Gentlemen!

The examples of acute mental illness that I have presented to you so far can be regarded as relatively pure and simple cases of acute somatopsychosis and acute allopsychosis, since the main elementary symptoms in the first consisted of disturbances of secondary identification in perception of physicality; and in the second in perception of the outside world. These disturbances of identification themselves involved exclusively the sensory domain, that is the relationship of s to A in our schema, even if, in detail, the subgrouping of symptoms as either anaesthesia, paraesthesia, or hyperaesthesia was often left in doubt, and open to discretion. If we are to pursue previously developed ideas about psychological mechanisms in a consistent fashion, we come to the question: Are there analogous disturbances of secondary identification in the third area of consciousness that we differentiated—that of personhood. In other words, just as our schema assumed centripetal conduction extending via the next sensory projection field into associated projection fields, can it also apply to interrelationships forming much more complicated associative complexes? Clearly an answer can be provided only from experiences in the clinic, since our whole schema can claim to be no more than a convenient aid for representing symptoms objectively, which is so extraordinarily difficult in our field. You will have already gathered from introductory comments at the beginning of our demonstrations that it has become necessary, just as with somatopsychic and allopsychic disorientation and disarray—and we had also got to know of motor disorientation and disarray—that we acknowledge autopsychic disorientation and disarray as effects of acute psychoses (p. 135). Disturbances of identification, analogous to those in the fields of physicality and of the outside world, can [Ed] also be found in the autopsychic field; and this enables us to differentiate a special group among the acute psychoses: the acute autopsychoses.

I have repeatedly stressed that, in the area of consciousness of personhood, it is no longer possible to use any spatial concept of eligible pathways. However, naturally, that will not stop us from recognizing that, in the overall complex concept of personhood—the sum of all memories as I defined it earlier—if all contrasts with the two other areas of consciousness (as the sum of all memory images) are to emerge correctly, subdivisions can be made, which are feasible, genuine, and determined empirically. They should therefore be recognized. Examples of this are character, and personal areas of interest—like professional and family interests—that are quite often independent of one another. Furthermore, we have to assume that, contained within the sum of all memories is a more limited complex, which appears to each person as ‘personality’ [Ed] in a narrower sense, and which is experienced as a unit. Disturbed identification with respect to this complex can come about without any demonstrable impairment of memory, in the sense I defined earlier. It must then remain in doubt whether diagnoses applied to sensory perceptions—hyperaesthesia, paraesthesia, and anaesthesia—still have a place. I would rather avoid attempting such distinctions. Expressions such as ‘psychic anaesthesia’ [Ed] and ‘psychic hyperaesthesia’ [Ed] etc., that you will find in other authors (I mean Griesinger [1] and Emminghaus [2] in particular), naturally have quite different meanings; but also, because of their subjective implications, in my view, they are not appropriate choices. In what follows, I see a most instructive example of highly acute autopsychosis, almost apoplectic in nature, in which both the Affect of autopsychic disarray, and the aberration in autopsychic orientation are seen in very pure form. In places I use actual recorded words and oral accounts of this highly educated and uncommonly expressive female patient.

To this end I quote some diary notes, recorded at my request from the summer of the year following her illness.

‘By looking at my limbs I always hoped to regain my consciousness, but this effort always ended with the feeling of having seen something familiar, without being able to be conscious of the unity of my body and mind. When taking a walk, especially in winter, I wandered around often in a state of utter unconsciousness. Then again, I have been transformed into a totally foreign being. Terrible were the days—which all seemed turned into weeks during the winter—when I was so nervous that I did not move, did not even dare turn over in bed, because the level of consciousness required for this caused me such anguish. This went so far that I always had to sit with my back leaning against something, because I could not have my back free without the question arising whether it still belonged to me. I am sensitive and irritable to a high degree; often obnoxious and unbearable, despite self-control. Probably I want to discover something that is unfathomable … for I have always felt as though I were composed of several people, none of whom was the right one, that is I myself. It is best that I live quite mechanically, or suppress as much as possible my quest to find myself. The worst days are those where restlessness and anxiety join me in this search.’ In addition the patient describes severe headaches, sometimes as pressure in the middle of the head, at other times as throbbing in the temples, and also backache. These always brought a feeling of coercion. It was often as if her head were being compressed, or everything was contracting internally.

