Selected Papers on Hysteria and Other Psychoneuroses/Chapter 5
The Defense Neuro-psychoses.
A Tentative Psychological Theory of Acquired Hysteria, Many Phobias and Obsessions, and Certain Hallucinatory Psychoses.
After an exhaustive study of many nervous patients afflicted with phobias and obsessions a tentative explanation of these symptoms urged itself upon me. This helped me afterwards happily to divine the origin of such morbid ideas in new and other cases, and I therefore believe it worthy of reporting and further examination. Simultaneously with this "psychological theory of phobias and obsessions," the examination of these patients resulted in a contribution to the theory of hysteria, or rather in an alteration of the same, which seems to imply an important and common character to hysteria as well as the mentioned neuroses. Furthermore I had the opportunity to look into the psychological mechanism of a form of indubitable psychic disease and found that my attempted observation shows an intelligible connection between these psychoses and the two neuroses mentioned. At the conclusion of this theme I will describe the supporting hypothesis which I have used in all three cases.
I am beginning with that alteration which seems to be necessary for the theory of the hysterical neuroses.
That the symptom-complex of hysteria as far as it can be understood justifies the assumption of a splitting of consciousness with the formation of separate psychic groups, has attained general recognition since P. Janet, J. Breuer, and others have given out their interesting work. Less understood are the opinions concerning the origin of this splitting of consciousness and concerning the role played by this character in the structure of the hysterical neuroses.
According to Janet's theory, the splitting of consciousness is a primary feature of the hysterical alteration. It is due to a congenital weakness of the capacity for psychic synthesis, and to a narrowing of the "field of consciousness" (champ du conscience) which as a psychic stigma proves the degeneration of hysterical individuals.
In contradistinction to Janet's views, which in my opinion admit the most manifold objections, are those advocated by J. Breuer in our joint communication. According to Breuer, the "basis and determination" of hysteria is the occurrence of peculiar dream-like conscious states with a narrowed association capacity, for which he proposes the name "hypnoid states." The splitting of consciousness is secondary and acquired, and originates because the ideas emerging in the hypnoid states are isolated from associative communication with the rest of consciousness.
I can now demonstrate two other extreme forms of hysteria in which it is impossible to show that the splitting of consciousness is primary in the sense of Janet. In the first of these forms I could repeatedly show that the splitting of the content of consciousness was an arbitrary act of the patient, that is, it was initiated through an exertion of the will which motive can be stated. I naturally do not maintain that the patient intended to produce a splitting of his consciousness; the patient's intention was different, but instead of attaining its aim it provoked a splitting of consciousness.
In the third form of hysteria, as we have demonstrated by psychic-analysis of intelligent patients, the splitting of consciousness plays only an insignificant and perhaps really no role. This includes those cases in which there had been no reaction to the traumatic stimulus and which were then adjusted and cured by ab-reaction. They are the pure retention hysterias.
In connection with the phobias and obsessions I have only to deal here with the second form of hysteria which for reasons to be presently explained I will designate as defense hysteria and thus distinguish it from the hypnoid and retention hysterias. Preliminarily I am able to call my cases of defense hysteria "acquired" hysterias for they show neither marked hereditary taints nor any degenerative disfigurements.
In those patients whom I have analyzed there existed psychic health until the moment in which a case of incompatibility occured in their ideation, that is, until there appeared an experience, idea, or feeling which evoked such a painful affect that the person decided to forget it because he did not trust his own ability to remove the resistance between the unbearable ideas and his ego.
Such incompatible ideas originate in the feminine sex on the basis of sexual experiences and feelings. With all desired precision the patients recall their efforts of defense, their intention "to push it away," not to think of it, to repress it. As appropriate examples I can easily cite the following cases from my own experience: A young lady reproached herself because, while nursing her sick father, she thought of a young man who made a slight erotic impression on her; a governess fell in love with her employer and decided to crowd it out of her mind because it was incompatible with her pride, etc.
