Selected Papers on Hysteria and Other Psychoneuroses/Chapter 1
The Psychic Mechanism of Hysterical Phenomena.
Instigated by a number of accidental observations we have investigated for a number of years the different forms and symptoms of hysteria in order to discover the cause and the process which provoked the phenomena in question for the first time, in a great many cases years back. In the great majority of cases we did not succeed in elucidating this starting point from the mere history, no matter how detailed it might have been, partly because we had to deal with experiences about which discussion was disagreeable to the patients, but mainly because they really could not recall them; often they had no inkling of the causal connection between the occasioning process and the pathological phenomenon. It was generally necessary to hypnotize the patients and reawaken the memory of that time in which the symptom first appeared, and we thus succeeded in exposing that connection in a most precise and convincing manner.
This method of examination in a great number of cases has furnished us with results which seem to be of theoretical as well as of practical value.
It is of theoretical value because it has shown to us that in the determination of the pathology of hysteria the accidental moment plays a much greater part than is generally known and recognized. It is quite evident that in "traumatic" hysteria it is the accident which evokes the syndrome. Moreover in hysterical crises, if patients state that they hallucinate in each attack the same process which evoked the first attack, here too, the causal connection seems quite clear. The state of affairs is more obscure in the other phenomena.
Our experiences have shown us that the most varied symptoms which pass as spontaneous, or so to say idiopathic attainments of hysteria, stand in just as stringent connection with the causal trauma as the transparent phenomena mentioned. To such causal moments we were able to refer neuralgias as well as the different kinds of anesthesias often of years' duration, contractures and paralyses, hysterical attacks and epileptiform convulsions which every observer has taken for real epilepsy, petit mal and tic-like affections, persistent vomiting and anorexia, even the refusal of nourishment, all kinds of visual disturbances, constantly recurring visual hallucinations, and similar affections. The disproportion between the hysterical symptoms of years' duration and the former cause is the same as the one we are regularly accustomed to see in the traumatic neurosis. Very often they are experiences of childhood which have established more or less intensive morbid phenomena for all succeeding years.
The connection is often so clear that it is perfectly manifest how the causal event produced just this and no other phenomenon. It is quite clearly determined by the cause. Thus let us take the most banal example; if a painful affect originates while eating but is repressed, it may produce nausea and vomiting and continue for months as a hysterical symptom. A girl was anxiously distressed while watching at a sick bed. She fell into a dreamy state and experienced a frightful hallucination, and at the same time her right arm hanging over the back of a chair became numb. This resulted in a paralysis, contracture, and anesthesia of that arm. She wanted to pray but could find no words, but finally succeeded in uttering an English prayer for children. Later, on developing a very grave and most complicated hysteria, she spoke, wrote, and understood only English, whereas her native tongue was incomprehensible to her for a year and a half. A very sick child finally falls asleep. The mother exerts all her will power to make no noise to awaken it, but just because she resolved to do so she emits a clicking sound with her tongue ("hysterical counter-will"). This was later repeated on another occasion when she wished to be absolutely quiet, developing into a tic which in the form of tongue clicking accompanied every excitement for years. A very intelligent man was present while his brother was anesthetized and his ankylosed hip stretched. At the moment when the joint yielded and crackled he perceived severe pain in his own hip which continued for almost a year.
In other cases the connection is not so simple, there being only as it were a symbolic relation between the cause and the pathological phenomenon, just as in the normal dream. Thus psychic pain may result in neuralgia, or the affect of moral disgust may cause vomiting. We have studied patients who were wont to make the most prolific use of such symbolization. In still other cases such a determination is at first sight incomprehensible, yet to this group belong the typical hysterical symptoms such as hemianesthesia, contraction of visual field, epileptiform convulsions and many others. The explanation of our views on this group we have to reserve for the more detailed discussion of the subject.
Such observations seem to demonstrate the pathogenic analogy between simple hysteria and traumatic neurosis and justify a broader conception of "traumatic hysteria." The active etiological factor in traumatic neurosis is really not the insignificant bodily injury but the affect of the fright, that is, the psychic trauma. In an analogous manner our investigations show that the causes of many, if not of all, cases of hysteria can be designated as psychic traumas. Every experience which produces the painful affect of fear, anxiety, shame or of psychic pain may act as a psychic trauma. Whether an experience becomes of traumatic importance naturally depends on the person affected as well on the determination to be mentioned later. In ordinary hysteria instead of one big trauma we not seldom find many partial traumas, grouped causes which can be of traumatic significance only when summarized and which belong together in so far as they form small fragments of the sorrowful tale. In still other cases apparently indifferent circumstances gain traumatic dignity through their connection with the real effective event or with a period of time of special excitability which they then retain but which otherwise would have no significance.
