The second meaning (death) was derived from (a) the previous fixed idea (just referred to), organized with that of insanity—namely, an unsophisticated medieval idea of hell which was conceived of as the equivalent of death and which had excited an intense horror of both; and (b) from the fact that in the unreality attacks there was a _struggling_ for air; struggling was in her mind, the equivalent of convulsions;[193] convulsions of unconsciousness; and unconsciousness of death. All these various ideas and the intense fears which each gave rise to had become organized into a complex, and, in consequence of these antecedent experiences in which self took a prominent part, the instinct of fear—as I conceive the matter—became incorporated within the self-regarding sentiment. (Anything that aroused this sentiment tended to arouse the emotion of fear, as in another person it would tend to arouse the emotion of pride, or self-abasement.) At any rate this organized complex was the setting which gave the meaning to her phobia. There can be, I think, no manner of doubt about this. The patient herself explained her viewpoint through these ideas here briefly summarized. The only question is as to the mechanism of the phobia. Now as Type D, of which these cases are examples, differs clinically from the preceding three types only in the addition of one more element—meaning—to the conscious psychic whole, a consistent interpretation would seem to compel us to postulate also a functioning subconscious complex or setting and in this case of the antecedent experiences disclosed as a factor in the mechanism and a part of the psychic whole. Out of this complex emerged into consciousness the idea of insanity and death and fear as the meaning of the unreality syndrome, the whole constituting the phobia psychosis.