I am unable to maintain that the exertion of the will, in crowding such thoughts out of one's mind, is a pathological act, nor am I able to state whether and how, the intentional forgetting succeeds in these persons who remain well under the same psychic influences. I only know that in the patients whom I analyzed such "forgetting" was unsuccessful and led to either a hysteria, obsession, or a hallucinatory psychosis. The ability to produce, by the exertion of the will one of these states all of which are connected with the splitting of consciousness, is to be considered as the expression of a pathological disposition, but it need not necessarily be identified with personal or hereditary "degeneration."
Over the road leading from the patient's exertion of the will to the origin of a neurotic symptom I formed a conception which in the current psychological abstractions may be thus expressed: The task assumed by the defensive ego to treat the incompatible idea as "non arrivée" can not be directly accomplished. The memory trace as well as the affect adhering to the idea are here and can not be exterminated. The task can however, be brought to an approximate solution if it is possible to change the strong idea into a weak one and to take away the affect or sum of excitement which adheres to it. The weak idea will then exert almost no claims on the association work; but the separated sum of excitement must be utilized in another direction.
Thus far the processes are the same in hysteria, in phobias and obsessions, but from now on their ways part. The unbearable idea in hysteria is rendered harmless because the sum of excitement is transformed into physical manifestations, a process for which I would like to propose the term conversion.
The conversion may be total or partial, and follows that motor or sensory innervation which is either ultimately or more loosely connected with the traumatic experience. In this way the ego succeeds in freeing itself from opposition but instead it becomes burdened with a memory symbol which remains in consciousness as an unadjusted motor innervation, or as a constantly recurring hallucinatory sensation similar to a parasite. It thus remains fixed until a conversion takes place in the opposite direction. The memory symbol of the repressed idea does not perish, but from now on forms the nucleus for a second psychic group.
I will follow up this view of the psycho-physical processes in hysteria with a few more words. If such a nucleus for an hysterical splitting is once formed in a "traumatic moment" it then increases in other moments which might be designated as "auxiliary traumatic" as soon as a newly formed similar impression succeeds in breaking through the barrier formed by the will and in adding new affects to the weakened idea, and in forcing for a while the associative union of both psychic groups until a new conversion produces defense. The condition thus attained in hysteria in regard to the distribution of the excitement, proves to be unstable in most cases. As shown by the familiar contrast of the attacks and the persistent symptoms, the excitement which was pushed on a false path (in the bodily innervation) now and then returns to the idea from which it was discharged and forces the person to associative elaboration or to adjustment in hysterical attacks. The effect of Breuer's cathartic method consists in the fact that it consciously reconducts the excitement from the physical into the psychic spheres and then forces an adjustment of the contradiction through intellectual work, and a discharge of the excitement through speech.
If the splitting of consciousness in acquired hysteria is due to an act of volition we can explain with surprising simplicity the remarkable fact that hypnosis regularly broadens the narrowed consciousness of hysteria, and causes the split off psychic groups to become accessible. For we know that it is peculiar to all sleep-like states to remove that distribution of excitement which depends on the "will" of the conscious personality.
We accordingly recognize that the characteristic moment of hysteria is not the splitting of consciousness but the ability of conversion and as an important part of the hitherto unknown disposition of hysteria we can mention the psycho-physical adaptation for the transference of a great sum of excitement into bodily innervation.
The adaptation does not in itself exclude psychic health, and leads to hysteria only in event of a psychic incompatibility or accumulation of excitement. With this turn, we—Breuer and I—come near to the familiar definitions of hysteria of Oppenheim and Strumpel  and deviate from Janet, who assigns to the splitting of consciousness too great a role in the characteristics of hysteria. The description here given can lay claim to the fact that it explains the connection between the conversion and the hysterical splitting of consciousness.
In a predisposed person if there is no adaptation for conversion and still for the purpose of defense a separation of the unbearable idea from its affect is undertaken, the affect must then remain in the psychic sphere. The weakened idea remains apart from all association in consciousness, but its freed affect attaches itself to other not in themselves unbearable ideas, which on account of this "false" connection become obsessions. This is in brief the psychological theory of the obsessions and phobias concerning which I have spoken above.
