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Program Director, University of Chicago Pritzker School of Medicine

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The feeling of happiness derived from the satisfaction of a wild instinctual impulse untamed by the ego is incomparably more intense than that derived from sating an instinct that has been tamed. The irresistibility of perverse instincts, and perhaps the attraction in general of forbidden things, finds an economic explanation here. Civilization And Its Discontents 4479 Another technique for fending off suffering is the employment of the displacements of libido which our mental apparatus permits of and through which its function gains so much in flexibility. The task here is that of shifting the instinctual aims in such a way that they cannot come up against frustration from the external world. One gains the most if one can sufficiently heighten the yield of pleasure from the sources of psychical and intellectual work. But their intensity is mild as compared with that derived from the sating of crude and primary instinctual impulses; it does not convulse our physical being. And the weak point of this method is that it is not applicable generally: it is accessible to only a few people. It presupposes the possession of special dispositions and gifts which are far from being common to any practical degree. And even to the few who do possess them, this method cannot give complete protection from suffering. It is not possible, within the limits of a short survey, to discuss adequately the significance of work for the economics of the libido. No other technique for the conduct of life attaches the individual so firmly to reality as laying emphasis on work; for his work at least gives him a secure place in a portion of reality, in the human community. The possibility it offers of displacing a large a mount of libidinal components, whether narcissistic, aggressive or even erotic, on to professional work and on to the human relations connected with it lends it a value by no means second to what it enjoys as something indispensible to the preservation and justification of existence in society. Professional activity is a source of special satisfaction if it is a freely chosen one if, that is to say, by means of sublimation, it makes possible the use of existing inclinations, of persisting or constitutionally reinforced instinctual impulses. The great majority of people only work under the stress of necessity, and this natural human aversion to work raises most difficult social problems. Civilization And Its Discontents 4480 While this procedure already clearly shows an intention of making oneself independent of the external world by seeking satisfaction in internal, psychical processes, the next procedure brings out those features yet more strongly. In it, the connection with reality is still further loosened; satisfaction is obtained from illusions, which are recognized as such without the discrepancy between them and reality being allowed to interfere with enjoyment. The region from which these illusions arise is the life of the imagination; at the time when the development of the sense of reality took place, this region was expressly exempted from the demands of reality-testing and was set apart for the purpose of fulfilling wishes which were difficult to carry out. At the head of these satisfactions through phantasy stands the enjoyment of works of art an enjoyment which, by the agency of the artist, is made accessible even to those who are not themselves creative. Nevertheless the mild narcosis induced in us by art can do no more than bring about a transient withdrawal from the pressure of vital needs, and it is not strong enough to make us forget real misery. It regards reality as the sole enemy and as the source of all suffering, with which it is impossible to live, so that one must break off all relations with it if one is to be in any way happy. But whoever, in desperate defiance, sets out upon this path to happiness will as a rule attain nothing. He becomes a madman, who for the most part finds no one to help him in carrying through his delusion. It is asserted, however, that each one of us behaves in some one respect like a paranoic, corrects some aspect of the world which is unbearable to him by the construction of a wish and introduces this delusion into reality. A special importance attaches to the case in which this attempt to procure a certainty of happiness and a protection against suffering through a delusional remoulding of reality is made by a considerable number of people in common. Civilization And Its Discontents 4481 I do not think that I have made a complete enumeration of the methods by which men strive to gain happiness and keep suffering away and I know, too, that the material might have been differently arranged. One procedure I have not yet mentioned not because I have forgotten it but because it will concern us later in another connection. And how could one possibly forget, of all others, this technique in the art of livingfi

