Kirmayer L J, Young A, Hayton B C
Division of Social and Transcultural Psychiatry, McGill University, Montreal, Quebec, Canada.
Psychiatr Clin North Am. 1995 Sep;18(3):503-21.
About a century ago, George Crile, a surgeon and experimental physiologist, suggested that the meaning of pain could be discovered in the context of evolution. Pain is a signal of a physical injury that would be otherwise ignored by the individual, a form of ignorance that would ultimately have mortal consequences. Crile believed that pain has a second purpose, that has important implications for how psychiatry now understands the emotions, specifically fear and anxiety. In essence, he suggested that fear is the memory of pain, and its adaptive advantage is that it enables individuals to anticipate and avoid injury. Fear-as-memory could be acquired either through individual experience (learned fear) or through species experience (instinctive fear). Among other things, this conception of pain and fear explained why surgical shock (from physical injury) and nervous shock (induced by fear or fright) appeared, at times, to provoke a similar physiologic response--a phenomenon first commented on by the British surgeon, Herbert Page. With this simple grammar, injury-pain-fear, Page and Crile laid the foundations for the modern concept of psychogenic trauma, extending the old idea of "trauma," meaning a wound or physical injury, to include psychological experiences and processes. The modern conception was completed by Freud, by connecting one more emotional state, anxiety. If fear is not simply a memory of pain but a memory that is bound to stimuli in the here-and-now, then anxiety is memory set loose. Put in other words, anxiety is the capacity to imagine pain and not merely to recollect pain. From the time of Beyond the Pleasure Principle (1919), anxiety took on a life of its own, so to speak, no longer part of the constellation of emotions and experiences identified by Page and Crile. Without an external object toward which to direct itself, fear becomes anxiety--a state of nervous anticipation of the unknown, of what is hidden in the shadows or penumbra of awareness. Anxiety is not a vector directed toward a threatening object or event in the environment but is situated in the person's own bodily experience, the workings of the mind, the Cartesian theater of self-representation. As an experience and event located entirely within the psyche, to be mastered by asserting a strong ego, reflections on anxiety became one of the self-constituting experiences of the Western concept of the person. In contemporary psychiatry, the constellation of injury, pain, fear, anxiety, memory, and imagination would seem to live on mainly in the context of traumatogenic anxiety and PTSD.(ABSTRACT TRUNCATED AT 400 WORDS)
大约一个世纪前，外科医生兼实验生理学家乔治·克里尔提出，可以在进化的背景下探寻疼痛的意义。疼痛是身体受伤的信号，否则个体可能会忽略这种伤害，而这种忽视最终可能会带来致命后果。克里尔认为疼痛还有第二个目的，这对当今精神病学如何理解情绪，尤其是恐惧和焦虑有着重要影响。从本质上讲，他认为恐惧是对疼痛的记忆，其适应性优势在于它能使个体预见并避免受伤。恐惧作为记忆既可以通过个体经历（习得性恐惧）获得，也可以通过物种经历（本能恐惧）获得。除此之外，这种对疼痛和恐惧的概念解释了为什么手术休克（由身体损伤引起）和神经休克（由恐惧或惊吓诱发）有时会引发相似的生理反应——这一现象最早由英国外科医生赫伯特·佩奇提出。凭借“损伤 - 疼痛 - 恐惧”这一简单模式，佩奇和克里尔奠定了心理创伤现代概念的基础，将“创伤”这一旧观念（意为伤口或身体损伤）扩展至包括心理体验和过程。弗洛伊德通过将另一种情绪状态——焦虑联系起来，完善了这一现代概念。如果恐惧不只是对疼痛的记忆，而是与当下刺激相关联的记忆，那么焦虑就是释放的记忆。换句话说，焦虑是想象疼痛的能力，而不仅仅是回忆疼痛。从《超越快乐原则》（1919 年）问世起，焦虑可以说有了自己的生命，不再是佩奇和克里尔所确定的情绪和体验范畴的一部分。没有外在对象可供指向，恐惧就变成了焦虑——一种对未知以及隐藏在意识阴影或边缘之物的紧张预期状态。焦虑不是指向环境中威胁性对象或事件的矢量，而是存在于个体自身的身体体验、心理活动以及自我呈现的笛卡尔剧场之中。作为一种完全存在于心理层面、需通过强化自我来掌控的体验和事件，对焦虑的思考成为了西方人格概念中自我构成的体验之一。在当代精神病学中，损伤、疼痛、恐惧、焦虑、记忆和想象这一系列因素似乎主要存在于创伤性焦虑和创伤后应激障碍的背景之中。