Nevertheless the causal connection between the provoking psychic trauma and the hysterical phenomena does not perhaps resemble the trauma which as the agent provocateur would call forth the symptom which would become independent and continue to exist. We have to claim still more, namely, that the psychic trauma or the memory of the same acts like a foreign body which even long after its penetration must continue to influence like a new causative factor. The proof of this we see in a most remarkable phenomenon which at the same time gives to our discoveries a distinct practical interest.
We found, at first to our greatest surprise, that the individual hysterical symptoms immediately disappeared without returning if we succeeded in thoroughly awakening the memories of the causal process with its accompanying affect, and if the patient circumstantially discussed the process giving free play to the affect. Affectless memories are almost utterly useless. The psychic process originally rebuffed must be reproduced as vividly as possible so as to bring it back into the statum nascendi and then be thoroughly "talked over." At the same time if we deal with such exciting manifestations as convulsions, neuralgias and hallucinations they appear once more with their full intensity and then vanish forever. Functional attacks like paralyses and anesthesias likewise disappear, but naturally without any appreciable distinctness of their momentary aggravation.
It is quite reasonable to suspect that one deals here with an unintentional suggestion. The patient expects to be relieved of his suffering and it is this expectation and not the discussion that is the effectual factor. But this is not so. The first observation of this kind in which a most complicated case of hysteria was analyzed and the individual causal symptoms separately abrogated, occurred in the year 1881, that is, in a "pre-suggestive" time. It was brought about through a spontaneous autohypnosis of the patient and caused the examiner the greatest surprise.
In reversing the sentence: cessante causa cessat effectus, we may conclude from this observation that the causal process continues to act in some way even after years, not indirectly by means of a chain of causal connecting links but directly as a provoking cause, just perhaps as in the awakened consciousness where the memory of a psychic pain may later call forth tears. The hysteric suffers mostly from reminiscences.
It would seem at first rather surprising that long-forgotten experiences should effect so intensively, and that their recollections should not be subject to the decay into which all our memories merge. We will perhaps gain some understanding of these facts by the following examinations.
The blurring or loss of an affect of memory depends on a great many factors. In the first place it is of great consequence whether there was an energetic reaction to the affectful experience or not. By reaction we here understand a whole series of voluntary or involuntary reflexes, from crying to an act of revenge, through which according to experience affects are discharged. If the success of this reaction is of sufficient strength it results in the disappearance of a great part of the affect. Language attests this fact of daily observation, in such expressions as "to give vent to one's feeling," to be "relieved by weeping," etc.
If the reaction is suppressed the affect remains united with the memory. An insult retaliated, be it only in words, is differently recalled than one that had to be taken in silence. Language also recognizes this distinction between the psychic and physical results and designates most characteristically the silently endured suffering as "grievance." The reaction of the person injured to the trauma has really no perfect "cathartic" effect unless it is an adequate reaction like revenge. But man finds a substitute for this action in speech through which help the affect can well nigh be ab-reacted ("abreagirt"). In other cases talking in the form of deploring and giving vent to the torments of the secret (confession) is in itself an adequate reflex. If such reaction does not result through deeds, words, or in the lightest case through weeping, the memory of the occurrence retains above all the affective accentuation.
The ab-reaction (abreagiren), however, is not the only form of discharge at the disposal of the normal psychic mechanism of the healthy person who has experienced a psychic trauma. The memory of the trauma even where it has not been ab-reacted enters into the great complex of the association. It joins the other experiences which are perhaps antagonistic to it and thus undergoes correction through the other ideas. For example, after an accident the memory of the danger and (dimmed) repetition of the fright is accompanied by the recollection of the further course, the rescue, and the consciousness of present security. The memory of a grievance may be corrected by a rectification of the state of affairs by reflecting upon one's own dignity and similar things. Thus the normal person is able to cause a disappearance of the accompanying affect by means of association.
