What has been happening all this time in the mind of the patient? We will assume that she knew at the beginning that her pains were fictitious; what course is now open to her if she wishes to end the deceit when her friends, by their pardonable credulity, have allowed themselves to be deceived and her troubles have been accepted by the doctor as real? Her pride or self-respect prevents open confession, and in her ignorance of the course of the supposed disease she thinks an unexpected recovery will reveal the fraud. Here are the materials for another mental conflict, and her alternatives are:–
1. To solve the conflict by confession or recovery, and I have shown the difficulties of this course.
2. To build a logic-tight compartment; to say, for example, ‘They have never given me a chance, and now I am quite right in imposing upon them as long as I can.’ But her feelings concerning right and wrong are probably too strong to maintain this attitude indefinitely.
3. To repress the consciousness of deceit and maintain her symptoms as the price of her peace of mind.
This last course is followed, and the patient is now a Dissociate. In the dissociated stream are:–
1. The original desires which led to the manifestation of disease–the desire for sympathy, the desire to have her own way, the ‘Will to Power.’
2. The knowledge of deceit.
3. The mechanism for maintaining the symptoms–the pains, the paralysis or contracture.
This stream is now independent of the main personality and out of its control; as far as the patient knows her pains are real, her deformity is a disease, and whoever doubts it is not only ignorant but cruel. We can now understand the capriciousness of the hysteric, her moods and contrary ways. On the one side is a mind with ordinary motives, and on the other is the split-off portion containing the complexes catalogued above. If the reader thinks this conception brings us back to the old one of demoniacal possession I will admit that the only difference lies in the definition of the demon.
The description of this imagined case will perhaps be acceptable to those who believe in the connection between hysteria and malingering. This connection I at one time emphasised, and I still believe that in some cases the repression of a knowledge of deceit plays an important part in the development of the disease. But motives are derived more or less from the unconscious, and when the unconscious elements predominate we approach the condition in which there has never existed any consciousness of deceit. The case of the soldier with an obsession to attack his companion does not admit of the hypothesis of a stage in which the symptom was due to a conscious desire to any end: but his repression might have shown itself, let us suppose, in a paralysis of his legs as a symbol of exhaustion or terror. Then we should have a hysteria in which there had never been any deceit complex, though in the absence of knowledge of the workings of the patient’s mind a firm believer in the ‘Will to Power’ theory might attribute the origin of the condition to a definite desire to escape the strain of war.
I can now state that some of the results of conflict between desire and reality form a graduated series, beginning at cases of conscious simulation, then passing on to those of hysteria with repression of the knowledge of deceit, and ending with cases where deceit has never existed; but no one theory explains satisfactorily the origin of all cases of hysteria.
It is difficult to understand those cases in which the hysteric inflicts injuries upon him or herself; the individual who thrusts needles into his body and comes to hospital again and again to have them removed is a curious but not very uncommon object. An ophthalmic surgeon of my acquaintance had a patient who placed irritants under the lid of one eye till the sight was lost and the organ was removed, and the process was begun on the remaining eye before the trick was discovered. Such things occur in the history of malingering, and what the consciousness can do the dissociated stream is equally capable of doing: the only difficulty is the very practical one of believing that the patient can carry out the necessary action without being fully aware of what is happening, unless we assume an abrupt dissociation with the main personality temporarily abolished.