Instinct and the Unconscious/A case of Claustrophobia

A CASE OF CLAUSTROPHOBIA[1]

The case I am about to record is that of a medical man, aged thirty-one, who from childhood has suffered from a dread of being in an enclosed space, and especially of being under conditions which would interfere with his speedy escape into the open.

When I saw him first his earliest memory of this dread went back to the time when at the age of six he slept with his elder brother in what is known in Scotland as a box-bed. The bed stood in a recess with doors which could be closed so as to give the appearance of a sitting-room. The child slept on the inner side of the bed next to the wall, and he still vividly remembers his feat and the desire to get out of bed, which he did not satisfy for fear of waking his brother. He would lie in a state of terror, wondering if he would be able to get out if the need arose.

His next memory bearing on his phobia is of being taken to see some men descending the shaft of a coal-pit. There came to him at once the fear that were he going down something might happen to prevent his getting out. He remembers that whenever in childhood he was taken for a journey by train he dreaded the tunnels, and if by chance the train stopped in a tunnel he feared that there might be an accident and that he would not be able to get out. This fear of tunnels became worse as he grew older. He would not travel by the tube-railway, and remembers his horror when on one occasion he had to do so. When he began to go to the theatre or other [p. 171] crowded building he was always troubled unless be was near the door, and he was never happy unless he could see a clear and speedy made of exit. As long as he can remember he has felt an intense sympathy whenever he has read of prisoners being confined in a narrow cell, and be has always been greatly disturbed by tales of burial alive.

He was always nervous and excitable as a child and suffered from night-terrors. He has been liable, as long as he can remember, to worry without knowing why. When about twelve years old he began to stammer, ascribing its onset to the imitation of a school-fellow. It soon passed off, but ever since be has been liable to stammer when out of health.

During boyhood he had occasional attacks of sleeplessness, loss of appetite, and inability to work. When about twenty-two years of age he decided to go in for medicine, and while reading for the preliminary had an attack of this kind more severe than usual, which prevented his working for some time. A similar attack during the second year of his medical studies made him fear that he would have to give up medicine, but the leisure of a vacation restored him, and he completed his medical course. While serving as house-surgeon he again broke down in health, but managed to finish his period of office, and then did very light work for nine months.

About six years ago, while a medical student, he heard of a German, whom I will call A., who received patients into his house in order to cure them of stammering and other nervous ailments. He stayed with him for two weeks, the treatment consisting mainly of a variety of suggestion in which the patients were told to relax their muscles and concentrate their minds on the qualities they desired to attain. A. had recently become acquainted with the work of Freud, and had visited Vienna in order to learn something of his methods. Some time later the patient again put himself under the care of A. in order to undergo a course of psycho-analysis. The analyst in this case does not appear to have been acquainted with the method of free association, and after an unsuccessful attempt to carry out a series of word-associations the process of psycho-analysis [p. 172] resolved itself into an inquiry into dreams. In company with others the patient was instructed about Freud and his views. He was told that the cause of his trouble certainly lay in some forgotten experience of childhood of a sexual nature. When he related his dreams they were invariably interpreted by means of symbolism of a sexual character. Thus, if he had dreamed of water, he was told that this indicated a wish for sexual intercourse. It is a striking feature of the process of examination and treatment to which the patient was subjected that it failed to discover the special dread of closed spaces from which he suffered. At this time he had not realised that his dread was exceptional or was capable of treatment. He had supposed that everyone objected to conditions which were so trying to himself, and it was only on account of his stammering and his general nervousness that he had sought treatment. Consequently he told A. nothing about his dread and the process of "analysis" failed to detect it. Not only did the treatment lead the mind of the patient exclusively in a sexual direction, but it also failed to discover or remedy the claustrophobia.