In addition there appears that general blurring of impressions, that fading of memories which we call "forgetting," and which above all wears out the affective ideas no longer active. It follows from our observations that those memories which become the causes of hysterical phenomena have been preserved for a long time with wonderful freshness and with their perfect emotional tone. As a further striking and a later realizable fact we have to mention that the patients do not perhaps have the same control of these as of their other memories of life. On the contrary, these experiences are either completely lacking from the memory of the patients in their usual psychic state or at most exist greatly abridged. Only after the patients are questioned in the hypnotic state do these memories appear with the undiminished vividness of fresh occurrences. Thus one of our patients in a hypnotic state reproduced with hallucinatory vividness throughout half a year all that excited her during an acute
hysteria on the same days of the preceding year. Her mother's diary which was unknown to the patient proved the faultless accuracy of the reproduction. Another patient, partly in hypnosis and partly in spontaneous attacks, went through with a hallucinatory distinctness all experiences of a hysterical psychosis which she passed through ten years before and for the greatest part of which she was amnesic until its reappearance. She also showed with surprising integrity and sentient force some etiologically important memories of fifteen to twenty-five years' duration which on their return acted with the full affective force of new experiences.
The reason for this we can only find in the fact that in all the aforesaid relations these memories assume an exceptional position in reference to disappearance. It was really shown that these memories correspond to traumas which were not sufficiently ab-reacted to ("abreagirt "). On closer investigation of the reasons for this prevention we can find at least two series of determinants through which the reaction to the trauma was discontinued.
To the first group we add those cases in which the patient has not reacted to psychic traumas because the nature of the trauma precluded a reaction as in the case of an irremediable loss of a beloved person or because social relations made the reaction impossible, or because it concerned things which the patient wishes to forget and which he therefore intentionally inhibited and repressed from his conscious memory. It is just those painful things which in the hypnotic state are found to be the basis of hysterical phenomena (hysterical delirium of saints, nuns, abstinent women, and well-bred children).
The second series of determinants is not conditioned by the content of the memories but by the psychic states with which the corresponding experiences in the patient have united. As a cause of hysterical symptoms one really finds in hypnosis presentations which are insignificant in themselves but which owe their preservation to the fact that they originated during a severe paralyzing affect like fright or directly in abnormal psychic conditions, as in the semi-hypnotic dreamy states of reveries, in auto-hypnosis and similar states. Here it is the nature of these conditions which makes a reaction to the incident impossible.
To be sure both determinants may unite, and as a matter of fact they often do. This is the case when a trauma in itself effective occurs in a state of a powerful paralyzing affect or in a transformed consciousness. But due to the psychic trauma it may also happen that in many persons one of these abnormal states occurs which in turn makes a reaction impossible.
What is common to both groups of determinants is the fact that those psychic traumas which are not rectified by reaction are also prevented from adjustment by associative elaboration. In the first group it is due to the resolution of the patient who wishes to forget the painful experiences and in this way, if possible, to exclude them from association, and in the second group the associative elaboration does not succeed because there is no productive associative relationship between the normal and pathological state of consciousness in which these presentations originated. We shall soon have occasion to discuss more fully these relationships.
Hence we can say, that the reason why the pathogenically formed presentations retain their freshness and affective force is because they are not subject to the normal waste through ab-reaction and reproduction in conditions of uninhibited association.
When we discussed the conditions which, according to our experience, are decisive in the development of hysterical phenomena from psychic traumas, we were forced to speak of abnormal states of consciousness in which such pathogenic presentations originate, and we had to emphasize the fact that the recollection of the effective psychic trauma is not to be found in the normal memory of the patient but in the hypnotized memory. The more we occupied ourselves with these phenomena the more certain became our convictions that the splitting of consciousness, so striking in the familiar classical cases of double consciousness, exists rudimentarily in every hysteria, and that the tendency to this dissociation, and with it the tendency towards the appearance of abnormal states of consciousness which we comprehend as "hypnoid states," is the chief phenomenon of this neurosis. In this view we agree with Binet and with both the Janets about whose most remarkable findings in anesthetics we have had no experience.
Hence, to the often cited axiom, "Hypnosis is artificial hysteria," we would like to add another: "The existence of hypnoid states is the basis and determination of hysteria." These hypnoid states in all their diversities agree among themselves and with hypnosis in the fact that their emerged presentations are very intensive but are excluded from the associative relations of the rest of the content of consciousness. The hypnoid states are associable among themselves, and their ideation may thus attain various high degrees of psychic organization. In other respects the nature of these states and the degree of their exclusiveness differ from the rest of the conscious processes as do the various states in hypnosis, which range from light somnolence to somnambulism, and from perfect memory to absolute amnesia.
If such hypnoid states already exist before the manifested disease they prepare the soil upon which the affect establishes the pathogenic memories and their somatic resulting manifestations. This behavior corresponds to the predisposed hysteria. But the results of our observations show that a severe trauma (like that of a traumatic neurosis) or a painful suppression (perhaps of a sexual affect) may bring about a splitting of presentation groups even in persons otherwise not predisposed. This would then be the mechanism of the psychically acquired hysteria. Between the extremes of these two forms we have to admit a series in which the facility of dissociation in the concerned individuals and the magnitude of the affect of the trauma vary inversely.