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In the latter, psychical intensity coincides with psychical value: the most intense elements are also the most important ones those which form the centre-point of the dream-thoughts. We know, it is true, that these are precisely elements which, on account of the censorship, cannot as a rule make their way into the content of the dream; nevertheless, it might well be that their immediate derivatives which represent them in the dream might bear a higher degree of intensity, without necessarily on that account forming the centre of the dream. But this expectation too is disappointed by a comparative study of dreams and the material from which they are derived. A direct derivative of what occupies a dominating position in the dream-thoughts can often only be discovered precisely in some transitory element of the dream which is quite overshadowed by more powerful images. The intensity of the elements of a dream turns out to be determined otherwise and by two independent factors. In the first place, it is easy to see that the elements by which the wish-fulfilment is expressed are represented with special intensity. And in the second place, analysis shows that the most vivid elements of a dream are the starting-point of the most numerous trains of thought that the most vivid elements are also those with the most numerous determinants. We shall not be altering the sense of this empirically based assertion if we put it in these terms: the greatest intensity is shown by those elements of a dream on whose formation the greatest amount of condensation has been expended. We may expect that it will eventually turn out to be possible to express this determinant and the other (namely relation to the wish- fulfilment) in a single formula. The Interpretation Of Dreams 800 the problem with which I have just dealt the causes of the greater or less intensity or clarity of particular elements of a dream is not to be confounded with another problem, which relates to the varying clarity of whole dreams or sections of dreams. In the former case clarity is contrasted with vagueness, but in the latter case it is contrasted with confusion. Nevertheless it cannot be doubted that the increase and decrease of the qualities in the two scales run parallel. A section of a dream which strikes us as perspicuous usually contains intense elements; a dream which is obscure, on the other hand, is composed of elements of small intensity. Yet the problem presented by the scale which runs from what is apparently clear to what is obscure and confused is far more complicated than that of the varying degrees of vividness of dream-elements. Indeed, for reasons which will appear later, the former problem cannot yet be discussed. In a few cases we find to our surprise that the impression of clarity or indistinctness given by a dream has no connection at all with the make-up of the dream itself but arises from the material of the dream-thoughts and is a constituent of it. Thus what I had taken to be a judgement on the completed dream was actually a part, and indeed the essential part, of the dream-content. The dream-work had in this case encroached, as it were, upon my first waking thoughts and had conveyed to me as a judgement upon the dream the part of the material of the dream-thoughts which it had not succeeded in representing accurately in the dream. At length, protesting repeatedly that she felt no certainty that her account was correct, she informed me that several people had come into the dream she herself, her husband and her father and that it was as though she had not known whether her husband was her father, or who her father was, or something of that sort. The form of a dream, or the form in which it is dreamt is used with quite surprising frequency for representing its concealed subject-matter. The Interpretation Of Dreams 801 Glosses on a dream, or apparently innocent comments on it, often serve to disguise a portion of what has been dreamt in the subtlest fashion, though in fact betraying it. A young man had a very clear dream which reminded him of some phantasies of his boyhood that had remained conscious. He mistook the number of his room and went into one in which an elderly lady and her two daughters were undressing and going to bed. Finally there was a man in the room who tried to throw me out, and I had to have a struggle with him.