I will now state what parts demanded in this theory can be directly demonstrated and what parts I have supplemented. Besides the end product of the process, the obsession, we can in the first place directly demonstrate the source from which the affect in the false connection originates. In all cases that I have analyzed it was the sexual life that has furnished a painful affect of precisely the same character as the one attached to the obsession. It is not theoretically excluded that this affect could not occasionally originate in other spheres, but I must say that thus far I have found no other origin. Moreover, one can readily understand that it is precisely the sexual life which furnishes the most manifold occasions for the appearance of unbearable ideas.
Moreover, the exertion of the will, the attempt at defence, upon which this theory lays stress is demonstated by the most unequivocal utterances of the patients. At least in a number of cases the patients themselves inform us that the phobia or obsession appeared only after the exertion of the will manifestly gained its point. "Something very disagreeable happened to me once and I have exerted all my power to push it away, not to think of it. When I have finally succeeded I have gotten the other thing instead, which I have not lost since." With these words a patient verified the main points of the theory here developed.
Not all who suffer from obsessions are so clear concerning the origin of the same. As a rule when we call the patient's attention to the original idea of a sexual nature we receive the following answer: "It could not have come from that. Why I have not thought much about it. For a moment I was frightened, then I distracted myself and since then it has not bothered me." In this, so frequent objection, we have the proof that the obsession represents a compensation or substitute for the unbearable sexual idea, and that it has taken its place in consciousness.
Between the patient's exertion of the will which succeeds in repressing the unacceptable sexual idea and the appearance of the obsession, which though in itself of little intensity, is here furnished with inconceivably strong affect, there is a yawning gap which the theory here developed will fill. The separation of the sexual idea from its affect and the connection of the latter with another suitable but not unbearable idea—these are processes which take place unconsciously which we can only presume but not prove by any clinico-psychological analysis. Perhaps it would be more correct to say that these are not really processes of a psychic nature but physical processes of which the psychic result so presents itself that the expressions " separation of the idea from its affect and false connection of the latter," seem actual occurrences.
Besides the cases evincing in turn the sexual unbearable idea and the obsession we find a series of others in which there are simultaneously obsessions and painfully accentuated sexual ideas. It will not do very well to call the latter "sexual obsessions"; they lack the essential character of obsessions in proving themselves fully justified, whereas the painfulness of the ordinary obsession is a problem for the doctor as well as the patient. From the amount of insight that could be obtained in such cases, it seems that we deal here with a continued defense against sexual ideas which are constantly renewed, a work heretofore not accomplished.
As long as the patients are aware of the sexual origin of their obsessions they often conceal them. If they complain they generally express surprise that this affect underlies the symptoms, at being afraid, and at having certain impulses, etc. To the experienced physician, however, the affect appears justified and intelligible; he finds the striking part only in the connection of such an affect with an idea unworthy of it. In other words the affect of the obsession appears to him as one dislocated or transposed, and if he has accepted the observations here laid down he can in a great many cases of obsessions attempt a retranslation into the sexual.
Any idea which either through its character may be combinable with an affect of such quality or which bears a certain relation to the unbearable by virtue of which it seems fit as a substitute for the same, may be used for the secondary connection of the freed affect. Thus, for example, freed anxiety, the sexual origin of which can not be recalled, attaches itself to the common primary phobias of man for animals, thunderstorms, darkness, etc., or to things which are unmistakably in some way associated with the sexual, such as urination, defecation, pollutions and infections.
The advantage gained by the ego in the transposition of the affect for the purpose of defense is considerably less than in the hysterical conversion of psychic excitement into somatic innervation. The affect under which the ego has suffered remains now as ever unchanged and undiminished, but the unbearable idea is suppressed and excluded from memory. The repressed ideas again form the nucleus of a second psychic group which I believe can be accessible without having recourse to hypnotism. That in the phobias and obsessions there appear none of the striking symptoms which in hysteria accompany the formation of an independent psychic group, is due to the fact that in the former case the whole transformation remains in the psychic sphere and the somatic innervation experiences no change.
What I have here said concerning obsessions I will explain by some examples which are probably of a typical nature:
1. A young girl suffers from obsessive reproaches. If she reads anything in the journal about false coiners she conceives the thought that she too, made counterfeit money; if a murder was anywhere committed by an unknown assassin she anxiously asked herself Whether she had not committed this crime. At the same time she is perfectly aware of the absurdity of these obsessive reproaches. For a time the consciousness of her guilt gained such a power over her that her judgment was suppressed, and she accused herself before her relatives and physician of having really committed all these crimes (Psychosis through simple aggravation—overwhelming psychosis—Überwältigungspsychose). A thorough examination revealed the source of the origin of this guilty conscience. Accidentally incited by a sensual feeling she allowed herself to be allured by a friend to masturbate. She practiced it for years with the full consciousness of her wrong doing, and under the most violent but useless self-reproaches.—The girl was cured after a few months' treatment and strict watching.
2. Another girl suffered from the fear of getting sudden desires of micturition and of being forced to wet herself. This began after such a desire had really forced her to leave a concert hall during the performance. This phobia had gradually caused her to become quite incapable of any enjoyment and social relationship. She felt secure only when she knew that there was a toilet in the neighborhood to which she could repair unobserved. An organic suffering which might have justified this lack of confidence of the control of the bladder was excluded. At home among quiet surroundings and during the night there was no such desire to micturate. Detailed examination showed that the desire to micturate appeared for the first time under the following conditions: A gentleman to whom she was not indifferent took a seat in the concert hall not far from her. She began to think and to picture to herself how she would sit near him as his wife. In this erotic, revery she experienced that physical feeling which must be compared to erection in the man, and which in her—I do not know whether it is general—ended in a slight desire to micturate. She now became extremely frightened over her otherwise accustomed sexual sensation because she had determined to overcome this as well as every desire, and in the next moment the affect transposed itself to the accompanying desire to micturate and forced her to leave the hall after a very painful struggle. In her life she was so prudish that she experienced an intensive horror for all things sexual, and could not conceive the thought of ever marrying; on the other hand she was sexually so hyperesthetic that during every erotic revery, which she gladly allowed herself, there appeared sensual feeling. The erection was always accompanied by the desire to micturate, and up to the time of the scene in the concert hall it had made no impression on her. The treatment led to an almost complete control of the phobia.
3. A young woman who had only one child after five years of married life complained of obsessive impulses to throw herself from the window or balcony, and of fears lest at the sight of a sharp knife she might kill her child. She admitted that the marriage relations were seldom practised and then only with caution against conception ; but she added that she did not miss this as she was not of a sensual nature. I then ventured to tell her that at the sight of a man she conceives erotic ideas, and that she therefore lost confidence in herself and imagined herself a depraved person fit for anything. The retranslation of the obsession into the sexual was successful; weeping, she soon admitted her long concealed marital misery, and then mentioned painful ideas of an unchanged sexual character such as the often recurring sensation of something forcing itself under her skirts.
I have made use of such experiences in the therapy of phobias and obsessions, and despite the patient's resistances I have redirected the attention to the repressed sexual ideas, and wherever feasible I have blocked the sources from which the same originated. To be sure I cannot maintain that all phobias and obsessions originate in the manner here revealed; first, my experience, in proportion to the abundance of these neuroses, embraces only a limited amount, and second, I, myself, know that these "psychasthenic" symptoms (according to Janet's designation) are not all of the same value. Thus, for instance, there are pure hysterical phobias. But I believe that the mechanism of the transposition of the affect will be demonstrated in the greater part of the phobias and obsessions, and I must assert that these neuroses, which are found just as often isolated as combined with hysteria and neurasthenia, are not to be thrown together with the ordinary neurasthenia for which fundamental symptom a psychic mechanism is not all to be assumed.
In both cases thus far considered the defense of the unbearable idea was brought about by the separation of the same from its affect; the idea though weakened and isolated remained in consciousness. There exists, however, a far more energetic and more successful form of defense wherein the ego misplaces the unbearable idea with its affect, and behaves as though the unbearable idea had never approached the ego. But at the moment when this is brought about the person suffers from a psychosis which can only be classified as an "hallucinatory confusion." A single example will explain this assertion, A young girl gives her first impulsive love to a man who she firmly believed reciprocated her love. As a matter of fact she was mistaken; the young man had other motives for visiting her. It was not long before she was disappointed ; at first she defended herself against it by converting hysterically the corresponding experience, and thus came to believe that he would come some day to ask her in marriage; but in consequence of the imperfect conversion and the constant pressure of new painful impressions, she felt unhappy and ill. She finally expects him with the greatest tension on a definite day, it is the day of a family reunion. The day passes but he does not come. After all the trains on which he could have come have passed she suddenly merged into an hallucinatory confusion. She thought that he did come, she heard his voice in the garden, and hastened down in her night gown to receive him. For two months after she lived in a happy dream, the content of which was that he was there, that he was always with her, and that everything was as before (before the time of the painfully defended disappointment). The hysteria and depression were thus conquered; during her sickness she never mentioned anything about the last period of doubt and suffering; she was happy as long as she was left undisturbed, and frenzied only when a regulation of her environment prevented her from accomplishing something which she thought quite natural as a result of her blissful dream. This psychosis, unintelligible as it was in its time, was revealed ten years later through hypnotic analysis.
The fact to which I call attention is this: That the content of such an hallucinatory psychosis consists in directly bringing into prominence that idea which was threatened by the motive of the disease. One is therefore justified in saying that through its flight into the psychosis the ego defended the unbearable idea; the process through which this has been brought about withdraws itself from self perception as well as from the psychological-clinical analysis. It is to be considered as the expression of a higher grade of pathological disposition, and can perhaps be explained as follows: The ego tears itself away from the unbearable idea, but as it hangs inseparably together with a part of reality, the ego while accomplishing this performance also detaches itself wholly or partially from reality. The latter is, in my opinion the condition under which hallucinatory vividness is decreed to particular ideas, and hence after very successful defense the person finds himself in a hallucinatory confusion.
I have but very few analyses of such psychoses at my disposal; but I believe that we deal with a very frequently employed type of psychic illness. For analogous examples such as the mother who becoming sick after the loss of her child continues to rock in her arms a piece of wood, or the jilted bride who in full dress expects her bridegroom, can be seen in every insane asylum. It will perhaps not be superfluous to mention that the three forms of defense here considered, and hence the three forms of disease to which this defense leads may be united in the same person. The simultaneous occurrence of phobias and hysterical symptom«, so frequently observed in praxis, really belongs to those moments which impede a pure separation of hysteria from other neuroses and urge the formation of the "mixed neuroses." To be sure the hallucinatory confusion is not frequently compatible with the continuation of hysteria and not as a rule with obsessions; but on the other hand it is not rare that a defense psychosis should episodically break through the course of a hysteria or mixed neurosis.
In conclusion I will mention in few words the subsidiary idea of which I have made use in this discussion of the defense neuroses. It is the idea that there is something to distinguish in all psychic functions (amount of affect, sum of excitement), that all qualities have a quantity though we have no means to measure the same—it is something that can be increased, diminished, displaced, and discharged, and that extends over the memory traces of the ideas perhaps like an electric charge over the surface of the body.
This hypothesis, which also underlies our theory of "ab-reaction" ("Preliminary Communication"), can be used in the same sense as the physicist uses the assumption of the current of electric fluid. It is preliminarily justified through its usefulness in the comprehension and elucidation of diverse psychic states.
- État mental des hystériques, Paris, 1893 and 1894. Quelques définitions récentes de I'hystérie, Arch, de Neurol., 1893, XXXV-VI.
- Oppenheim: Hysteria is an exaggerated expression of emotion. But the "expression of emotion" represents that amount of psychic excitement which normally experiences conversion.
- Strümpel : The disturbance of hysteria lies in the psycho-physical, there where the physical and psychical are connected with each other.
- Janet, in the second chapter of his spirited essay "Quelques definitions," etc., has treated the objection that the splitting of consciousness belongs also to the psychoses and the so called psychaesthenia, but in my opinion he has not satisfactorily solved it. It is essentially this objection which urged him to call hysteria a form of degeneration. But through no characteristic is he able to separate sufficiently the hysterical splitting of consciousness from the psychopathic, etc.
- The group of typical phobias, for which agoraphobia is a prototype, cannot be reduced to the psychic mechanisms here developed. Furthermore the mechanism of agoraphobia deviates in one decisive point from that of the real obsessions and from phobias based on such. Here there is no repressed idea from which the affect of fear has been separated. The fear of this phobia has another origin.