We are unable to give anything new concerning the formation of the predisposed hypnoid states. We presume that they often develop from "reveries" very common to the normal for which, for example, the feminine handwork offers so much opportunity. The questions why "the pathological associations" formed in such states are so firm and why they exert a stronger influence on the somatic processes than other presentations, all fall together with the problem of the effectivity of hypnotic suggestions in general. Our experiences in this matter do not show us anything new, on the other hand they throw light on the contradiction between the sentence "Hysteria is a psychosis" and the fact that among hysterics one may meet persons of the clearest intellects, the strongest wills, greatest principles, and of the subtlest minds. In these cases such characteristics are only true for the waking thought of the person, for in his hypnotic state he is alienated just as we are in the dream. Yet, whereas our dream' psychoses do not influence our waking state, the products of hypnotic states project as hysterical phenomena into the waking state.
Almost the same assertions that we have advanced in reference to the continuous hysterical symptoms we may also repeat concerning hysterical crises. As is known we have Charcot's schematic description of the "major" hysterical attack which when complete shows four phases: (1) The epileptoid, (2) the grand movements, (3) the emotional—attitudes passionnelles (hallucinatory phase), and (4) the delirious. By shortening or prolonging the attack and by isolating the individual phases Charcot caused a succession of all those forms of the hysterical attack which are really observed more frequently than the complete grande attaque.
Our attempted explanation refers to the third phase, that is the attitudes passionnelles. Wherever it is prominent it contains the hallucinatory reproduction of a memory which was significant for the hysterical onset. It is the memory of a grand trauma, the so called χατ'εξοχὴν of traumatic hysteria or of a series of connected partial traumas found at the basis of the common hysteria. Finally the attack may bring back that occurrence which on account of its meeting with a moment of special predisposition was raised to a trauma.
There are also attacks which ostensibly consist only of motor phenomena and lack the passionnelle phase. It is possible during such an attack of general twitching, cataleptic rigidity or an attaque de sommeil, to put one's self en rapport with the patient, or still better, if one succeeds in evoking the attack in a hypnotic state, it will then be found that here, too, the root of it is the memory of a psychic trauma, or of a series of traumas which make themselves otherwise prominent in an hallucinatory phase. A little girl had suffered for years from attacks of general convulsions which could be and were taken for epileptic. She was hypnotized for purposes of differential diagnosis and she immediately merged into one of her attacks. On being asked what she saw she said, "The dog, the dog is coming," and it was really found that the first attack of this kind appeared after she was pursued by a mad dog. The success of the therapy then verified our diagnosis.
An official who became hysterical as a result of ill treatment on the part of his employer suffered from attacks, during which he fell to the floor raging furiously without uttering a word or displaying any hallucinations. The attack was provoked in a state of hypnosis and he then stated that he lived through the scene during which his employer insulted him in the street and struck him with a cane. A few days later he came to me complaining that he had the same attack, but this time it was shown in the hypnosis that he went through the scene which was really connected with the onset of his disease; it was the scene in the court room when he was unable to get satisfaction for the ill treatment which he received, etc.
The memories which appear in hysterical attacks or which can be awakened in them correspond in all other respects to the causes which we have found as the basis of the continuous hysterical symptoms. Like these they refer to psychic traumas which were prevented from alleviation by ab-reaction or by associative elaboration, like these they lack entirely or in their essential components the memory possibilities of normal consciousness and appear to belong to the ideation of hypnoid states of consciousness with limited associations. Finally they are also amenable to therapeutic proof. Our observations have often taught us that a memory which has always evoked attacks becomes incapacitated when in a hypnotic state it is brought to reaction and associative correction.
The motor phenomena of the hysterical attack can partly be interpreted as the memory of a general form of reaction of the accompanying affect, or partly as a direct motor expression of this memory (like the fidgeting of the whole body which even infants make use of), and partly, like the hysterical stigmata—the continuous symptoms—they are inexplainable on this assumption.
