CHAPTER VI

NOTES ON T H E PSYCHO-ANALYTICAL I N ­
VESTIGATION A N D T R E A T M E N T OF
M A N I C - DEPRESSIVE INSANITY AND
A L L I E D C O N D I T I O N S (1911) 1

W
HEREAS states of morbid anxiety have been dealt
w i t h i n detail i n the literature of psycho-analysis,
depressive states have hitherto received less atten­
tion. Nevertheless the affect of depression is as widely
spread among all forms of neuroses and psychoses as is
that of anxiety. The two affects are often present together
or successively i n one individual; so that a patient suffering
from an anxiety-neurosis w i l l be subject to states of mental
depression, and a melancholic w i l l complain of having
anxiety.
One of the earliest results of Freud's investigation of
the neuroses was the discovery that neurotic anxiety o r i g i ­
nated from sexual repression; and this origin served to
differentiate i t from ordinary fear. I n the same way we
can distinguish between the affect of sadness or grief and
neurotic depression, the latter being unconsciously m o t i ­
vated and a consequence of repression.
Anxiety and depression are related to each other in the
same way as are fear and grief. W e fear a coming e v i l ;
we grieve over one that has occurred. A neurotic w i l l be
attacked w i t h anxiety when his instinct strives for a grati­
fication which repression prevents h i m from attaining;
depression sets in when he has to give up his sexual aim
1
[ N o . 2 6 , A . B.]
137
I38 SELECTED PAPERS OF KARL ABRAHAM VI

without having obtained gratification. H e feels himself

unloved and incapable of loving, and therefore he despairs
of his life and his future. This affect lasts until the cause
of it ceases to operate, either through an actual change in
his situation or through a psychological modification of the
displeasurable ideas w i t h which he is faced. Every neurotic
state of depression, just like every anxiety-state, to which
it is closely related, contains a tendency to deny life.
These remarks contain very little that is new to those
who regard the neuroses from the Freudian point of view,
although surprisingly little has been written in the literature
of psycho-analysis concerning the psychology of neurotic
depression. But the affect of depression in the sphere of
the psychoses awaits more precise investigation. This task
is complicated by the fact that a good part of the diseases
in question run a * cyclical ' course in which there is an
alteration between melancholic and manic states. The few
preliminary studies which have hitherto been published
1

have only dealt with one of these two phases at a time.

D u r i n g the last few years I have met with six undoubted
cases of this kind in my practice. T w o of these were light
manic-depressive cases (so-called cyclothymia), one of whom
I treated only for a short time. The t h i r d , a female patient,
suffered from short but rapidly recurring states of depression
accompanied by typical melancholic symptoms. T w o more
had succumbed to a depressive psychosis for the first time,
but had previously shown a tendency to slight changes o f
mood in a manic or depressive direction. The last patient
had been overtaken by a severe and obstinate psychosis at
the age of forty-five.
Most psychiatrists, following Kraepelin, do not con­
sider states of depression as belonging to manic-depressive
insanity i f they come on after the patient's fortieth year.
Nevertheless, as the analysis proceeded this last case dis­
closed such a marked similarity in its psychic structure to
those cases which did undoubtedly belong to the manic­
1
Maeder, * Psychoanalyse bei einer melancholischen Depression * (1910). B r i l l ,
* E i n F a l l von periodischer Depression psychogenen U r s p r u n g s * (1911). Jones,
* P s y c h o - A n a l y t i c Notes on a Case of H y p o m a n i a ' (1910).
igil NOTES ON MANIC-DEPRESSIVE INSANITY 139

depressive insanities that I should certainly class i t i n

that group. I do not, however, intend this as a statement
o f opinion concerning the line of demarcation between the
two psychoses. A n d I do not wish to discuss states of
depression occurring i n dementia praecox.
Even i n m y first analysis o f a depressive psychosis I
was immediately struck by its structural similarity w i t h an
obsessional neurosis. I n obsessional neurotics — I refer 1

