Psychotherapy Part 71

Psychasthenia, Natural and Acquired.--There are two forms of the mental incapacity that underlies many of the curious symptom-complexes that have been studied under the term psychasthenia. One is natural, that is, inherent in the special character of the individual, and the other acquired through disease or exhausting labor, worry, or anxiety.

Some people are born without sufficient mental energy to do the work they attempt to accomplish. This is true, also, in the physical order.

It is often pitiable to see young men who have not the physical strength necessary for athletic exercises, or the dexterity required for them, faithfully trying to accomplish by effort what others do with ease. When there is some natural defect in the way they will usually fail, no matter how much they strive. Just in the same way some persons are not able to accomplish certain more serious purposes requiring special mental ability or power which they attempt. Their brothers, their friends, their schoolmates, may have the ability, and they cannot understand why they should not have it, but the fact remains that they are not possessed of it and if they try to make up for this defect by overwork they simply break down.

Differential Diagnosis.--Each of the two forms of mental incapacity, congenital and acquired, must be carefully differentiated and treated from a special standpoint. With regard to congenital lack of mental control, all that the doctor can do is to counsel against the a.s.sumption of duties and responsibilities that are too heavy for the patient. Some people have not enough nervous energy to run a business with many details, and some even find it difficult to try to do things involving much less responsibility. There is no use for a man five feet in height, weighing one hundred pounds, to try to be a stevedore.

There is no use for men of delicate muscular build to try to make their living at heavy manual labor; they simply wear themselves out in a very short time. This inadaptability is recognized at once. Just the same thing is true with regard to many nervous systems, but the recognition is not so easy or immediate. Some cannot stand the strain of intricate business details or the burden of responsibility in important transactions. They must be taught to be satisfied, then, with quiet simple lives without what is for them, excessive responsibility and without strenuous business worries. A country life with regular hours, plenty of open air and as little responsibility as possible, is the ideal for them.

The most difficult problem in this matter is the question of diagnosis. As a rule, the history is the most helpful for this. The patient tells of having found difficulty all his life whenever anything of special significance was placed on his shoulders. He is one of those who were born tired and remain so all their lives. It has been the custom to blame these people; they are rather to be pitied.

If they are born in circ.u.mstances that allow of their {599} living quietly in the country, they accomplish a certain amount of work quite successfully and live happy, contented lives. If they are born in the city where the hurry and bustle around them and the insistence of friends that they must take up responsibilities becomes poignant, they get discouraged and even despondent. It is from this cla.s.s of patients that the "ne'er-do-wells" of modern life are recruited. They form the under-stratum of trampdom, the scions of good families with the wanderl.u.s.t, the willing but incapable. Certain of them become vicious and criminal, either because they do not want to work or because their mentality is perverted in some way. Such patients cannot be treated with any hope of their becoming successful exemplars of the strenuous life, but they may be directed into the less exacting occupations of country life and so live quiet, useful and happy lives. For the congenital cla.s.s we can do little except to prevent them from trying to do things that are beyond their mental capacity and helping them to see just what their limitations are.

_Mental Exhaustion_.--Many disturbances of mental energy are acquired.

These may be either functional or organic. For the organic variety we cannot do much, since it is dependent on changes in organs that are permanent. We can, however, usually predispose the patient's mind to the recognition of the fact that he should no longer try to devote himself to occupations that const.i.tute a special drain on his nervous energy. The man, for instance, who is already suffering from arterio-sclerosis must be warned that worry and work will surely hasten the process and that his nervous symptoms cannot be cured, but must be palliated. He must be advised to lessen his mental strain and to take up something which, while occupying his mind, does not make insistent calls on his vitality. In this matter it must be remembered that when a man over fifty develops nervous symptoms, as a rule there is no question of functional trouble but of organic change and usually heart or arteries or kidneys are at fault.