This process of so-called psycho-analysis had no result which satisfied the patient. On the contrary, after two months of it his sleep became so disturbed and his general condition so the worse that he gave up the treatment and returned home. Nevertheless, he was left with the firm conviction, which he retained till he came under my care, that the root of his troubles lay in some forgotten sexual experience. This belief was so strong that he continued to search out for himself some forgotten experience of this kind, but without success, and shortly before the outbreak of the war he was thinking of going to Vienna to consult Freud and find whether the master himself might not succeed in discovering the lost memory.

The outbreak of the war interfered with this plan. At that time the patient was still suffering from the effects of his breakdown when a house-surgeon, but as soon as he had recovered sufficiently he joined the R.A.M.C. and went to France. When he reached the front he had to live and work in dugouts [p. 173] and was at once troubled by the dread of the limited space, and especially by the fear that he might not be able to get out if anything happened. His dread was greatly stimulated on his first day in a dug-out when, on asking the use of .spade and shovel, he was told that they were to be used in case he was buried. It was only when he found others living and working in comfort in dug-outs that for the first time he realised the exceptional nature of his dread, and recognised that he was the subject of an abnormal condition. After two attacks of trench-fever his dread was greatly accentuated and increased to such an extent as to make his life almost unendurable. He slept so badly that he had recourse to hypnotics and often spent a large part of the night walking about the trenches rather than remain in his dug-out. His health became so impaired that he was advised by his commanding-officer to consult the A.D.M.S., who sent him into hospital. He was there treated by rest and was given paraldehyde every night. He was told to keep his thoughts from war-experience and to dwell exclusively on pleasant topics such as beautiful scenery.

After three weeks in hospital in France he was sent to London where he was again treated by rest and hypnotics. When he came under my care he had been sleeping very badly in spite of the hypnotics. He had been having terrifying dreams of warfare from which he would awake sweating profusely and think that he was dying. These dreams had become less frequent but still occurred. He stammered very badly and was often depressed and restless. He found it difficult to read anything which required a mental effort and complained that his memory was defective, especially for recent occurrences. He had occasional frontal headache and suffered from pain and discomfort after food, which he ascribed to the paraldehyde he had taken, and he was liable to alternating constipation and diarrhœa. His deep reflexes were somewhat exaggerated.

In obtaining his history I learnt about his interest in Freud, and about the previous attempts to remedy his condition by means of psycho-analysis. It was only when I explained to [p. 174] him my views concerning the exaggerated interest in sex shown by Freud and his disciples that he learnt for the first time that forgotten experience of other than a sexual kind might take a part in the production of nervous states. It was agreed that "psycho-analysis" should be given a fresh trial from this point of view.

The next interview was devoted to a full inquiry into his previous experience in analysis, the results of which have already been given. As a preliminary to the following sitting I asked him to remember as fully as possible any dreams he might have in the interval, and to record any memories which came into his mind while thinking over the dreams. He was instructed to come to me at once if he had any dreams of interest. A few days later he dreamed of being in France, and of being chased by someone into a deep hole in which his pursuer killed a rabbit in place of himself and threw it into a pond covered with scum. The rabbit came to life again, and was swimming in the pond when a girl tried to kill it with a poleaxe, but only succeeded in making a gash in its back with the sharper end. The patient told her to kill it with the blunt limb and awoke. In the dream the rabbit was regarded as a ferocious animal which the patient feared would get away, and this fear continued for some time after he awoke..

While thinking over the dream in bed immediately after awaking, there came into the patient's mind an incident which had occurred soon after he had gone to live in the house with the box-bed. At this time his brother kept pet rabbits, and in order to annoy his brother after a quarrel the patient had struck one of the rabbits on the head and it had become unconscious. The brother became angry and was proceeding to "hammer" the patient when the rabbit came to life again. The incident had made a great impression at the time, but so far as the patient knew he had not thought of it since he was a boy. While telling me the dream on the following day another incident from the same period came into his mind. Near the house was a pond, and shortly after the incident with the rabbit the patient saw [p. 175] three boys trying to drown a dog. They threw it into the water with a brick tied round its neck, but as the animal was still able to swim the boys threw stones at it, injuring its eyes and mouth till it sank. Here again the patient had not thought of the incident for years, though he remembered that he could not visit the pond later without fear. This recollection was followed by another which occurred a year or two later. He and two other boys tried to drown a rat in a bucket at the house of one of the boys, but the animal was so strong that they could hardly keep it in. The patient remembered that he experienced definite fear at the thought that the animal would escape.

