a particular effect of the trauma. Many of the neurotically disposed persons, up to the moment when the trauma upsets them, have supported themselves only through an illusion connected with their narcissism, namely, through the belief in their immortality and invulnerability. The effect of an explosion, a wound, or things of a like nature suddenly destroys this belief. The narcissistic security gives way to a feeling of powerlessness and the neurosis sets in.
Ideas discussed in this chapter
Text from Project Gutenberg, public domain in the United States.