In recent years we have come to realize that typhoid fever often makes serious inroads upon a patient's vitality which can only be retrieved by care, not alone for some months but, if possible, even for some years, not to put an overstrain on the vital energy. Certain other diseases produce an even more lasting effect. A sufferer from well-developed tuberculosis will probably never be able to go back to the strenuous city life. If he attempts to do so, not only is there danger of a recurrence of his tuberculosis, but there may even be a development of neurotic symptoms. Syphilis is another disease that leaves patients in a condition in which it is dangerous for them to a.s.sume the serious responsibilities of an exacting occupation and especially anything that involves excitement and worry. Syphilitic patients should be warned of the danger of pursuing vocations that make such demands upon them. It is the actor, the broker, the speculator, and the strenuous business man generally, who is likely to suffer from parasyphilitic conditions, tabes, paresis and the like, much more than those who follow occupations that make less demands on them.

Functional Mental Incapacity.--In a large number of cases the incapacity to do things because of lack of mental energy is due to functional disturbances of the nervous system. These are the most important for the psycho-therapeutist because much can be accomplished for them. Nearly always the patient can be benefited by advice and suggestion, and very often some {600} unfavorable factor at work, using up his mental energy to no purpose, will be discovered. In order to do good, however, careful study of the individual patient is the most important element. The most frequent functional disturbance of the nervous system, leading to exhaustion of mental energy, is over-attention to one's self and to one's occupations. Men can do many complicated things quite naturally and easily, but when they carefully watch themselves doing them, accomplishment is not so ready and the task is double. They tire much easier, for, as a rule, what they are doing could be accomplished automatically and they are using up energy attending to it. This is probably one of the commonest causes for the rather frequent development of that state called nervous exhaustion in our time. People watch themselves too closely and by so doing they not only use up energy unnecessarily in the surveillance, but also they hamper their powers to do things and so consume additional energy in overcoming this inhibition.

Morbidly introspective people watch almost ceaselessly everything they do. They not only watch themselves work and worry about it, but they watch themselves play and grow solicitous that it will do them good; they watch themselves divert themselves to see if it is giving them real recreation and so spoil the diversion; they watch themselves eat and disturb their appet.i.te, and watch themselves digest and hamper digestion; they even try at least to watch themselves sleep and so interfere with sleep. Many of the cases of insomnia are really due to this over-attention. They fear they will not sleep, they worry about it, they keep themselves awake hoping that they will sleep, and in the more serious cases even during sleep itself they are so solicitous that their dreams become very vivid and a form of unconscious cerebration goes on with surveillance of themselves. They do not rest even in sleep. They wake feeling not rested, they get up with a consciousness that they are beginning a long day without being properly refreshed and they exhaust enough energy to complete a good part of the day's work in wondering whether they will be able to go on with their occupation for the day, whatever it may be.

_Inhibitory Surveillance_.--People become afraid that they cannot or that they may not do things well and set a guard over themselves. This is ill.u.s.trated very well in the doubts about accomplishment because of which they keep going back to see what they have done and how it was done, though usually it was accomplished quite well without any conscious attention. Dreads form another phase of this att.i.tude of mind. For those who are affected with them they make a thing hard to do before it is begun, and harder to accomplish after it has been entered upon because of the suggestion that it may lead to some serious results, or they even inhibit their activities to a marked extent by their solicitude with regard to them. They worry about things before the event and thus consume energy uselessly. Worry has been defined as anxious solicitude about what we have to do next week at the same time that we occupy ourselves with what we are doing now and have to do in the next hour or two. The solicitude about next week is quite useless, as a rule, until the time comes, and it merely disturbs what we are doing now, making it harder to do and making errors in it almost inevitable, and so preparing ourselves for discouragement because of mistakes that have been made and still further adding to the difficulty of accomplishment.

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_Inhibition of Automatism_.--These introspective people disturb themselves by over-attention to things that need no attention, that are accomplished automatically, and that are not done nearly so well if they are attended to. Not only is it true that it is harder to do work that ought to be accomplished automatically if much attention is given to it, but also nature resents the surveillance. Not only the brain does not work so well if watched to see whether perhaps it is working too much, or whether there are too many feelings in our head while we are doing things, but even the stomach resents being watched and does not do its work as well. The same thing is probably true for every one of our organic functions. In the chapters on the heart we call attention to the fact that surveillance makes a perfectly healthy though nervous heart miss beats. There is a dual waste of nervous energy then. We are employing our attention watching things done that need not be watched, and by that fact we are inhibiting natural processes and requiring that more energy shall be put into them for their accomplishment, and even then accomplishing them with discouraging imperfection.