In the light of the incident which came to mind later the prominence of animals in these recollections of childhood may have been significant, and all the incidents are more or less connected with the emotion of fear, but they did not seem at the time to have any relation to the phobia. It is especially noteworthy that they were not thought by the patient himself to be significant as was the case with the recollection which occurred later. They were, however, very useful in convincing the patient of the possibility of recalling forgotten incidents of childhood, and showing him that incidents other than those of a sexual nature might be recalled. They suggested that the method he was following might, if persevered in, lead to memories more obviously related to his symptoms.

Three nights later he had another dream. As he lay in bed thinking over the dream, there came into his mind an incident dating back to three or four years of age which had so greatly affected him at the time that it now seemed to the patient almost incredible that it could ever have gone out of his mind, and yet it had so completely gone from his manifest memory that attempts prolonged over years had failed to resuscitate it. The incident was of a kind which convinced him at once that the long-sought memory had been found. Unfortunately his interest in the regained memory was so great that the dream which had suggested it was completely forgotten and all attempts to recall it were unavailing. [p. 176]

The incident which he remembered was a visit to an old rag-and-bone merchant who lived near the house which his parents then occupied. This old man was in the habit of giving boys a halfpenny when they took to him anything of value. The child had found something and had taken it alone to the house of the old man. He had been admitted through a dark narrow passage from which he entered the house by a turning about half-way along the passage. At the end of the passage was a brown spaniel. Having received his reward, the child came out alone to find the door shut. He was too small to open the door, and the dog at the other end of the passage began to growl. The child was terrified. His state of terror came back to him vividly as the incident returned to his mind after all the years of oblivion in which it had lain. The influence which the incident made on his mind is shown by his recollection that ever afterwards he was afraid to pass the house of the old man, and if forced to do so, always kept to the opposite side of the street.

Ten days later the patient dreamed that he visited Edinburgh for the purpose of taking the Diploma in Psychological Medicine. As he lay in bed thinking over his dream and its possible antecedents, he found that he was saying to himself over and over again the name "McCann." He could not at first remember that he knew anyone so called, but it suddenly flashed on his mind that it was the name of the old rag-and-bone merchant in whose house he had been terrified.

One thing was needed to make the story complete. It seemed possible that these thoughts, recalled in consequence of thinking over dreams, might be purely fictitious. It might be that in his intense desire to find some experience of childhood which would explain his dread, the patient might have dreamed, or thought of, purely imaginary incidents which had been mistaken for real-memories. Luckily the patient's parents are still alive, and on inquiry from them it was learnt that an old rag-and-bone merchant had lived in the neighbourhood in such a house as the patient remembered and that his name was McCann. Until they were told some twenty-seven years later they had no idea [p. 177] that their child knew anything of the old man entered his house.

I propose first to consider this case in so far as it affords evidence concerning the forgetting of unpleasant experience and the possibility of recalling such experience to manifest memory. It is well to distinguish this problem from the quite separate problems how far such forgotten experience acts as the basis of morbid states and how far the recalling of the forgotten experience to manifest consciousness is of value therapeutically.

The main facts of the case from the first of these three points of view is that by following a certain procedure there came back to the patient a memory from early childhood which had, so far as he knew, been completely absent from his manifest consciousness for about twenty-seven years. It had been so completely forgotten that even six years devoted to research into his infantile memories had failed to recall it. If it had not been for the independent confirmation of his parents the whole memory might have been dismissed as fictitious, but their evidence makes it clear that we have to do with the revival of a genuine memory.