Of special significance for the hysterical attack is the aforementioned theory, namely, that in hysteria there are presentation groups which come to light in hypnoid states which are excluded from the rest of the associative process but are associable among themselves, thus representing a more or less highly organized rudimentary second consciousness, a condition seconde. A persistent hysterical symptom therefore corresponds to a projection of this second state into a bodily innervation otherwise controlled by the normal consciousness. A hysterical attack gives evidence of a higher organization of this second state, and if of recent origin it signifies a moment in which this hypnoid consciousness gained control of the whole existence, and hence we have an acute hysteria, but if it is a recurrent attack containing a memory we simply have a repetition of the same. Charcot has already given utterance to the fact that the hysterical attack must be the rudiment of a condition seconde. During the attack the control of the whole bodily innervation is transferred to the hypnoid consciousness. As familiar experiences show, the normal consciousness is not always repressed, it may even perceive the motor phenomena of the attack while the psychic processes of the same escape its cognizance.
The typical course of a grave hysteria, as everybody knows, is as follows: At first an ideation is formed in the hypnoid state which after sufficient development gains control in a period of "acute hysteria" of the bodily innervation and the existence of the patient thus forming persistent symptoms and attacks, and then with the exception of some remnants there is a recovery. If the normal personality can regain the upper hand, all that survived the hypnoid ideation then returns in hysterical attacks and at times it reproduces, in the personality, states which are again amenable to influences and capable of being affected by traumas. Frequently a sort of equilibrium then results among the psychic groups which are united in the same person; attack and normal life go hand in hand without influencing each other. The attack then comes spontaneously just as memories are wont to come; it may also be provoked just as memories may be by the laws of association. The provocation of the attack results either through stimulating a hysterogenic zone or through a new experience which by similarity recalls the pathogenic experience. We hope to be able to show that there is no essential difference between the apparently two diverse determinants, and that in both cases the hyperesthetic memory is touched. In other cases there is a great lability of equilibrium, the attack appears as a manifestation of the hypnoid remnant of consciousness as often as the normal person becomes exhausted and incapacitated. We cannot disregard the fact that in such cases the attack becomes denuded of its original significance and may return as a contentless motor reaction.
It remains a task for future investigation to discover what conditions are decisive in determining whether a hysterical individuality should manifest itself in attacks, in persistent symptoms, or in a mingling of both.
We can now understand in what manner the psychotherapeutic method propounded by us exerts its curative effect. It abrogates the efficacy of the original not ab-reacted presentation of affording an outlet to the strangulated affect through speech. It brings it to associative correction by drawing it into normal consciousness (in mild hypnosis) or it is done away with through the physician's suggestion just as happens in somnambulism with amnesia.
We maintain that the therapeutic gain obtained by applying this process is quite significant. To be sure we do not cure the hysterical predisposition as we do not block the way for the recurrence of hypnoid states; moreover, in the productive stage of acute hysteria our procedure is unable to prevent the replacement of the carefully abrogated phenomena by new ones. But when this acute stage has run its course and its remnants continue as persistent hysterical symptoms and attacks, our radical method usually removes them forever, and herein it seems to surpass the efficacy of direct suggestion as practiced at present by psychotherapists.
If by disclosing the psychic mechanisms of hysterical phenomena we have taken a step forward on the path so successfully started by Charcot with his explanation and experimental imitation of hystero-traumatic paralysis, we are well aware that in doing this we have only advanced our knowledge in the mechanisms of hysterical symptoms and not in the subjective causes of hysteria. We have but touched upon the etiology of hysteria and could only throw light on the causes of the acquired forms, the significance of the accidental moments in the neurosis.
- Written in collaboration with Dr. Joseph Breuer.
- The possibility of such a therapy was clearly recognized by Delboeuf and Binet, as is shown by the accompanying quotations: Delboeuf, Le magnétisme animal, Paris, 1889: "On s'expliquerait des lors comment le magnétiseur aide à guerison. Il remet le sujet dans l'état oû le mal s'est manifesté et combat par la parole le même mal, mais renaissant." (Binet, Les altérations de la personnalité, 1892, p. 243): "... peut-être verra-t-on qu'en reportant le malade par un artifice mental, au moment meme ou le symptome a apparu paur la premiere fois, on rend ce malade plus docile a une suggestion curative." In the interesting book of Janet, L'Automatism Psychologique, Paris, 1889, we find the description of a cure brought about in a hysterical girl by a process similar to our method.
- We are unable to distinguish in this preliminary contribution what there is new in this content and what can be found in such other authors as Moebius and Strümpell who present similar views on hysteria. The greatest similarity to our theoretical and therapeutical accomplishments we accidentally found in some published observations of Benedict which we shall discuss hereafter.
- The German abreagiren has no exact English equivalent. It will therefore be rendered throughout the text by "ab-react," the literal meaning is to react away from or to react off. It has different shades of meaning, from defense reaction to emotional catharsis, which can be discerned from the context.