Only after several years of what she perceived to be a wholly intolerable state, was there gradual improvement, and in 1890 she felt almost well again. Following the menopause a relapse occurred in 1894, but not nearly as violent as during the first episode; and, even now, 3 years later, she is not fully recovered. However, her general condition is only slightly disturbed, and she appears to be thriving, and is still remarkably youthful.

To leave no doubt about the importance of this case, I have to pass the following comments: Although her self-control towards the doctor always remained adequately preserved so that she always seemed competent socially, her feeling of unhappiness often rose to unbearable heights, with reckless outbursts of despair towards her relatives. For years there was the most profound world-weariness, and our fear of imminent suicide was allayed, not just because of its being forbidden by her religious convictions: Religion gave her a certain solace. She had cut herself off from dealing with people for years, not only by her own wish, but also because her situation required it; and it was only because of the great sacrifice and personal attachment of an older sister who shared her isolation, that made it possible for the patient’s treatment to be carried out outside a mental institution. From all of this it appears that her clinical state was an actual mental illness; and, notwithstanding the well-preserved formal mental activity, in no way could she be construed as a ‘borderline’ [Ed] case better classed amongst the neuroses.

From our point of view the case is also very clear, because it presents a typical example of autopsychic disarray and disorientation. Addition of somatopsychic disarray and disorientation should not distract us from this view, but will, on the contrary, strengthen it. Manifold abnormal sensations of which she complained belong here only in part; in other ways their importance is probably that of independent, hysterical concomitants.

With regard to the aetiology of this case, you will not complain about its being placed with the multiform picture of ‘hysterical psychoses’ [Ed]. A decisive criterion here would be the internal relationship between the symptom picture and other undoubted hysterical mental illnesses, about which I speak soon. With regard to the present case, given that the course of illness was continual and, taking a long-term view, it was clearly abating. Periodic fluctuations in its intensity were indeed felt very strongly in subjective terms, but remained quite mild in objective assessments. There was never any talk of ‘exchange’ [Ed] of symptoms as is alleged to be characteristic of hysteria; and there were no actual hysterical stigmata such as fainting, sensory disturbances, ovarian neuralgia, etc.

Gentlemen! In the literature—indeed not only the psychiatric but also the scientific literature—you will already have encountered cases which bear a certain internal relationship with the one I just described; I mean the states of dual, or alternating consciousness, from the psychiatric side, often unwisely described as ‘twilight states’ [Ed]. However, the latter name should be reserved solely for those acute psychoses where there is stupefaction of the sensorium per se [W], and therefore an actual clouding of consciousness to an appreciable degree. This is not the situation in cases hitherto described—the sensorium is apparently well-preserved; on the other hand, to some extent, there is a break in continuity in consciousness of personhood, such that two personalities, very different from each other, override each other, the one appearing in place of the other. In this case, memory of the abnormally modified personality, that is the experiences, actions, and thoughts are either completely lost—as an autopsychic memory deficit for the time in question—or remains just as a synoptic, blurred memory, or one extending only to individual actions and experiences during this time. What interests us here, however, is not the memory deficit, but the state of mind at the time to which the memory deficit refers which, on account of its significant deviation from consciousness of personhood in the normal state, has been called the ‘second state’, état second [W] of French authors. Such changing states (which, at the same time remain steady in themselves), one of which is normal, the other aberrant, can follow each other in multiple successions; and memory will then always reach back just to the same-sense phases, so that consciousness of personhood actually breaks up into two—and in rare cases more—such groupings. These groupings, being independent of one another, owe their co-existence in a brain to some extent merely to chance. Independence of one personage from another is thereby defined not just by the selection of certain memories, but also by the fields of interest, likes and dislikes, personality traits, etc. A previously irreproachable character can, in the ‘second state’ [Ed], adopt the state of mind of a bestial criminal [3]. Although I do not deny the theoretical interest in these most enigmatic states, this should not affect their factual status. However, they appear to be partly artifacts of hypnotic suggestion, and are also so rare—I have, for example, never been faced with such a case—that they need not detain us, given the urgent requirements of the clinic. It is sufficient to have mentioned it.