It will be well here to consider the conditions which led to the recovery of this long-forgotten incident. The facts that it should have eluded observation although diligently sought for six years, and that it should have come so readily to light at a later time, suggest that there was something faulty in the process by which the search had been conducted before the patient came under my care. We may inquire why his previous attempts to discover the memory had failed when they succeeded so rapidly as soon as the subject was approached by a different method.

One cause of failure is undoubtedly to be found in the previous turning of the patient's thoughts exclusively in the direction of sex. He had been assured that the memory to be revived would be concerned with sexual experience. All his endeavours had been devoted to the end of finding such an experience. We could hardly have a better example of the obstruction placed in the path of knowledge by the exclusive preoccupation [p. 178] of the Freudian school with the problem of sex. In dealing with this subject on another occasion[2] I have dwelt on the part taken by the exaggerated, if not morbid, interest in sex in producing the widespread prejudice against Freud's psychology which undoubtedly exists. The case I now record shows that the evil goes much deeper, and that the exclusive interest in sex map actually obstruct the discovery of an infantile experience which furnishes as good an example as could be desired of unconscious experience and of the possibility of recalling it to manifest memory.

A second, and perhaps more important, cause of failure is that until the patient came under my care his attention had not been especially directed to his claustrophobia It was only when he recognised that his fear of being in a dug-out in France was not shared by others that he realised the specific character of his dread. It was only when he came under my care that for the first time the process or analysis started from and centred round the dread of closed spaces. Throughout all our conversations the attention of the patient was tuned in this direction, thus leading the dream-thoughts to occupy themselves with this topic until they reached and brought to the surface the memory which had lain dormant for twenty-seven years. The case well shows that the process of analysis by which forgotten experience is laid bare is not a loose method of examination which may start anywhere and be carried on anyhow, but, if it is to be successful, must be based on definite principles. It must start from some special symptom or other experience, and must be conducted with a definite relation to the experience it is desired to reach.

The previous failure of the patient to recover his infantile experience is to be explained, partly by the exclusively sexual direction of his interest, partly by the process of examination and inquiry having failed to start from the dread of closed spaces to which the infantile experience has so obvious a relation. A problem which remains for consideration is whether the later success was merely due to these two faults having been [p. 179] remedied, or whether there was any positive virtue in the special method which was then employed. This method is essentially that of free association as understood by Freud -- the method of "abstraction" of Morton Prince -- but starting from the incidents of a dream and carried out during the time immediately following the dream. In my own experience I have found this time especially favourable for the recovery of memories, the state of half-wakefulness seeming to be especially favourable to the freedom of association. The employment of free association under these conditions must, except under very special circumstances, be concluded in the main by the patient himself. The physician helps in the process by leading the waking thoughts of the patient in a direction calculated to arouse the desired experience, and he may also, as in the present case, help to elicit memories other than those which are recalled immediately after the dream, but the method is only suited to intelligent and well-instructed patients.

