Theoretical and Clinical Notes on the Interaction of Some Relevant Variables in the Production of Neurotic Disturbances

The general theme chosen for discussion at the conference which gave rise to the present paper was that of the interaction of external and internal factors in producing illness. As I thought about this intricate topic it seemed essential to me to clarify, in the first place, some questions of terminology. While there can be little disagreement on what constitutes the range of external factors (real experiences) which impinge on the mental apparatus, the meaning of the term "internal" appears to be much more ambiguous and calls for elucidation and clarification. It seems to me that it can be conceptualized in at least three different ways. In the first place it encompasses one of the polarities in the dichotomy between nature and nurture. In this sense it would refer to what has been denoted by such terms as "innate," "constitutional," "dispositional" or "hereditary," and our topic would then largely be concerned with similar considerations as those in John Benjamin's paper on "The Innate and the Experiential in Development" (1961). A second possibility of conceptualizing "internal" is in terms of the demands of the instinctual drives, thus juxtaposing such demands with those arising from the outside world and studying the outcome—whether adaptive or maladaptive—of conflicts between what can essentially be reduced to a contrast between the dynamic forces of the pleasure principle on the one hand and the reality principle on the other. This conceptualization