The preceding chapters have outlined the major philosophies of the structures and functions of the mind and their normal development. Each scheme describes a complicated system with multiple opportunities for processes to go awry. Since the major
psychologies were derived from clinical practice, and since clinicians only become involved when things go wrong, each school of thought takes its own approach to the genesis and nature of psychopathology. Each school’s view of normal development and function is intimately linked to its view of how things go amiss.

Moods, of course, are a vital part of normal mental life. Emotions color our individual worlds and add a special dimension to experience. In clinical practice, however, and in the theories that underlie it, emotions are considered a special case of psychopathology, stemming from the same roots as disorders of thought, perception, and behavior. (Perhaps it is for this reason that most of the literature uses the term “affect” to describe what is more precisely identified as “mood,” or, in everyday language, “emotion.”) Therefore our review of psychopathology will incorporate each theory’s view of emotional states.

The original topographic model of drive psychology generated a schema of psychopathology that was as mechanical as the underlying theory itself and was of severely limited clinical applicability. From about 1885 to 1897, the focus was on the so-called “actual neuroses,” namely neurasthenia and anxiety neuroses. In certain individuals who had been rendered neuropathic by congenital or hereditary predisposition, unhygienic sexual practices produced symptoms directly. Excessive masturbation or nocturnal emissions yielded neurasthenia, a condition marked by lassitude, fatigue, and somatic symptoms such as headache and dyspepsia. Sexual frustration or sexual activity that did not result in gratification produced anxiety neuroses, marked by persistent anxiety punctuated by anxiety attacks.

This model of “dammed-up libido” lacked enough explanatory capacity to survive without substantial modification. As psychoanalysts became more attentive to the nature and workings of the drives, a second model emerged and held sway from about 1897 to 1923. Energy was the domain of the drives, not of the affect itself. Emotions were now considered to be drive derivatives, and psychopathology was the result of conflicts originating from the drives. The classical formulation of hysteria formed the bedrock of psychoanalytic explanation of behavioral pathology.

Freud and Josef Breuer examined and treated a number of patients with “hysteria,” i.e., symptoms of muscular or sensory impairment not traceable to any somatic cause. Drawing on the work of Jean Martin Charcot and Pierre Janet in Paris, they at first hypnotized their hysterical patients and discovered emotional conflicts that were being symbolically represented in the hysterical symptoms. For example, in the case of “Fraulein Elizabeth von R.,” the patient’s younger sister became sick during her pregnancy. Fraulein von R. went for a walk with her sister’s husband. Returning home a few days later, she awoke with unexplained pain and weakness in her legs. Under hypnosis, it became evident that she desired her brother-in-law but of course could not acknowledge this forbidden attraction. In the topographic model of the time, her desire was suppressed, and her guilt was manifest as pain and weakness in the very legs that took her on the walk. Hypnosis soon proved unnecessary as Freud and Breuer found patients could recall “forgotten” events when fully awake, and the other cases they studied supported the same formula:

Hysteria, obsessions, and phobias all shared the same formula and were classified together as the defense neuropsychoses. Obsessions represented attachments to symbolic displacements of the objects of earlier psychosexual stages (oral, anal, phallic); phobias embodied the overwhelming fear of such objects, similarly displaced into contemporary symbols.

This revolutionary formulation, elegant for its time and context, begged questions: What is the mechanism that diverts emotion and its energy from conscious to unconscious? How is that energy converted to the observed symptoms? In what part of the mental apparatus is emotion contained? The reader may now see how the accumulation of more clinical experience pushed the model past its limits and forced these questions. In yet another creative leap, Freud produced the structural model, as described in Chapter 1, which addressed these difficulties and expanded the horizon of psychodynamic explanation of psychopathology.

The structural model, introduced in 1923, postulated the presence of id, ego, and superego, allowing the fundamental problems of the topographic model of psychopathology to be addressed. At its most basic, the structural formulation of psychopathology maintains:

Thus Fraulein von R.’s circumstances could be more fully explicated: Her desire for her brother-in-law, originating in libidinal id impulses, was rejected by her superego even before it ever reached conscious awareness. Ego contained it first by repression, which only worked temporarily. As the urges persisted just beyond awareness, ego was forced to redirect the libidinal energy through symbolic representation in somatic symptoms.

The expansion of drive theory to include a conflict model allowed psychoanalysis to address many more dimensions of psychopathology, including affect. For Freud and his followers, the primary emotion was anxiety; all others were modifications, displacements, or substitutions. The model of anxiety based in structural theory held that anxiety of one sort is the inevitable result when the influx of energy from any stimulus is greater than what the individual can master. This type of anxiety was labeled traumatic anxiety; birth was the prototype for such a stimulus. The growing infant experiences similar sorts of automatic anxiety when he or she is hungry or in pain. Because the ego is still immature, this reflex form of anxiety is almost the only entity in the infant’s affective repertoire.

Later, the ego gains the capacity for memory and can connect traumatic, anxiety-provoking events to their surroundings. The infant notices that he or she only gets hungry in the absence of
mother; that the dog barks and causes fear. The young ego associates the departure of mother or the presence of the dog with sensations of anxiety and develops the capacity for signal anxiety. Even though there is nothing inherently traumatic about the presence of the dog or the absence of the mother, the child has come to associate those signal events with impending anxiety.

Signal anxiety in the more mature ego can deal similarly with internal stimuli, those stemming from unacceptable id impulses. In the presence of a forbidden love object, the wishes of unrestrained libido would be intolerable. The experience of signal anxiety when he or she approaches is weaker and much more manageable. Additionally, it allows the ego to prepare an array of defenses to contain and manage the drive derivatives.

The first and most indispensable tool of the ego in managing anxiety is the defense mechanism of repression. Unacceptable impulses are unconsciously extruded from the ego and returned to the id. But with the impulses goes all their associated energy; so when ego engages in repression, it feeds some of its energy to the id, which then presses its desires all the more powerfully. Too much repression, therefore, promotes the emergence of emotional, cognitive, and/or behavioral pathology. This constellation was named anxiety neurosis. Collectively, the earlier-defined defense neuropsychoses (hysteria, obsessions, and phobias) and anxiety neurosis were now labeled as the psychoneuroses.