Thus far I have dealt only with the evidence provided by this case of claustrophobia in favour of the reality of unconscious experience and with the means by which it may again come to form part of the system of fully conscious memories. I have now to consider how far this case supports the contention that the forgetting of such experience acts as the basis of pathological states. In the case before us the pathological state is a definite example of a phobia. The problem for decision is whether the specific dread from which the patient suffered for so many years is the direct product of the forgotten experience of his childhood. The whole character of the infantile experience is one well calculated to produce such a fear as that from which the patient had so long suffered. The situation of a small child of four in a dark narrow passage with a strange growling dog as his sole companion is certainly one we might well expect to produce a lasting impression. The infantile experience accounts for the special feature of the claustrophobia that it is not so much a closed space itself which the patient dreads, but it is the fear that he may not be able to escape which especially haunts his mind. The inability of the child [p. 180] of four to open the door leading him from darkness and danger into light and safety seems to have been perpetuated in the special character of the claustrophobia afflicting the man of thirty. Throughout his life it has been when he sees no way of escape, whether at a distance from an exit, in a tunnel, or tube-railway, that the dread comes upon him, and when he went to France it was more especially the fear of being buried in his dug-out which drove him to leave conditions usually regarded as those of comparative safety to wander in the more dangerous trenches. This close correspondence between the infantile experience and the dread of later life can leave little doubt that the two are definitely related to one another, and that the infantile experience was the primary condition of the claustrophobia. It would seem probable that the phobia was accentuated and fixed later by his experience at the age of six, when night after night he lay in the box-bed, fearing to show any signs of fear owing to the presence of his brother. The process seems to have been one in which the great potentialities of an infantile impression were developed and fixed so that the emotional condition associated with the experience of the infant came to form part of the constitution of the boy and man. It is possibly owing to this later experience that the dread which was to occupy and often master the mind of the patient for nearly thirty years had as its object the narrow space rather than the dog which was the more immediate cause of the child's terror. So far as the patient remembers he has never had any fear of dogs, but it is possible that there was a period when the dread of the child was also directed to the animal, and that it was only the later and long-continued terror at the age of six which transferred the dread so completely to the other chief element of the earlier experience.

Another problem for consideration is how far his case supports Freud's special theory of "repression"[3] and active forgetting. What is needed here is some definite explanation of the process by which the acute and fully conscious terror of the child became converted into forgotten experience which was [p. 181] only restored to manifest consciousness after many years. What can have been the nature of the process by which the fully conscious mid vivid terror of the infant of four was converted into something unknown and unsuspected, working in subterranean fashion to reproduce .a vague state of dread or terror whenever the patient was exposed to conditions similar to those of his infantile experience? This topic belongs to the most difficult and obscure department of the subject. In the case of adults there is reason to believe that the process of active forgetting or suppression may in some cases take place more or less suddenly as the result of a shock or during a period of unconsciousness or delirium. On the other hand, it may be the result of a long-continued process of witting or half-witting exclusion from attention. It is difficult to imagine the latter kind of process taking place in a child of four or five. It seemed possible that it was the result of an illness in which the forgetting was assisted by some condition which produced an obvious modification of consciousness. I therefore asked my patient to make inquiries into the history of his early illnesses. He found that when between two and three years of age he had an attack of scarlet fever, so severe that the doctor despaired of his recovery. Between five and six he had enteric fever, which does not seem to have been especially severe. When about six or seven years old he had an abscess in the shoulder which lasted some months. Later he had pleurisy and was delirious, and there was again for a time little hope of his recovery. This was followed by an abscess in the foot which took some months to heal. The patient thus had a succession of severe illnesses both before and after the incident which seemed to have determined his claustrophobia The scarlet fever may have so weakened his health as to make him susceptible to suppression or to enhance an innate susceptibility in this direction, while one of the later illnesses may have provided an opportunity for conditions which would assist the process of suppression itself. I have now considered how far we can accept this case as evidence for the reality of unconscious experience and for the view that such experience is the basis of the pathological state [p. 182] of claustrophobia There still remains the question how far the case supports the contention of Freud that the bringing of unconscious experience to light is of therapeutical value. Two problems should be carefully distinguished. It is one problem whether the restoration of a forgotten experience to manifest memory relieves nervous morbid states, and it is a different problem to discover through what processes the "cure" works.