to severe cases—the libido cannot develop i n a normal

manner, because two different tendencies—hatred and love
— a r e always interfering w i t h each other. T h e tendency
such a person has to adopt a hostile attitude towards
the external world is so great that his capacity for love is
reduced to a m i n i m u m . A t the same time he is weakened
and deprived of his energy through the repression of his
hatred or, to be more correct, through repression of the
originally over-strong sadistic component o f his libido.
There is a similar uncertainty i n his choice of object as
regards its sex. H i s inability to establish his libido i n a
definite position causes h i m to have a general feeling of
uncertainty and leads to doubting mania. H e is neither
able to form a resolution nor to make a clear judgement;
in every situation he suffers from feelings o f inadequacy
and stands helpless before the problems o f life.
I w i l l now give as briefly as possible the history of a
case o f cyclothymia as i t appeared after a successful analysis
had been made.
The patient remembered that his sexual instinct had
shown itself very precociously—before he was i n his sixth
year—and had set in w i t h great violence. H i s first sexual
object at that time had been a governess whose presence
had excited h i m . She still figured very vividly i n his
phantasies. H i s emotional excitement had led h i m to
practise onanism, which he had done by lying on his
stomach and making rubbing movements. H e had been
discovered doing this by his nurse (formerly his wet-nurse),
who expressly forbade h i m to do i t , and whipped h i m when­
1
T h e f o l l o w i n g b r i e f d e s c r i p t i o n adheres closely t o F r e u d ' s c h a r a c t e r i z a t i o n i n
h i s paper, * N o t e s u p o n a Case o f Obsessional N e u r o s i s * (1909).
I4O SELECTED PAPERS OF KARL ABRAHAM VI

ever he disobeyed her. She also impressed upon h i m the

fact that he would suffer for i t all his life. Later, when he
was at school he had been attracted i n an erotic way by a
school-fellow for a period of several years.
I n his childhood and later he had never felt satisfied
at home. H e always had the impression that his parents
favoured his elder brother, who was unusually clever, while
he had only an average intelligence. H e also believed
that his younger brother, who was delicate, received greater
attention from his mother than he d i d . The result of this
was that he had a hostile attitude towards his parents, and
one of jealousy and hatred towards his brothers. The
intensity of this hate can be seen from a couple of impulsive
acts which he carried out in his childhood. O n two occasions
when quarrelling over trifles he had become very violent
towards his younger brother, and had knocked h i m
down and seriously hurt h i m . Such violence is particularly
remarkable when we learn that at school he was always the
smallest and weakest among his contemporaries. H e never
made any real companions, but generally kept to himself.
H e was industrious, but had little to show for i t . A t
puberty i t became evident that his sexual instinct, which
at first had shown itself so strongly, had become paralysed
through repression. I n contrast to his attitude in child­
hood he d i d not feel attracted to the female sex. H i s
sexual activity was the same that he had carried out in
childhood; but he did not perform i t i n the waking state
but only i n his sleep or half-asleep. H e had no friends.
H e was quite aware of his lack of real energy when he
compared himself w i t h others. H e found no encourage­
ment at home; on the contrary, his father used to say con­
temptuous things about h i m i n his presence. Added to
all these depressing factors he suffered a definite psychic
trauma: a teacher had the brutality to call h i m a physical
and mental cripple in front of the whole class. H i s first
attack of depression appeared soon after this.
Even later on he made no companions. H e kept
away from them intentionally, too, because he was afraid
of being thought an inferior sort of person. Children
I9II NOTES ON MANIC-DEPRESSIVE INSANITY I4I

were the only human beings he got on well w i t h and liked,

because w i t h them he d i d not have his usual feeling of
inadequacy. H i s life.was a solitary one. H e was posi­
tively afraid of women. H e was capable of normal sexual
intercourse, but had no inclination for i t and failed to
obtain gratification from i t . H i s onanistic practices i n his
sleep were his chief sexual activity even i n later years. He
showed little energy in practical life; i t was always difficult
for h i m to f o r m a resolution or to come to a decision in
difficult situations.
U p to this point the patient's history coincided in all
its details w i t h what we find in obsessional neurotics.
Nevertheless, we do not find obsessional symptoms in h i m
but a circular parathymia that had recurred many times
during the last twenty years.
I n his depressive phase the patient's frame of m i n d
was * depressed ' or * apathetic' ( I reproduce his own
words) according to the severity of his condition. H e was
inhibited, had to force himself to do the simplest things,
and spoke slowly and softly. H e wished he was dead,
and entertained thoughts o f suicide. H i s thoughts had a
depressive content. H e would often say to himself, ' I
am an outcast', ' I am accursed ', * I am branded ', ' I do
not belong to the world ', H e had an indefinite feeling
that his state of depression was a punishment. H e felt
non-existent and would often imagine himself disappearing
from the w o r l d without leaving a trace. D u r i n g these
states of m i n d he suffered from exhaustion, anxiety and
feelings of pressure i n the head. The depressive phase
generally lasted some weeks, though i t was of shorter
duration at times. T h e intensity of the depression varied
i n different attacks; he would have perhaps two or three
marked states of melancholy and probably six or more
slighter ones i n the course of a year. H i s depression
gradually increased d u r i n g the course of an attack until i t
reached a certain height, where i t remained for a time, and
then gradually diminished. This process was conscious to
h i m and perceptible to other people.
W h e n the patient was about twenty-eight years old a
142 SELECTED PAPERS OF KARL ABRAHAM VI

