The Loss of Reality in Neurosis and Psychosis
The Loss of Reality in Neurosis and Psychosis
Accordingly, the initial difference is expressed thus in the final outcome: in neurosis a piece of reality is avoided by a sort of flight, whereas in psychosis it is remodelled. Or we might say: in psychosis, the initial flight is succeeded by an active phase of remodelling; in neurosis, the initial obedience is succeeded by a deferred attempt at flight. Or again, expressed in yet another way: neurosis does not disavow the reality, it only ignores it; psychosis disavows it and tries to replace it. We call behaviour ‘normal’ or ‘healthy’, if it combines certain features of both reactions – if it disavows the reality as little as does a neurosis, but if it then exerts itself, as does a psychosis, to effect an alteration of that reality. Of course, this expedient, normal, behaviour leads to work being carried out on the external world; it does not stop, as in psychosis, at effecting internal changes. It is no longer autoplastic but alloplastic.
In a psychosis, the transforming of reality is carried out upon the psychical precipitates of former relations to it – that is, upon the memory-traces, ideas and judgements which have been previously derived from reality and by which reality was represented in the mind. But this relation was never a closed one; it was continually being enriched and altered by fresh perceptions. Thus the psychosis is also faced with the task of procuring for itself perceptions of a kind which shall correspond to the new reality; and this is most radically effected by means of hallucination. The fact that, in so many forms and cases of psychosis, the paramnesias, the delusions and the hallucinations that occur are of a most distressing character and are bound up with a generation of anxiety – this fact is without doubt a sign that the whole process of remodelling is carried through against forces which oppose it violently. We may construct the process on the model of a neurosis, with which we are more familiar. There we see that a reaction of anxiety sets in whenever the repressed instinct makes a thrust forward, and that the outcome of the conflict is only a compromise and does not provide complete satisfaction. Probably in a psychosis the rejected piece of reality constantly forces itself upon the mind, just as the repressed instinct does in a neurosis, and that is why in both cases the consequences too are the same. The elucidation of the various mechanisms which are designed, in the psychoses, to turn the subject away from reality and to reconstruct reality – this is a task for specialized psychiatric study which has not yet been taken in hand.
There is, therefore, a further analogy between a neurosis and a psychosis, in that in both of them the task which is undertaken in the second step is partly unsuccessful. For the repressed instinct is unable to procure a full substitute (in neurosis); and the representation of reality cannot be remoulded into satisfying forms (not, at least, in every species of mental illness). But the emphasis is different in the two cases. In a psychosis it falls entirely on the first step, which is pathological in itself and cannot but lead to illness. In a neurosis, on the other hand, it falls on the second step, on the failure of the repression, whereas the first step may succeed, and does succeed in innumerable instances without overstepping the bounds of health – even though it does so at a certain price and not without leaving behind traces of the psychical expenditure it has called for. These distinctions, and perhaps many others as well, are a result of the topographical difference in the initial situation of the pathogenic conflict – namely whether in it the ego yielded to its allegiance to the real world or to its dependence on the id.
A neurosis usually contents itself with avoiding the piece of reality in question and protecting itself against coming into contact with it. The sharp distinction between neurosis and psychosis, however, is weakened by the circumstance that in neurosis, too, there is no lack of attempts to replace a disagreeable reality by one which is more in keeping with the subject’s wishes. This is made possible by the existence of a world of phantasy, of a domain which became separated from the real external world at the time of the introduction of the reality principle. This domain has since been kept free from the demands of the exigencies of life, like a kind of ‘reservation’; it is not inaccessible to the ego, but is only loosely attached to it. It is from this world of phantasy that the neurosis draws the material for its new wishful constructions, and it usually finds that material along the path of regression to a more satisfying real past.