A Manic-Depressive Episode Presenting a Frank Wish-Realization Construction

The symptoms of the psychoneuroses have been shown to be compromise effects resulting from the pressure of the real world from without in conflict with unconscious impulses, trends or wishes within. The psychoneurotic nevertheless does not lose his grip on reality and therefore in spite of his disease remains sane. But in certain psychoses the mind overrides reality and creates a dream-world of its own. Freud has expressed this as “the flight from reality.” In many psychoses these effects or manifestations of the inner structures or fantasies are. so converted, disguised, or symbolized that their real nature is recognized with difficulty. This is particularly so in the great majority of cases. No cooperation on the part of the patient can be expected. The very fact of the presence of what in ordinary language we call insanity implies an inability to cooperate. The patient has, as it were, closed the doors of the mind and anyone attempting to open them is regarded as an intruder, the result being the establishment of a resistance very real, and difficult if not impossible to overcome, since it is scarcely comparable to the resistance of the psychoneurotic (which is ordinarily amenable to persuasion) being like many other of the patient's symptoms often subtile and highly disguised.

Occasionally however a mental case is seen in which a simple report of the patient's daily doings and verbal expressions discovers a fantasy lying, not deep beneath the surface, but exposed so that anyone may read. Such fantasies, we find, present similar complex formations to those found in the psychoneuroses. Thus, while a psychoneurosis, let us say an obsessional state, can be compared to a waking dream with only the manifest content exposed certain psychoses can be compared to a waking dream with the latent content exposed. It is this that makes the speech and actions of some of the insane so often repellent to the normal. Even symbolic disguise is eliminated and the deepest trends and