condition of hypomania appeared, and this now alternated

w i t h his depressive attacks. A t the commencement of this
manic phase he would be roused out of his apathy and
would become mentally active and gradually even over­
active. H e used to do a great deal, knew no fatigue, woke
early in the morning, and concerned himself w i t h plans
connected w i t h his career. H e became enterprising and
believed himself capable of performing great things, was
talkative and inclined to laugh and joke and make puns.
H e noticed himself that his thoughts had something
volatile in t h e m ; a slight degree of * flight of ideas * could
be observed. H e spoke more quickly, more forcibly and
louder than usual. H i s frame of m i n d was cheerful and
a little elevated. A t the height of his manic phase his
euphoria tended to pass over into irritability and impulsive
violence. I f , for example, some one disturbed h i m i n his
work, or stepped in his way, or drove a motor-car quickly
past h i m , he responded w i t h a violent affect of anger and
felt inclined to knock the offender down on the spot.
W h i l e i n this state he used often to become involved in
real quarrels in which he behaved very unfeelingly. I n
the periods of depression he slept well but during the manic
phase he was very restless, especially during the second
half of the night. Nearly every night a sexual excitement
used to overtake h i m w i t h sudden violence.
Although his libido had appeared very early and with
great force i n his childhood, the patient had for the most
part lost the capacity for loving or hating. H e had become
incapable of loving, i n the same manner as the obsessional
neurotic. Although he was not impotent, he did not
obtain actual sexual enjoyment, and he used to get greater
satisfaction from a pollution than coitus. H i s sexual
activities were i n the main restricted to his sleep. I n this,
like the neurotic, he showed an auto-erotic tendency to
isolate himself from the external world. People of this
kind can only enjoy pleasure in complete seclusion; every
living being, every inanimate object, is a disturbing element.
I t is only when they have achieved the complete exclusion
of every external impression—as is the case when they are
igil NOTES ON MANIC-DEPRESSIVE INSANITY I43

asleep—that they can enjoy a gratification of their sexual

wishes, by dreaming them. Our patient expressed this i n
the following words : * I feel happiest i n bed; then I feel
as though I were i n my own house V
A t puberty i n especial the patient was made aware that
he was behind his companions of the same age i n many
important respects. H e had never felt their equal physi­
cally. H e had also been afraid of being inferior mentally,
especially i n comparison w i t h his elder brother. A n d now
the feeling of sexual inadequacy was added. I t was
precisely at this time that his teacher's criticism * (a mental
and physical cripple ') struck h i m like a blow. Its great
effect was explained by the fact that i t recalled to his
memory the prophecy of his wet-nurse, when she had
threatened h i m w i t h lifelong unhappiness because of his
masturbation. Just when he was entering upon manhood
therefore, and ought to have had masculine feelings like his
companions, his old feelings of inadequacy received a power­
ful reinforcement. I t was i n this connection that he had
had the first state of depression he could recollect.
As we so often see i n the obsessional neuroses, the
outbreak of the real illness occurred when the patient had
to make a final decision about his attitude towards the
external w o r l d and the future application o f his libido. I n
my other analyses a similar conflict had brought on the
first state of depression. For example, one of m y patients
had become engaged to be married ; soon afterwards a
feeling of incapacity to love overcame h i m , and he fell into
a severe melancholic depression.
I n every one of these cases i t could be discovered that
the disease proceeded f r o m an attitude of hate which
was paralysing the patient's capacity to love. As i n the
obsessional neuroses, other conflicts in the instinctual life
of the patients as well can be shown to be factors i n the
psychogenesis of the illness. I should like to mention
especially the patient's uncertainty as to his sexual role i n
1
I m i g h t r e m a r k that the other male patients whose depressive psychoses I was
able to analyse behaved i n the same w a y . None o f them were impotent, but they
h a d a l l derived more pleasure f r o m auto-erotic behaviour a l l a l o n g , a n d to have a n y
relations w i t h w o m e n was a difficult a n d troublesome business for t h e m .
144 SELECTED PAPERS OF KARL ABRAHAM VI

this connection. I n Maeder's case a conflict of this k i n d

1

between a male and female attitude was particularly pro­

nounced; and i n two of my patients I found a condition
surprisingly similar to that described by h i m .
I n their further development, however, the two diseases
diverge from each other. The obsessional neurosis creates
substitutive aims i n place of the original unattainable
sexual aims; and the symptoms of mental compulsion are
connected w i t h the carrying out of such substitutive aims.
The development of the depressive psychoses is different.
I n this case repression is followed by a process of * projec­
t i o n ' w i t h which we are familiar from our knowledge of
the psychogenesis of certain mental disturbances.
I n his Psycho-Analytic Notes upon an Autobiographical
c