_Mental Short-Circuit_.--The reflex mental process that particularly affects many individuals in our time and makes it hard for them to do their work, has been well described under the figure of a short-circuit in an electrical dynamo. The short-circuit diverts the current so that instead of acting outside the dynamo and performing useful work, it is discharged within the machine, brings about deterioration of its elements and soon leads to a reduction in the amount of electrical energy that that particular dynamo can develop.

a.s.sociation Fibers Diversion.--Prof. Michael Foster in the Wilde Lecture for 1898, "The Physical Basis of Psychical Events," [Footnote 44] has many valuable suggestions with regard to the mechanism of mental operations on the neuron theory. He has particularly dwelt on the function of the a.s.sociation fibers in connection with mental operations, or with the raising of sensation to the plane of mentality. A portion of the brain that is originating impulses, instead of sending them down to the periphery, through the projection fibers, to lead to the accomplishment of external work, may have its messages diverted through the a.s.sociation fibers to other portions of the brain and thus do harm rather than good.

[Footnote 44: _Proceedings of Manchester Literary and Philosophical a.s.sociation_, 1898.]

Occurrence of Psychasthenia.--It must not be thought that these curiously interesting conditions occur only among people of low intellectual caliber, or in those of narrow intellectual interests, mere specialists who may have acquired a reputation for doing one thing well. They are frequent among the most intellectual cla.s.ses.

Brain workers of all kinds, unless they are careful to vary the interests of life, unless, as suggested in the chapters on Occupation of Mind and Diversion of Mind, they have a hobby besides their usual occupations, are likely to suffer in this way. As a matter of fact, many intellectual people have had what are called nervous breakdowns of this kind. A biographical dictionary shows any number of them. Dr.

Gould's Biographic Clinics furnish many doc.u.ments for the study of these conditions. A typical instance, told by the sufferer himself, the distinguished Sir Francis Galton, is of special significance for the psychotherapeutist. I {602} quote because it ill.u.s.trates the fact that such breakdowns do not portend a short or subsequently listless life, for Sir Francis, a most successful scientific investigator, lived well beyond fourscore years in the full possession of health of mind and body.

It was during my third year at Cambridge that I broke down entirely in health and had to lose a term and go home. I suffered from intermittent pulse and a variety of brain symptoms of an alarming kind. A mill seemed to be working inside my head; I could not banish obsessing ideas; at times I could hardly read a book, and found it painful to look at even a printed page. Fortunately I did not suffer from sleeplessness, and my digestion failed but little. Even a brief interval of mental rest did me good, and it seemed as if a long dose of it might wholly restore me. It would have been madness to continue the kind of studious life that I had been leading. I had been much too zealous, had worked too irregularly and in too many directions, and had done myself serious harm. It was as though I had tried to make a steam-engine perform more work than it was constructed for, by tampering with its safety-valve and thereby straining its mechanism. Happily the human body may sometimes repair itself, which the steam-engine cannot.

The physician with experience in such cases would be much more apt to say, "Happily we can learn to control our mental energy and not let it go to waste by foolish persistence at one set of ideas constantly, nor be dissipated in surveillance of functions that work automatically if left to themselves."

Etiological Factors.--This form of mental incapacity develops particularly in people after they have gone through a prolonged period of hard work and then have come to a time when they are much freer than they were before. They are p.r.o.ne to think that they exhausted their nerve force during the preceding period of labor and that now they are paying for it. Almost invariably what is really happening is that they now have much more time to occupy themselves with themselves and about themselves and to worry over their ills, real and imaginary.

This is the typical nervous breakdown, as it used to be called, of elderly retired merchants or bankers. They have looked forward all their lives to a time when they could enjoy themselves doing nothing.

They retire from business and then their troubles begin. It is no wonder that the old proverb, "A machine rusts out much sooner than it wears out" should have been so often quoted with regard to this condition. A man who has been working busily at something all his life cannot stop all at once and do nothing. He cannot learn to occupy himself with trivial things. Commonly, he has few, if any, interests apart from his business and he very soon wears the novelty off these and then introspection comes to make him exaggerate the significance of every feeling that he has, every stiffness that occurs, every muscle twinge due to change in the weather, until he becomes supremely miserable.