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The choice of free association as a means of investigating the forgotten unconscious material seems so strange that a word in justification of it will not be out of place. To be sure, this material did not bring up what had actually been forgotten, but it brought up such plain and numerous hints at it that, with the help of a certain amount of supplementing and interpreting, the doctor was able to guess (to reconstruct) the forgotten material from it. Thus free association together with the art of interpretation performed the same function as had previously been performed by hypnotism. A Short Account Of Psycho-Analysis 4106 It looked as though our work had been made much more difficult and complicated; but the inestimable gain was that an insight was now obtained into an interplay of forces which had been concealed from the observer by the hypnotic state. It became evident that the work of uncovering what had been pathogenically forgotten had to struggle against a constant and very intense resistance. The critical objections which the patient raised in order to avoid communicating the ideas which occurred to him, and against which the fundamental rule of psycho-analysis was directed, had themselves already been manifestations of this resistance. A consideration of the phenomena of resistance led to one of the corner-stones of the psycho- analytic theory of the neuroses the theory of repression. It was plausible to suppose that the same forces which were now struggling against the pathogenic material being made conscious had at an earlier time made the same efforts with success. The impressions and mental impulses, for which the symptoms were now serving as substitutes, had not been forgotten without reason or on account of a constitutional in capacity for synthesis (as Janet supposed); they had, though the influence of other mental forces, met with a repression the success and evidence of which was precisely their being debarred from consciousness and excluded from memory. It was only in consequence of this repression that they had become pathogenic that is, had succeeded in manifesting themselves along unusual paths as symptoms. A conflict between two groups of mental trends had to be looked on as the ground for repression and accordingly as the cause of every neurotic illness. And here experience taught us a new and surprising fact about the nature of the forces that were struggling against each other. Thus the symptoms were a substitute for forbidden satisfactions and the illness seemed to correspond to an incomplete subjugation of the immoral side of human beings. A Short Account Of Psycho-Analysis 4107 Advance in knowledge made ever clearer the enormous part played in mental life by sexual wishful impulses, and led to a detailed study of the nature and development of the sexual instinct. This led to the revelation of something that had hitherto been fundamentally overlooked by science infantile sexuality, which, from the tenderest age onwards, is manifested both in physical reactions and in mental attitudes. In order to bring together this sexuality of children with what is described as the normal sexuality of adults and the abnormal sexual life of perverts, the concept of what was sexual had itself to be corrected and widened in a manner which could be justified by the evolution of the sexual instinct. During that time psycho-analysis gradually acquired a theory which appeared to give a satisfactory account of the origin, meaning and purpose of neurotic symptoms and provided a rational basis for medical attempts at curing the complaint. They are: emphasis on instinctual life (affectivity), on mental dynamics, on the fact that even the apparently most obscure and arbitrary mental phenomena invariably have a meaning and a causation, the theory of psychical conflict and of the pathogenic nature of repression, the view that symptoms are substitutive satisfactions, the recognition of the aetiological importance of sexual life, and in particular of the beginnings of infantile sexuality. From a philosophical standpoint this theory was bound to adopt the view that the mental does not coincide with the conscious, that mental processes are in themselves unconscious and are only made conscious by the functioning of special organs (agencies or systems). By way of completing this list, I will add that among the affective attitudes of childhood the complicated emotional relation of children to their parents what is known as the Oedipus complex came into prominence. If the conditions postulated by psycho-analysis really existed, they were of a fundamental nature and must be able to find expression in other phenomena besides hysterical ones. But if this inference were correct, psycho-analysis would have ceased to be of interest only to neurologists; it could claim the attention of everyone to whom psychological research was of any importance. Its findings would not only have to be taken into account in the field of pathological mental life but could not be overlooked either in coming to an understanding of normal functioning. A Short Account Of Psycho-Analysis 4109 Evidence of its being of use for throwing light on other than pathological mental activity was early forthcoming in connection with two kinds of phenomena: with the very frequent parapraxes that occur in everyday life such as forgetting things, slips of the tongue, and mislaying objects and with the dreams dreamt by healthy and psychically normal people.

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Tables, tables laid for a meal, and boards also stand for women no doubt by antithesis, since the contours of their bodies are eliminated in the symbols. No doubt this is not only because neckties are long, dependent objects and peculiar to men, but also because they can be chosen according to taste a liberty which, in the case of the object symbolized, is forbidden by Nature. Marcinowski has published a collection of dreams illustrated by their dreamers with drawings that ostensibly represent landscapes and other localities occurring in the dreams. Whereas to the innocent eye they appear as plans, maps, and so on, closer inspection shows that they represent the human body, the genitals, etc. If one of the ordinary symbols for a penis occurs in a dream doubled or multiplied, it is to be regarded as a warding-off of castration. The appearance in dreams of lizards animals whose tails grow again if they are pulled off has the same significance. Small animals and vermin represent small children for instance, undesired brothers and sisters. Being plagued with vermin is often a the Interpretation Of Dreams sign of pregnancy. He had in fact started a liason with this girl and had paid several visits to her in her bedroom. She had not unnaturally been afraid that the landlady might become suspicious, and, on the day before the dream, she had proposed that they should meet in an unoccupied room. It would hardly be possible to imagine clearer proof of an identification between a woman and a room. We were put on the alert by this objection, and began to turn our attention to the appearance of steps, staircases and ladders in dreams, and were soon in a position to show that staircases (and analogous things) were unquestionably symbols of copulation. It shows us that "mounting" [German "steigen"] is used as a direct equivalent for the sexual act. We speak of a man as a "Steiger" [a "mounter"] and of "nachsteigen" ["to run after", literally "to climb after"]. In French the steps on a staircase are called "marches" and "un vieux marcheur" has the same meaning as our "ein alter Steiger" ["an old rake"]. It represents a man with a necktie consisting of a snake which is turning in the direction of a girl. Many of these show penetration, and further examination has proved them correct: for instance, his section on the symbolism of death.