Account of a Case of Paranoia (Dementia Paranoides)' Freud

gives a definite formulation of the psychogenesis of paranoia.
H e sets out i n short formulae the stages which lead up to
the final construction of the paranoic delusion. I will
here attempt to give a similar formulation of the genesis
of the depressive psychoses, on the basis of my analyses of
depressive mental disturbances.
Freud considers that i n a large portion at least of cases
of paranoic delusions the nucleus of the conflict lies i n
homosexual wish-phantasies, ue* in the patient's love of a
person of the same sex. The formula for this is: ' I (a
man) love h i m (a man)'. This attitude raises objections i n
the patient and is loudly contradicted, so that the statement
runs: * I do not love h i m , I hate h i m ' . Since internal
perceptions are replaced by external ones i n paranoia, this
hatred is represented as a result of the hatred endured
by the patient from without, and the third formula is :
' I do not love h i m — I hate him—because he persecutes
me'.
I n the psychoses with which we are here concerned a
different conflict lies concealed. I t is derived from an
attitude of the libido in which hatred predominates. This
attitude is first directed against the person's nearest relatives
and becomes generalized later on. I t can be expressed i n
1
[See footnote, p. 138.]
i g i l NOTES ON MANIC-DEPRESSIVE INSANITY 145

the following formula: ' I cannot love people; I have to

hate them \
T h e pronounced feelings o f inadequacy f r o m which
such patients suffer arise f r o m this discomforting internal
perception* I f the content of the perception is repressed
and projected externally, the patient gets the idea that he is
not loved by his environment but hated by i t (again first
of all by his parents, etc., and then by a wider circle o f
people). T h i s idea is detached f r o m its primary causal
connection w i t h his own attitude of hate, and is brought
into association w i t h other—psychical and physical—
deficiencies. 1
I t seems as though a great quantity o f such
feelings o f inferiority favoured the formation o f depressive
states.
Thus we obtain the second formula: * People do not
love me, they hate me . . . because o f my inborn defects. 2

Therefore I am unhappy and depressed.*

T h e repressed sadistic impulses do not remain quiescent,
however. They show a tendency to return into conscious­
ness and appear again i n various f o r m s — i n dreams and
symptomatic acts, but especially i n an inclination to annoy
other people, i n violent desires for revenge or i n criminal
impulses. These symptomatic states are not usually
apparent to direct observation, because for the most part
they are not p u t into action; but a deeper insight into the
patient's mind—as afforded i n the catamnesis, for instance
— w i l l b r i n g a great deal o f this k i n d of thing to light.
A n d i f they are overlooked i n the depressive phase there is
more opportunity for observing them i n the manic one.
I shall have more to sa^ about this subject later on.
I t is more especially i n regard to such desires to commit
acts of violence or revenge that the patients have a tendency
to ascribe their feelings to the torturing consciousness o f
their own physical or psychical defects, instead o f to their
imperfectly repressed sadism. Every patient who belongs
to the manic-depressive group inclines to draw the same
I n m a n y cases, a n d p a r t i c u l a r l y i n the slighter ones, the original connection
1

is o n l y partly lost; but even so the tendency to displacement is clearly recognizable.

C f . w i t h this the e t y m o l o g y o f the G e r m a n w o r d hdsslick (* u g l y *) = * that
2

w h i c h arouses hate \
146 SELECTED PAPERS OF KARL ABRAHAM VI

conclusion as Richard I I I . , who enumerates all his own

failings w i t h pitiless self-cruelty and then sums u p :
And therefore, since I cannot prove a lover . . .
I am determined to prove a villain.

Richard cannot love by reason of his defects which

make h i m hateful to others; and he wants to be revenged
for this. Each of our patients wishes to do the same, but
cannot, because his instinctual activity is paralysed by
repression.
New and morbid states, such as feelings of guilt,
result from the suppression of these frequent impulses
of hatred and revenge. Experience so far seems to show
that the more violent were the person's unconscious impulses
of revenge the more marked is his tendency to form
delusional ideas of guilt. Such delusions, as is well known,
may attain enormous proportions, so that the patient
declares that he alone has been guilty o f all sins since the
world began, or that all wickedness originates from h i m
alone. I n these persons an insatiable sadism directed
towards all persons and all things has been repressed in the
unconscious. The idea of such an enormous guilt is o f
course extremely painful to their consciousness; for where
there is a great degree of repressed sadism there will be a
corresponding severity in the depressive affect. Neverthe­
less the idea o f guilt contains the fulfilment o f a w i s h —
of the repressed wish to be a criminal of the deepest dye,
to have incurred more guilt than everyone else put together.
This, too, reminds us of certain psychic processes in
obsessional neurotics, as, for instance, their belief in the
* omnipotence of their thoughts. They frequently suffer
9

from anxiety lest they have been guilty of the death of a

certain person by having thought about his death. The
sadistic impulses are repressed in the obsessional neurotic
also: because he cannot act in conformity w i t h his original
instincts he unconsciously gives himself up to phantasies
of being able to kill by means of thoughts. This wish does
not appear as such in consciousness but i t takes the form
of a tormenting anxiety.
TQX1 NOTES ON MANIC-DEPRESSIVE INSANITY 147