As a rule, these patients are simple, practical, common-sense, business men, and it is hard for the physician to think that there is nothing more than a functional neurosis present. It is even more difficult for the patient to be made to appreciate that his ills are mainly due to his own over-attention to himself in this idleness that he has looked forward to with so much pleasure. Ordinary medicines fail to relieve and the regular professional man seldom succeeds in doing these patients much good. They const.i.tute the richest material for the quack and the charlatan. Much occupied with their ills they tell their friends all about them. Whenever a strong impression is produced {603} on their mind by a promise to cure them with some new wonderful remedy they are favorably influenced, often get better and then are walking advertis.e.m.e.nts for the particular quack who has happened to benefit them. It is this cla.s.s of people that has given more trouble to legislative committees of medical societies than any other. Some of them appeal to legislators whenever a bill for the admission of some new form of pract.i.tioners of medicine comes up with the story of how much benefit they derived from the treatment. Since they have been successful business men their word carries weight. It is curious how little the making of money, though often presumed to be so, is a test of real intelligence. It is often the man of one idea with no intellectual breadth who is the best money-getter.

These conditions develop almost entirely in predisposed individuals who, for some reason, are trying to overdo the energy they possess, and who, as a consequence, have lost a certain control over themselves. At times, of course, they occur in persons who have so little occupation of mind that thoughts of various kinds along these lines become insistently suggestive and cannot be thrown off because the patients' interests are not sufficiently deep or sufficiently varied to occupy their attention. The rational treatment of them, then, must be founded on a careful study of individual cases, the recognition of the special cause, and also the occasions at work in each case, a neutralization of unfavorable suggestion and a provision of such favorable suggestions and occupation of mind as will enable the patient to rid himself of the annoyance occasioned by these and the physical symptoms that so often develop as a consequence. In a certain number of cases a history of corresponding or equivalent affections in preceding generations will be found. In many patients, however, there is no such history, though there is usually the story of symptomatic mental conditions of one or other of the types mentioned, earlier in life. When in good health physically the patient has very little bother from them. When run down in weight or when worried or anxious about business or from the stress of important responsibilities these symptoms may become bothersome mentally and physically. Often it will be impossible to obliterate them entirely, but always they can be greatly improved and the patient can be made to realize that they are not seriously significant, that in mild form they are rather common and that, above all, they are not so peculiar to the individual as he is likely to think, with consequent increase of the unfavorable suggestion.

CHAPTER II

HALLUCINATIONS

Hallucinations Differentiated from Illusions and Delusions.--Hallucinations are vivid impressions on the consciousness which appeal to their subject as strongly as if they were really the result of sensory impressions, though those who experience them know, either at the moment, or on investigation afterwards, that they had no objective reality, that is, were not due to any external physical cause. Illusions are deceptions of the senses, due to the imperfection of the senses or the conditions in which the perception occurs. {604} Delusions are mental states in which ideas are accepted, or conclusions drawn, or information a.s.sumed to be gained, though the whole process is mental and has no relation to reality. (For ill.u.s.trations of illusions see chapter with that t.i.tle in the Appendix.)

Hallucinations lie in between illusions and delusions as a mode of deception. They are mental occurrences, but they seem to come from the senses and probably the best explanation for them is that a previous sensory impression is vaguely aroused and then finds its way into the consciousness as if it were coming through the senses. It has been suggested that they might be due to a reversal of the nervous process by which a sensation reaches the brain. The external object produces the sensation, this travels along a nerve causing a perception, this perception is stored in the memory, and then, when very vividly reawakened, causes impulses to travel backward along the nerve to the periphery with the production of a feeling very like sensation.