As regards the first problem, there is no doubt that the recovery of the forgotten experience of my patient had a great effect on his state. A few days after recalling the memory he sat without disturbance in the middle of a crowded picture-house under conditions which for years before would have given him the most serious discomfort and dread. The patient himself was so confident that he wished me to lock him in some subterranean chamber of the hospital, but I need hardly say that I declined to put him to, any such heroic test. He has since travelled in the tube-railway with no discomfort whatever, so that the ordinary conditions which had brought his phobia into activity for many years no longer have this effect. He has even been down a coal-mine, when be went for more than a mile along narrow underground passages, the mere thought of which would once have made him shrink in horror. A striking sequel of the recovery of his infantile memory is that terrifying dreams of being unable to escape from enclosed spaces from which he formerly suffered now trouble him no longer, and he had a dream, in which he found himself in a narrow cell in the company of a bloodhound, and was amazed in the dream that he should be so happy and comfortable in this situation.

The effect on the other symptoms from which he was suffering as the result of his war experience has been less satisfactory. His stammering improved to some extent, and still more striking than any objective improvement was the disappearance of a dread of stammering which had been a constant source of trouble since coming home from France, He became able to take plenty of physical and mental exercise, but he continued to sleep badly and be troubled by disturbing dreams of warfare. The continuance of these symptoms, however, is certainly due [p. 183] to the fact that though his claustrophobia had formed the starting-point of his general war-neurosis, the neurosis was kept active by other forms of anxiety.

In connection with his broken sleep and disturbing dreams of warfare one point may be considered. In entering upon the line of treatment which I have described in this paper I hesitated whether I was justified in possibly adding to his other causes of loss of sleep by asking him to attend to and think over his dreams. The progress of the case speedily removed any apprehensions of this kind. After his infantile memories had been discovered he continued to be interested in his dreams and their analysis, but did not find that the process interfered with his sleep. Even while on the search for forgotten memories he did not attempt any analysis of that class of dream, dealing with scenes of war, which especially disturbed his sleep.

The last problem I have to consider is concerned with the agency by which the recovery of the lost memory has so greatly relieved the claustrophobia of the patient according to the older views of Freud and his disciples the raising of suppressed experience to the surface is in itself sufficient to bring shout the disappearance of morbid states, and this curative action is often cited as evidence in favour of the general theory of suppression. The case before us might well be regarded as striking evidence in favour of their view. The recollection of the incident of his childhood has been followed by the disappearance of the dread which has been with him for so many years. It might seem at first sight evident that this disappearance has been the direct result of the reintegration of the forgotten and suppressed experience with his ordinary personality. Another possibility must, however, be considered.

The whole procedure of psycho-analysis is calculated to bring into play the agencies of faith and suggestion. Thus, the patient had been assured from his first attempt at psycho-analysis that the recovery of a forgotten experience of childhood would effect a cure. It was evident when he came under my care that in spite of previous failure his mind was still dominated by the belief that if the right experience could be found he [p. 184] would recover. When the memory of the passage and the dog came back to him his mind was filled with a sense of comfort as regards his illness such as he had not known for years.

I did nothing to enhance his confidence in the Freudian interpretation of the process by which the recovery of a lost memory produces a cure, but in spite of my own scepticism concerning the mechanism of recovery, I was careful to say nothing which would have disturbed his faith. This faith was so beat that it cannot be excluded as a factor in the therapeutic success of the revival of the forgotten experience. His case has one feature, however, which suggests, if it cannot be said to prove, that the recovery of the memory rather than the influence of faith and suggestion was the essential agent in producing the disappearance of his dread. For years the patient had believed that the recovery of the right memory would cure his stammering and get rid of his general nervousness. For reasons already considered, his faith had not had the state of claustrophobia as its object. Nevertheless, it was this symptom which was so greatly relieved, though we cannot yet say that it has been wholly cured.[4] The stammering and general nervousness, on. the other hand, which had throughout been the special objects round which his faith was working, though altered for the good, have been relieved in far less degree. The argument is not conclusive, because the direction of the patient's attention towards his claustrophobia, which was an essential element of my treatment, may have acted as an instrument by means of which the agencies of faith and suggestion already working in the patient's mind were turned towards his claustrophobia.