As a result of the repression of sadism, depression,

anxiety, and self-reproach arise. B u t i f such an important
source o f pleasure f r o m which the active instincts flow is
obstructed there is bound to be a reinforcement o f the
masochistic tendencies. T h e patient w i l l adopt a passive
attitude, and w i l l obtain pleasure from his suffering and
f r o m continually t h i n k i n g about himself. T h u s even the
deepest melancholic distress contains a hidden source of
pleasure.
Before the actual state of depression sets i n many
patients are more than usually energetic i n their pursuits
and manner o f life. T h e y often sublimate i n a forced
manner libido which they cannot direct to its true purpose.
They do this so as to shut their eyes to the conflict w i t h i n
them, and to ward off the depressive frame of m i n d which is
tending to break into consciousness. T h i s attitude often
succeeds for long periods, but never completely. The
person who has to combat disturbing influences for a long
time can never enjoy peace or security w i t h i n himself.
A n y situation w h i c h requires a definite decision i n the field
of the libido w i l l cause a sudden collapse of his psychic
equilibrium which he has so laboriously kept u p . W h e n
the state of depression breaks out his previous interests
(sublimations) suddenly cease; and this leads to a narrow­
ing o f his mental outlook w h i c h may become so pronounced
as to attain to monoideism.
W h e n the depressive psychosis has become manifest
its cardinal feature seems to be a mental inhibition which
renders a rapport between the patient and the external
w o r l d more difficult. Incapable of making a lasting and
positive application of his libido, the patient unconsciously
seeks seclusion f r o m the w o r l d , and his auto-erotic trend
manifests itself i n his inhibition. There are other means,
it is true, by which neuroses and psychoses can give symp­
tomatic expression to an auto-erotic tendency. T h a t i t
should be inhibition rather than some other symptom that
appears i n this case is fully explained from the fact that
the inhibition is able to serve other unconscious tendencies
at the same time. I refer i n particular to the tendency
I48 SELECTED PAPERS OF KARL ABRAHAM VI

towards a * negation of life \ The higher degrees of

inhibition in especial—ue. depressive stupor—represent a
symbolic dying. The patient does not react even to the
application of strong external stimuli, just as though he were
no longer alive. I t is to be expressly noted that in the
foregoing remarks only two causes of the inhibition have
been considered. I n every case analysis revealed still
further determinants, connected with the individual circum­
stances of the patient.
Certain features commonly present in states of depres­
sion become comprehensible i f we accept the well-founded
conclusions of psycho-analytic experience. Take, for i n ­
stance, the frequent ideas of impoverishment. The patient
complains, let us say, that he and his family are exposed to
starvation. I f a pecuniary loss has actually preceded the
onset of his illness, he will assert that he cannot possibly
endure the blow and that he is completely ruined. These
strange ideas, which often entirely dominate the patient's
thoughts, are explicable from the identification of libido
and m o n e y — o f sexual and pecuniary * p o w e r ' — w i t h 1

which we are so familiar. The patient's libido has dis­

appeared from the world, as i t were. Whereas other
people can invest their libido i n the objects of the external
world he has no such capital to expend. H i s feeling of
poverty springs from a repressed perception of his own
incapacity to love.
W e very frequently meet with fears or pronounced
delusions centering round the same idea i n states of de­
pression connected w i t h the period of involution. As far
as my not very extensive psycho-analytical experience o f
these conditions goes, I have reason to believe that i t is
people whose erotic life has been without gratification who
are liable to such delusions. I n the preceding decade of
their life they had repressed this fact and had taken refuge
in all kinds of compensations. But their repressions are
not able to cope w i t h the upheaval of the climacteric.
They now pass in review, as i t were, their wasted life, and
1
[ T h e G e r m a n w o r d used, Fermogen, means both * wealth ' a n d 4
capacity *
i n the sense o f sexual potency.—TransJ]
i g i l NOTES ON MANIC-DEPRESSIVE INSANITY 149