Frequency.--While hallucinations are often supposed to be only incidents in the life of the insane, or at least of those who are in the danger zone near mental disequilibration, carefully collected recent observations show that many perfectly sane people have experienced them, and some of them have been much disturbed by them for fear they portended loss of mental control or some developing pathological condition. A certain number of men and women have seen things that either had no existence or existed only for them and for the moment, and that evidently were due to some state of mind rather than to their senses. They have heard things that were not said or that were not audible to others, or that were only reproductions of their memory of previous sounds and quite naturally such mysterious manifestations disquiet them. It was the rule in the past to dismiss such phenomena without serious consideration, or at most to consider that they were only subjective manifestations not worth discussing, or to go to the opposite extreme and say that they were due to mental disturbances.

Of course, as a rule, hallucinations are an index of mental disturbance. No matter how apparently sane the patient, this must be the first thought and must be carefully excluded before proceeding with the case. The subject of hallucinations is larger than that, however, and it is a mistake to brush it aside in every case as if it were either very serious or of no importance and that in either case nothing can be done to relieve solicitude about it. Physicians can often do much, first to prevent hallucinations by getting at the physical causes of them; second, to prevent them from disturbing patients seriously by showing them how common are such experiences and by indicating their possible physical significance; third, by securing such mental discipline and control as will render their recurrence much less frequent; and, fourth, they can make the almost inevitable unfavorable effect upon the mind of the patient and then reflexly upon his body, much less than it would otherwise be, by sympathetically discussing and entering into the details of them enough, at least, to explain their significance or throw some light on their origin in physical conditions.

Hallucinations of vision, the seeing of things and persons that have no real existence at the time and place they are seen, are usually considered to be rather uncommon and to occur only in those whose mentality is seriously disturbed. Careful studies of the subject, however, show that at least one in ten {605} of educated people consulted have had some hallucinations of vision. Either they have wakened up, or they have dreamt that they waked in the early morning, and have seen some one whom they knew, but knew to be at the moment at a distance, standing near them. Such visions have gradually faded away or suddenly disappeared. Occasionally these persons have in full light had some appearance, wraithlike or otherwise, some manifestation that appeals to vision, yet that they knew at the time or learned afterwards was non-existent.

Many people are backward about confessing that they have had such experiences, for they fear that it will make them ridiculous or even cause them to be suspected of disturbed mentality. Just as soon as it is made clear to them that their admissions will be taken as evidence for a phenomenon to be discussed seriously, many more than would otherwise be thought confess to such hallucinations. Most of these, it may be said at once, are quite sensible people, a great many of them belong to the educated cla.s.ses; all of them are trustworthy witnesses as far as good will goes, and the circ.u.mstances of their hallucinations are such in many cases that there cannot be a mere mistake, or error of judgment.

The frequency with which hallucinations occur may be appreciated from the investigation made some years ago at the instance of the Congress of Experimental Psychology. The following question was put to 17,000 persons, mostly residents of Great Britain, and answers received: "Have you ever, when believing yourself to be completely awake, had a vivid impression of seeing or being touched by living beings or inanimate objects, or of hearing a voice, which impression, so far as you could discover, was not due to any external physical cause?" The answers showed that 655 out of 8,372 men and 1,029 out of 8,628 women had experienced a sensory hallucination at some time in their lives.

Some of them had had a number of them. That is, one out of ten in the educated cla.s.ses has had some hallucination, and nearly one out of every eight women. An a.n.a.lysis of the statistics, however, brings out some interesting suggestions. There were nearly twice as many hallucinations related as having occurred during the year before the question was asked as in the preceding years. There was a definite reduction in the number that had occurred in all the preceding years, except the fifth and tenth, and these were evidently due to uncertainties of memory, so that five- and ten-year periods seemed about the length of time that had pa.s.sed since the event.

It is evident then that in spite of the fact that an hallucination would seem to be very important and surely startling enough to be well remembered, it is yet easily forgotten, since even a year's interval made so much difference in the number that were remembered. The committee, after considering this easy forgetfulness in the matter, considered that to arrive at the actual total of visual hallucinations experienced by this group of 17,000 persons during the ten-year period in question, the numbers in the table should be multiplied by four.

That means that probably very nearly one in three people have had an hallucination of some kind within ten years. The great majority of the visual hallucinations consist of apparitions of human figures. Other forms that are seen are so few, as Mr. Podmore has insisted in his "Telepathic Hallucinations, The New View of Ghosts," [Footnote 45]

that they are almost negligible. A frank {606} discussion of these details with a person who is much disturbed by having experienced an hallucination is the best possible remedy for the physical and mental disturbance that may result.

