Freud - Complete Works (17 page)

Studies On Hysteria

79

DISCUSSION

   Unless we have first come to a
complete agreement upon the terminology involved, it is not easy to
decide whether a particular case is to be reckoned as a hysteria or
some other neurosis (I am speaking here of neuroses which are not
of a purely neurasthenic type; and we have still to await the
directing hand which shall set up boundary-marks in the region of
the commonly occurring mixed neuroses and which shall bring out the
features essential for their characterization. If, accordingly, we
are still accustomed to diagnosing a hysteria, in the narrower
sense of the term, from its similarity to familiar typical cases,
we shall scarcely be able to dispute the fact that the case of Frau
Emmy von N. was one of hysteria. The mildness of her deliria and
hallucinations (while her other mental activities remained intact),
the change in her personality and store of memories when she was in
a state of artificial somnambulism, the anaesthesia in her painful
leg, certain data revealed in her anamnesis, her ovarian neuralgia,
etc., admit of no doubt as to the hysterical nature of the illness,
or at least of the patient. That the question can be raised at all
is due only to one particular feature of the case, which also
provides an opportunity for a comment that is of general validity.
As we have explained in the ‘Preliminary Communication’
which appears at the beginning of this volume, we regard hysterical
symptoms as the effects and residues of excitations which have
acted upon the nervous system as traumas. Residues of this kind are
not left behind if the original excitation has been discharged by
abreaction or thought-activity. It is impossible any longer at this
point to avoid introducing the idea of quantities (even though not
measurable ones). We must regard the process as though a sum of
excitation impinging on the nervous system is transformed into
chronic symptoms in so far as it has not been employed for external
action in proportion to its amount. Now we are accustomed to find
in hysteria that a considerable part of this ‘sum of
excitation’ of the trauma is transformed into purely somatic
symptoms. It is this characteristic of hysteria which has so long
stood in the way of its being recognized as a psychical
disorder.

   If, for the sake of brevity, we
adopt the term ‘conversion’ to signify the
transformation of psychical excitation into chronic somatic
symptoms, which is so characteristic of hysteria, then we may say
that the case of Frau Emmy von N. exhibited only a small amount of
conversion. The excitation, which was originally psychical,
remained for the most part in the psychical sphere, and it is easy
to see that this gives it a resemblance to the other,
non-hysterical neuroses. There are cases of hysteria in which the
whole surplus of stimulation undergoes conversion, so that the
somatic symptoms of hysteria intrude into what appears to be an
entirely normal consciousness. An incomplete transformation is
however more usual, so that some part at least of the affect that
accompanies the trauma persists in consciousness as a component of
the subject’s state of feeling.

Studies On Hysteria

80

   The psychical symptoms in our
present case of hysteria with very little conversion can be divided
into alterations of mood (anxiety, melancholic depression), phobias
and abulias (inhibitions of will). The two latter classes of
psychical disturbance are regarded by the French school of
psychiatrists as stigmata of neurotic degeneracy, but in our case
they are seen to have been adequately determined by traumatic
experiences. These phobias and abulias were for the most part of
traumatic origin, as I shall show in detail.

   Some of the phobias, it is true,
corresponded to the primary phobias of human beings, and especially
of neuropaths - in particular, for instance, her fear of animals
(snakes and toads, as well as all the vermin of which
Mephistopheles boasted himself master), and of thunderstorms and so
on. But these phobias too were established more firmly by traumatic
events. Thus her fear of toads was strengthened by her experience
in early childhood of having a dead toad thrown at her by one of
her brothers, which led to her first attack of hysterical spasms;
and similarly, her fear of thunderstorms was brought out by the
shock which gave rise to her clacking, and her fear of fogs by her
walk on the Island of Rügen. Nevertheless, in this group the
primary - or, one might say, the instinctive - fear (regarded as a
psychical stigma) plays the preponderant part.

   The other, more specific phobias
were also accounted for by particular events. Her dread of
unexpected and sudden shocks was the consequence of the terrible
impression made on her by seeing her husband, when he seemed to be
in the best of health, succumb to a heart-attack before her eyes.
Her dread of strangers, and of people in general, turned out to be
derived from the time when she was being persecuted by her family
and was inclined to see one of their agents in every stranger and
when it seemed to her likely that strangers knew of the things that
were being spread abroad about her in writing and by word of mouth.
Her fear of asylums and their inmates went back to a whole series
of unhappy events in her family and to stories poured into her
listening ears by a stupid servant-girl. Apart from this, this
phobia was supported on the one hand by the primary and instinctive
horror of insanity felt by healthy people, and on the other hand by
the fear, felt by her no less than by all neurotics, of going mad
herself. Her highly specific fear that someone was standing behind
her was determined by a number of terrifying experiences in her
youth and later life. Since the episode in the hotel, which was
especially distressing to her because of its erotic implications,
her fear of a stranger creeping into her room was greatly
emphasized. Finally, her fear of being buried alive, which she
shared with so many neuropaths, was entirely explained by her
belief that her husband was not dead when his body was carried out
- a belief which gave such moving expression to her inability to
accept the fact that her life with the man she loved had come to a
sudden end. In my opinion, however, all these psychical factors,
though they may account for the
choice
of these phobias,
cannot explain their
persistence
. It is necessary, I think,
to adduce a
neurotic
factor to account for this persistence
- the fact that the patient had been living for years in a state of
sexual abstinence. Such circumstances are among the most frequent
causes of a tendency to anxiety.

Studies On Hysteria

81

   Our patient’s abulias
(inhibitions of will, inability to act) admit even less than the
phobias of being regarded as psychical stigmata due to a general
limitation of capacity. On the contrary, the hypnotic analysis of
the case made it clear that her abulias were determined by a
twofold psychical mechanism which was at bottom a single one. In
the first place an abulia may simply be the consequence of a
phobia. This is so when the phobia is attached to an action of the
subject’s own instead of to an expectation - for instance, in
our present case, the fear of going out or of mixing with people,
as compared with the fear of someone creeping into the room. Here
the inhibition of will is caused by the anxiety attendant upon the
performance of the action. It would be wrong to regard abulias of
this kind as symptoms distinct from the corresponding phobias,
though it must be admitted that such phobias can exist (provided
they are not too severe) without producing abulias. The second
class of abulias depends on the presence of affectively-toned and
unresolved associations which are opposed to linking up with other
associations, and particularly with any that are incompatible with
them. Our patient’s anorexia offers a most brilliant instance
of this kind of abulia. She ate so little because she did not like
the taste, and she could not enjoy the taste because the act of
eating had from the earliest times been connected with memories of
disgust whose sum of affect had never been to any degree
diminished; and it is impossible to eat with disgust and pleasure
at the same time. Her old-established disgust at meal times had
persisted undiminished because she was obliged constantly to
suppress it, instead of getting rid of it by reaction. In her
childhood she had been forced, under threat of punishment, to eat
the cold meal that disgusted her, and in her later years she had
been prevented out of consideration for her brothers from
expressing the affects to which she was exposed during their meals
together.

   At this point I may perhaps refer
to a short paper in which I have tried to give a psychological
explanation of hysterical paralyses (Freud 1893
c
). I there
arrived at a hypothesis that the cause of these paralyses lay in
the inaccessibility to fresh associations of a group of ideas
connected, let us say, with one of the extremities of the body;
this associative inaccessibility depended in turn on the fact that
the idea of the paralysed limb was involved in the recollection of
the trauma - a recollection loaded with affect that had not been
disposed of. I showed from examples from ordinary life that a
cathexis such as this of an idea whose affect is unresolved always
involves a certain amount of associative inaccessibility and of
incompatibility with new cathexes.

Studies On Hysteria

82

   I have not hitherto succeeded in
confirming, by means of hypnotic analysis, this theory about motor
paralyses, but I can adduce Frau von N.’s anorexia as proving
that this mechanism is the operative one in certain abulias, and
abulias are no thing other than a highly specialized - or, to use a
French expression, ‘systematized’ - kind of psychical
paralysis.

   Frau von N.’s psychical
situation can be characterized in all essentials by emphasizing two
points. (1) The distressing affects attaching to her traumatic
experiences had remained unresolved - for instance, her depression,
her pain (about her husband’s death), her resentment (at
being persecuted by his relatives), her disgust (at the compulsory
meals), her fear (about her many frightening experiences), and so
on. (2) Her memory exhibited a lively activity which, sometimes
spontaneously, sometimes in response to a contemporary stimulus
(e.g. the news of the revolution in San Domingo), brought her
traumas with their accompanying affects bit by bit into her
present-day consciousness. My therapeutic procedure was based on
the course of this activity of her memory and endeavoured day by
day to resolve and get rid of whatever that particular day had
brought to the surface, till the accessible stock of her
pathological memories seemed to be exhausted.

   These two psychical
characteristics, which I regard as generally present in hysterical
paroxysms, opened the way to a number of important considerations.
I will, however, put off discussing them till I have given some
attention to the mechanism of the somatic symptoms.

   It is not possible to assign the
same origin to all the somatic symptoms of these patients. On the
contrary, even from this case, which was not rich in them, we find
that the somatic symptoms of a hysteria can arise in a variety of
ways. I will venture, in the first place, to include pains among
somatic symptoms. So far as I can see, one set of Frau von
N.’s pains were certainly determined organically by the
slight mortifications (of a rheumatic kind) in the muscles, tendons
or fascia which cause so much more pain to neurotics than to normal
people. Another set of pains were in all probability
memories
of pains - were mnemic symbols of the times of
agitation and sick-nursing which played such a large part in the
patient’s life. These pains, too, may well have been
originally justified on organic grounds but had since then been
adapted for the purposes of the neurosis. I base these assertions
about Frau von N.’s pains mainly on observations made
elsewhere which I shall report on a later page. On this particular
point little information could be gathered from the patient
herself.

Studies On Hysteria

83

   Some of the striking motor
phenomena exhibited by Frau von N. were simply an expression of the
emotions and could easily be recognized in that light. Thus, the
way in which she stretched her hands in front of her with her
fingers spread out and crooked expressed horror, and similarly her
facial play. This, of course, was a more lively and uninhibited way
of expressing her emotions than was usual with women of her
education and race. Indeed, she herself was restrained, almost
stiff in her expressive movements when she was not in a hysterical
state. Others of her motor symptoms were, according to herself,
directly related to her pains. She played restlessly with her
fingers (1888) or rubbed her hands against one another (1889) so as
to prevent herself from screaming. This reason reminds one forcibly
of one of the principles laid down by Darwin to explain the
expression of the emotions - the principle of the overflow of
excitation, which accounts, for instance, for dogs wagging their
tails. We are all of us accustomed, when we are affected by painful
stimuli, to replace screaming by other sorts of motor innervations.
A person who has made up his mind at the dentist’s to keep
his head and mouth still and not to put his hand in the way, may at
least start drumming with his feet.

   A more complicated method of
conversion is revealed by Frau von N.’s
tic
-like
movements, such as clicking with the tongue and stammering, calling
out the name ‘Emmy’ in confusional states, using the
composite formula ‘Keep still! Don’t say anything!
Don’t touch me!’ (1888). Of these motor manifestations,
the stammering and clacking can be explained in accordance with a
mechanism which I have described, in a short paper on the treatment
of a case by hypnotic suggestion (1892-93), as ‘the putting
into effect of antithetic ideas’. The process, as exemplified
in our present instance, would be as follows. Our hysterical
patient, exhausted by worry and long hours of watching by the
bedside of her sick child which had at last fallen asleep, said to
herself: ‘Now you must be perfectly still so as not to awaken
the child.’ This intention probably gave rise to an
antithetic idea in the form of a fear that she might make a noise
all the same that would wake the child from the sleep which she had
so long hoped for. Similar antithetic ideas arise in us in a marked
manner when we feel uncertain whether we can carry out some
important intention.