at the same time feel that i t is too late to alter i t . T h e i r

consciousness strongly resists all ideas connected w i t h this
fact; but not being strong enough to banish them com­
pletely, i t has to allow them entrance i n a disguised f o r m .
They are still painful i n the form of a delusion of impoverish­
ment, but not as intolerable as before.
Viewed externally, the manic phase of the cyclical dis­
turbances is the complete opposite of the depressive one.
A manic psychotic appears very cheerful on the surface;
and unless a deeper investigation is carried out by psycho­
analytic methods i t m i g h t appear that the two phases are
the opposite o f each other even as regards their content.
Psycho-analysis shows, however, that both phases are
dominated by the same complexes, and that i t is only the
patient's attitude towards those complexes which is different.
I n the depressive state he allows himself to be weighed down
by his complex, and sees no other way out of his misery but
d e a t h ; i n the manic state he treats the complex w i t h
1

indifference.
T h e onset o f the mania occurs when repression is no
longer able to resist the assaults of the repressed instincts.
T h e patient, especially i n cases of severe maniacal excita­
tion, is as i f swept off his feet by them. I t is especially
important to notice that positive and negative libido (love
and hate, erotic desires and agressive hostility) surge up
into consciousness w i t h equal force.
T h i s manic state, i n which libidinal impulses o f both
kinds have access to consciousness, once more establishes a
condition which the patient has experienced before—-in his
early childhood, that is. Whereas i n the depressive patient
everything tends to the negation of life, to death, i n the
manic patient life begins anew. The manic patient returns
to a stage i n which his impulses had not succumbed to
repression, i n which he foresaw nothing of the approaching
conflict. I t is characteristic that such patients often say
that they feel themselves * as though new-born \ M a n i a
contains the fulfilment of Faust's wish :
Some patients cling to the idea that they can be cured by the fulfilment of
1

some external condition—usually one, however, which never can be fulfilled.

 150 SELECTED PAPERS OF KARL ABRAHAM VI

Bring back m y passion's unquenched fires,

T h e heavenly smart o f bliss restore;
Hate's s t r e n g t h — t h e steel o f love's desires—
B r i n g back the y o u t h I was once more.

The maniac's frame of mind differs both from normal

and from depressive states, partly in its care-free and u n ­
restrained cheerfulness, partly i n its increased irritability
and feeling of self-importance. The one or the other altera­
tion can predominate according to the individuality of the
patient or the different stages of the disease.
The affect of pleasure i n mania is derived from the same
source as is that of pleasure in w i t . W h a t I have to say
about this is therefore i n close agreement w i t h Freud's
theory of w i t .
1

Whereas the melancholiac exhibits a state of general

inhibition, i n the manic patient even normal inhibitions
of the instincts are partly or wholly abolished. The
saving of expenditure i n inhibition thus effected be­
comes a source of pleasure, and moreover a lasting one,
while w i t only causes a transitory suspension o f the
inhibitions.
Economy of inhibition is, however, by no means the
only source of manic pleasure. The removal of inhibitions
renders accessible once more old sources of pleasure which
had been suppressed; and this shows how deeply mania is
rooted in the infantile.
The technique of the manic production of thoughts
may be regarded as a third source of pleasure. Abolition
of logical control and playing w i t h words—-two essential
features of manic ideational processes—indicate an exten­
sive * return to infantile freedom'.
Melancholic inhibition of thought finds its reverse in
the manic flight of ideas. I n the melancholic phase there
is a narrowing of the circle of ideas, in the manic phase a
rapid change of the content of consciousness. The essential
difference between flight of ideas and normal thinking' is
that whereas in thinking or speaking the healthy person
consistently keeps in view the aim of his mental processes
1
Der Witz, und seine Bexiehung zum Unbewussten, 1905,
i g i l NOTES ON MANIC-DEPRESSIVE INSANITY I£I

the manic patient very easily loses sight of that a i m . 1

This
differentiation serves to characterize the external aspect of
the flight o f ideas, but not its significance for the manic
subject. I t is especially to be noted that the flight of ideas
offers the patient considerable possibilities for obtaining
pleasure. As has already been said, psychic work is
economized where the abolition o f logical control is re­
moved and where the sound instead of the sense has to be
considered. But the flight of ideas has yet another function,
and a double one: i t makes i t possible to glide by means
of light allusions over those ideas that are painful to con­
sciousness, for example, ideas of inadequacy; that is to say,
it favours—like w i t — t r a n s i t i o n to another circle of ideas.
A n d i t also permits o f playful allusion to pleasurable things
which are as a rule suppressed.
T h e similarity between the m i n d o f the maniac and that
of the child is characterized in a number of ways of which
only one need be mentioned in this place. I n the slighter
states o f manic exaltation the patient has a k i n d of careless
gaiety which bears an obviously childish character. The
psychiatrist who has had much to do w i t h such patients can
clearly see that his rapport w i t h them is the same as w i t h
a child of about five years of age.
T h e severer forms o f mania resemble a frenzy of
freedom. T h e sadistic component-instinct is freed from
its fetters. A l l reserve disappears, and a tendency to
reckless and aggressive conduct takes its place. I n this
stage the maniac reacts to trifling occurrences w i t h violent
outbursts of anger and w i t h excessive feelings of revenge.
I n the same way, when his exaltation had reached a certain
height, the cyclothymic patient mentioned above used to
feel an impulse to strike down anyone who d i d not at once
make way for h i m i n the street. The patients often have
an excessive feeling o f power, measuring i t not by actual
performance but by the violence of their instincts, which
they are now able to perceive i n an unusual degree. Fairly
frequently there appear grandiose ideas which are very similar
to children's boasts about their knowledge and power.
1
Liepmann, Vber Ideenflucht (1904).
152 SELECTED PAPERS OF KARL ABRAHAM VI

Arising from the case of cyclothymia already described

at length, there is one important question which I cannot
attempt to answer definitely. I t remains to be explained
why, when the patient was about twenty-eight, states of
manic exaltation should have appeared in addition to the
depressive state which had already existed for a long time.
I t may be that i t was a case where psychosexual puberty
followed a long time after physical maturity. W e often
see the development of instinctual life delayed in a similar
manner in neurotics. On this hypothesis the patient would
not have experienced an increase of his instinctual life at
puberty but have been overtaken, like a woman, by a wave
of repression; and i t would only have been towards the
end of his third decade that a certain awakening o f his
instincts would have occurred i n the form of the first manic
state. A n d i n fact it was at that age that his sexual interests
turned more to the female sex and less towards auto-erotism
than before.
I must now say a few words about the therapeutic
effects of psycho-analysis.
The case I have most fully reported i n these pages was
so far analysed at the time when I read my paper at W e i m a r 1

that its structure was apparent i n general. But there still

remained a great deal o f work to be done on i t ; and thera­
peutic results were only just beginning to be discernible.
These have become more clearly visible during the last two
and a half months. Naturally a definite opinion as regards
a cure cannot yet be given, for after twenty years o f illness,
interrupted by free intervals of varying length, an improve­
ment of two months' duration signifies very little. But
I should like to record the result up to the present. I n
the period mentioned, no further state o f depression has
appeared, and the last one passed off very easily. I n con­
sequence o f this the patient has been able to do continuous
work. D u r i n g the same period there did twice occur a
changed frame of mind in a manic direction, which could
not escape a careful observation; but i t was of a far milder
character than his previous states of exaltation. A n d ,
1
[See No. 2 6 , A . B.]
i g i l NOTES ON MANIC-DEPRESSIVE INSANITY 153

besides this, certain hitherto regularly observed phenomena

were absent. Between these last two manic phases there has
been no depressive one, as was usually the case, but a state
which could be called normal, since no cyclothymic pheno­
mena were present. For the rest we shall have to follow
the further course o f the case. There is only one more
t h i n g I should like to a d d : I f the patient succeeds i n
permanently maintaining a state similar to that of the last
two months, even this partial improvement w i l l be o f
great value to h i m . I n the other case of cyclothymia the
period of observation has been too short to permit of an
opinion regarding therapeutic results. But its pathological
structure was found to be remarkably similar to that of the
first case.
T h e t h i r d case described at the beginning o f this paper
showed the effectiveness of analysis i n a striking manner,
i n spite o f the fact that external circumstances obliged the
treatment to cease after about forty sittings. Even i n the
early part of the treatment I was able to cut short a melan­
cholic depression which had j u s t developed i n the patient,
a t h i n g which had never happened before; and as treatment
proceeded its effect became more lasting and expressed
itself i n a distinct amelioration i n the patient's frame of m i n d ,
and i n a considerable increase o f his capacity for w o r k . I n
the months following the cessation of his analysis his state
of m i n d d i d not sink back to its former level. I t may be
noted that i n this case the preponderating attitude of hatred,
the feeling o f incapacity to love and the association of depres­
sion w i t h feelings of inadequacy were clearly to be seen.
I n the two above-mentioned cases of a melancholic
depression occurring for the first time, a consistent analysis
could not be carried out on account of external difficulties.
Nevertheless, its effect was unmistakable. By the help o f
a psycho-analytical interpretation of certain facts and
connections I succeeded i n attaining a greater psychic
rapport w i t h the patients than I had ever previously achieved.
I t is usually extraordinarily difficult to establish a trans­
ference i n these patients who have turned away from all
the w o r l d i n their depression. Psycho-analysis, which has
Ij*4 SELECTED PAPERS OF KARL ABRAHAM VI

hitherto enabled us to overcome this obstacle, seems to me

for this reason to be the only rational therapy to apply to
the manic-depressive psychoses.
The sixth case confirms this view w i t h greater certainty,
since I was able to carry the treatment through to the end.
I t had a remarkably good result. The patient came to me
for treatment fifteen months after the onset of his trouble.
Before this, treatment i n various sanatoria had had only a
palliative effect i n relieving one or two symptoms, A few
weeks after the commencement of psycho-analytic treat­
ment the patient felt occasional relief. H i s severe depression
began to subside after four weeks. H e said that at moments
he had a feeling of hope that he would once again be
capable of work. H e attained a certain degree of insight
and said: ' 1 am so egoistic now that I consider my fate
the most tragic i n the world \ I n the third month of
treatment his frame of m i n d was freer on the whole; his
various forms of mental expression were not all so greatly
inhibited, and there were whole days on which he used to
feel well and occupy himself w i t h plans for the future.
A t this time he once said w i t h reference to his frame of
m i n d : * W h e n i t is all right I am happier and more care-free
than I have ever been b e f o r e I n the fourth month he
said that he had no more actual feelings of depression.
D u r i n g the fifth month, i n which the sittings no longer took
place daily, distinct variations in his condition were notice­
able, but the tendency to improvement was unmistakable.
I n the sixth month he was able to discontinue the treatment;
and the change for the better i n him was noticeable to his
acquaintances. Since then six months have passed without
his having had a relapse.
From a diagnostic point of view the case was quite
clearly a depressive psychosis and not a neurosis of the
climacteric period. I am unfortunately unable to publish
details of the case; they are of such a peculiar k i n d that
the incognito of the patient could not be preserved i f I d i d .
There are also other considerations which necessitate a
quite special discretion—a fact which is greatly to be
regretted from a scientific point of view.
i g i l NOTES ON MANIC-DEPRESSIVE INSANITY I £5

There is one objection that m i g h t be raised regarding

the therapeutic results obtained i n this case, and that is
that I had begun treating i t precisely at that period when
the melancholia was passing off, and that i t would have
been cured without m y doing a n y t h i n g ; and from this i t
would follow that psycho-analysis d i d not possess that
therapeutic value which I attribute to i t . I n answer to
this I may say that I have all along been careful to avoid
falling into an error of this k i n d . W h e n I undertook the
treatment I had before me a patient who was to all appear­
ances unsusceptible to external influence and who had
quite broken down under his illness; and I was very
sceptical as to the result of the treatment. I was the more
astonished when, after overcoming considerable resistances,
I succeeded i n explaining certain ideas that completely
dominated the patient, and observed the effect of this
interpretative w o r k . This initial improvement and every
subsequent one followed directly upon the removal o f
definite products o f repression. D u r i n g the whole course
o f the analysis I could most distinctly observe that the
patient's improvement went hand i n hand w i t h the progress
of his analysis.
I n thus communicating the scientific and practical results
o f my psycho-analyses of psychoses showing exaltation and
depression I am quite aware of their incompleteness, and I
hasten to point out these defects myself. I am not i n a
position to give as much weight to my observations as I
could have wished, since I cannot submit a detailed report
o f the cases analysed. I have already mentioned the
reasons for this i n one of the cases. I n three other very
instructive cases motives of discretion likewise prevented
me from communicating any details. N o r w i l l intelligent
criticism reproach me for adopting this course. Those
who take a serious interest i n psycho-analysis w i l l make
good the deficiencies i n m y work by their own independent
investigations. T h a t further investigations are very greatly
needed I am fully aware. Certain questions have not been
considered at all or only barely touched upon i n this paper.
For instance, although we have been able to recognize up
I56 SELECTED PAPERS OF KARL ABRAHAM VI

to what point the psychogenesis of obsessional neuroses

and cyclical psychoses resemble each other, we have not
the least idea why at this point one group of individuals
should take one path and the other group another.
One thing more may be said concerning the therapeutic
aspect of the question. I n those patients who have pro­
longed free intervals between their manic or depressive
attacks, psycho-analysis should be begun during that free
period. The advantage is obvious, for analysis cannot be
carried out on severely inhibited melancholic patients or
on inattentive maniacal ones.
Although our results at present are incomplete, i t is
only psycho-analysis that will reveal the hidden structure
of this large group of mental diseases. A n d moreover,
its first therapeutic results i n this sphere justify us i n the
expectation that i t may be reserved for psycho-analysis to
lead psychiatry out of the impasse of therapeutic nihilism.