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However, it is also possible that these A common differential diagnostic issue with which symptoms may be largely explained by dementia. S consulting neuropsychologists deal is the referral to dis- may have given up former hobbies such as clock building tinguish between depression and dementia in elderly pa- because he no longer has adequate visuospatial functioning tients. Because large quantities of later in the disease, even straightforward tasks such as choline are found in lecithin, a substance contained in washing dishes or taking out the garbage may be difficult foods such as egg whites and chocolate, researchers once to begin, because the affected person does not know thought that by increasing dietary choline, they might where to start. In the mid-1990s, tacrine (Cognex), which is a long-acting acetylcholinesterase in- Treatment hibitor, received a fiurry of attention. It appeared to show some positive effects, but also resulted in a side effect of No currently available treatments can reverse, halt, liver toxicity. We simply do not yet designed specifically to enhance cholinergic activity in the know enough about the neurophysiology and causes of brain. At this point, however, the search is still on to find the disease to develop medical treatments tailored to at- the right combination of noticeable memory enhancement tack the underlying mechanisms. Most target method being researched to increase cholinergic neuronal the cholinergic system, and therefore memory. The cholinergic system neurons in the basal fore- pairment not directly attributable to the disease). Researchers as our understanding of the underlying pathophysiol- have tried varied approaches to augment levels of brain ogy develops. A truly effective solution will have to conquer conditions associated with aging such as respiratory or the pervasive cognitive decline. Behavioral, psychiatric, and cognitive difficulties also amplify hallucinations or sensory illusions. Attempts most management strategies seek to restructure the envi- to manage these symptoms use either pharmacologic or ronment to ensure safety, provide appropriate stimula- behavioral tools. As the disease Common behavioral and affective symptoms associ- progresses, the person needs more constant supervision. If a patient is living at home, the burden on care- Minor tranquilizers or antidepressants may aid depression givers can be enormous. Summary Psychological studies of the elderly have established that aging itself does not necessarily cause dementia. Instead, aging produces predictable changes in patterns of abilities in crystallized and fluid intelligence. Healthy and active individuals in their 60s, 70s, and 80s do not necessarily differ substantially from their past level of functioning in the level of their crystallized cognitive skills or abilities. Relatively stable skills include well-learned verbal abilities such as reading, writing, and speaking; simple arithmetic ability; and immediate and long-term memory. In contrast, fluid intelligence, including short-term memory, abstract and novel problem solving, and behavioral slowing are examples of types of functioning that normal aging may compromise. An understanding of precise neuropsy- chological deficits can improve the medical management even of patients with irreversible dementia. Neu- ropsychologists play an important role in comprehensive medical, functional, psychosocial, and neuropsy- chological assessment. By recommending logical, cost-effective home modifications, unique ideas, and products, homes can accommodate those dealing with age-related conditions and embrace the special needs of people as they age. This site includes a brief description and diagnostic crite- ria for most major brain diseases. This site provides updates on dementia research, a virtual chat room, a dementia support group, and other links. Overview Subcortical dementias are so named because, although these conditions often affect cortical areas and functioning, the structures that are prominently damaged are subcortical.

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