[Footnote 45: The Twentieth Century Science Series, New York, 1910.]

Sir Francis Galton, well known for his investigation of many subjects and who may well be called the father of biometrics or statistical biology, in his "Memories of My Life" [Footnote 46] tells of his own investigations of the visions of sane persons. The fact that he delivered a lecture on this subject at the Royal Inst.i.tution of London shows how seriously his studies were made and how much value scientists placed on them. Galton's well-recognized training in the careful weighing of evidence and his ability to strip phenomena of everything that might divert their significance from what they really were, add to the worth of his conclusions. Those who care to study the subject further will find his discussion in the _Proceedings of the Royal Inst.i.tution_ (London, 1882).

[Footnote 46: New York, 1909.]

There are few people beyond middle age who have not had one or more curious experiences in the matter of visions or appearances. Mostly these have been vague and have not proved a disturbing element in the minds of the subjects. Many more than are thought, however, have seen visions vividly and with a detail that makes it almost impossible for them to believe that what they saw was merely an externation of ideas already in their mind. In this matter it must not be forgotten that the dreams of many people, especially nervous people, often present themselves with marvelous vividness of detail. They see people or places in their dreams and reason about them quite rationally.

Occasionally a dream will bring back details that have been forgotten.

The dreaming state seems in some people to have wonderful power over the subconscious. Things that are not remembered at all in the waking state sometimes come back in dreams, and only then are recalled by the individual as representing past events in his life. He is apt to wonder where the details could possibly come from, since he had before no conscious memory of them. This same thing holds for the day-dreams or sudden visual appearances that come when the attention has been wrapped in something else.

A typical example of such visual hallucinations is the following incident told by a prominent London physician of himself:

One afternoon at tea time, before a meeting of the Royal Society, Sir Risdon Bennett (1809-1891, a well-known physician. President of the College of Physicians in 1876, and a fellow of the Royal Society), drew me apart and told me of a strange experience he had had very recently. He was writing in his study separated by a thin wall from the pa.s.sage, when he heard the well-known postman's knock, followed by the entrance into his study of a man dressed in a fantastic medieval costume, perfectly distinct in every particular, b.u.t.tons and all, who, after a brief time, faded and disappeared. Sir Risdon says that he felt in perfect health; his pulse and breathing were normal and so forth, and he was naturally alarmed at the prospect of some impending brain disorder. Nothing, however, of the sort had followed. The same appearance recurred; he thought the postman's knock somehow originated the hallucination. ... I heard the story at length, very shortly after the event, told me with painstaking and scientific exactness and in tones that clearly indicated the narrator's earnest desire to be minutely correct.

Those who are especially interested in this subject will find any number of similar stories, some apparently rich with meaning, most of them quite {607} meaningless, in the volumes of transactions of the English Psychic Research Society, in F. W. H. Myers' "Human Personality," in Podmore's "Naturalizing the Supernatural," in Flammarion's "The Unknown," or many other books published in recent years. It is quite easy to get sufficient material to bring rea.s.surance to any patient that visual hallucinations, at least, mean nothing serious for the mind or body of the individual having the experience.

Hallucinations in the Past.--It must not be thought, however, that this subject of hallucinations is new. Literature is full of it and from the earliest times we find traces of it. Egyptian, Babylonian and Chaldean writers mention them. Nor indeed is the scientific consideration of the subject new. Aristotle speaks of them and it is evident that many of the old writers thought of them as psychic incidents on some physical basis, or at least due to some predisposition in the individual or in some special state of his senses. Two generations ago Johann Muller, the great German physiologist, discussed the whole subject at length in a monograph, and considered it of so much importance for physicians that he introduced a resume of it into his great text-book of physiology. His explanation of the occurrence of visual hallucinations is not only a striking ill.u.s.tration of the thoroughly scientific character of his treatment of the subject, but it serves to show how well men considered these subjects long before the present fad for the study of abnormal psychology or mental influence came in. His discussion of the subject is sufficient of itself to make any patient understand his hallucinations and keep them from bothering him better than anything else I know: