Freud - Complete Works (37 page)

   This is due to the operation of
simultaneity, which, indeed, governs our normal associations. Every
sense-perception calls back into consciousness any other
sense-perception that appeared originally at the same time. (Cf.
the text-book example of the visual image of a sheep and the sound
of its bleating, etc.) If the original affect was accompanied by a
vivid sense-impression, the latter is called up once more when the
affect is repeated; and since it is a question of discharging
excessively great excitation, the sense-impression emerges, not as
a recollection, but as a hallucination. Almost all our case
histories provide instances of this. It is also what happened in
the case of a woman who experienced a painful affect at a time when
she was having violent toothache due to periostitis, and who
thenceforward suffered from infra-orbital neuralgia whenever the
affect was renewed or even recollected.

Studies On Hysteria

187

   What we have here is the
facilitation of abnormal reflexes according to the general laws of
association. But sometimes (though, it must be admitted, only in
higher degrees of hysteria) true sequences of associated ideas lie
between the affect and its reflex. Here we have
determination
through symbolism
. What unites the affect and its reflex is
often some ridiculous play upon words or associations by sound, but
this only happens in dream-like states when the critical powers are
low and lies outside the group of phenomena with which we are here
dealing.

   In a large number of cases the
path taken by the train of determination remains unintelligible to
us, because we often have a very incomplete insight into the
patient’s mental state and an imperfect knowledge of the
ideas which were active at the time of the origin of the hysterical
phenomenon. But we may assume that the process is not entirely
unlike what we can observe clearly in more favourable cases.

   The experiences which released
the original affect, the excitation of which was then converted
into a somatic phenomenon, are described by us as
psychical
traumas
, and the pathological manifestation arising in this
way, as
hysterical symptoms of traumatic origin
. (The term
‘traumatic hysteria’ has already been applied to
phenomena which, as being consequences of physical injuries-traumas
in the narrowest sense of the word - form part of the class of
‘traumatic neuroses’.)

   The genesis of hysterical
phenomena that are determined by traumas finds a perfect analogy in
the hysterical conversion of the psychical excitation which
originates, not from external stimuli nor from the inhibition of
normal psychical reflexes, but from the inhibition of the course of
association. The simplest example and model of this is afforded by
the excitation which arises when we cannot recollect a name or
cannot solve a riddle, and so on. If someone tells us the name or
gives us the answer to the riddle, the chain of associations is
ended, and the excitation vanishes, just as it does on the ending
of a reflex chain. The strength of the excitation caused by the
blocking of a line of associations is in direct ratio to the
interest which we take in them - that is, to the degree to which
they set our will in motion. Since, however, the search for a
solution of the problem, or whatever it may be, always involves a
large amount of work, though it may be to no purpose, even a
powerful excitation finds employment and does not press for
discharge, and consequently never becomes pathogenic.

Studies On Hysteria

188

   It does, however, become
pathogenic if the course of associations is inhibited owing to
ideas of equal importance being irreconcilable - if, for instance,
fresh thoughts come into conflict with old-established ideational
complexes. Such are the torments of religious doubt to which many
people succumb and many more succumbed in the past. Even in such
cases, however, the excitation and the accompanying psychical pain
(the feeling of unpleasure) only reach any considerable height if
some volitional interest of the subject’s comes into play -
if, for instance, a doubter feels himself threatened in the matter
of his happiness or his salvation. Such a factor is always present,
however, when the conflict is one between firmly-rooted complexes
of moral ideas in which one has been brought up and the
recollection of actions or merely thoughts of one’s own,
which are irreconcilable with them; when, in other words, one feels
the pangs of conscience. The volitional interest in being pleased
with one’s own personality and satisfied with it comes into
operation here and increases to the highest degree the excitation
due to the inhibition of associations. It is a matter of everyday
experience that a conflict like this between irreconcilable ideas
has a pathogenic effect. What are mostly in question are ideas and
processes connected with sexual life: masturbation in an adolescent
with moral sensibilities; or, in a strictly conscientious married
woman, becoming aware of an attraction to a man who is not her
husband. Indeed, the first emergence of sexual feelings and ideas
is very often in itself enough to bring about an intense state of
excitation, owing to its conflicting with a deeply-rooted idea of
moral purity.¹

   A state of excitation of this
kind is usually followed by psychical consequences, such as
pathological depression and anxiety-states (Freud). Sometimes,
however, concurrent circumstances bring about an abnormal somatic
phenomenon in which the excitation is discharged. Thus there may be
vomiting where the feeling of uncleanness produces a physical
feeling of nausea, or a
tussis nervosa
, as in Anna O. (Case
History 1), when moral anxiety provokes a spasm of the glottis, and
so on.²

  
¹
Cf. on this point some interesting
observations and comments by Benedikt.

  
²
Compare a passage in Mach’s
‘Bewegungsempfindungen’ which deserves to be
recalled in this connection: ‘It has often been found during
the experiments (on giddiness) which I have described, that in
general a feeling of nausea set in if it was difficult to bring the
sensations of movement into harmony with the optical impressions.
It appeared as though a part of the stimulus proceeding from the
labyrinth had been compelled to leave the optic tracts, which were
closed to it on account of another stimulus, and to enter upon
quite other tracts . . . I have also repeatedly
observed a feeling of nausea in making an attempt to combine
stereoscopic images which are widely separated.’

  
Here we have nothing less than the physiological pattern for the
generation of pathological, hysterical phenomena as a result of the
co-existence of vivid ideas which are irreconcilable with one
another.

Studies On Hysteria

189

   There is a normal, appropriate
reaction to excitation caused by very vivid and irreconcilable
ideas - namely, to communicate them by speech. An amusingly
exaggerated picture of the urge to do this is given in the story of
Midas’s barber, who spoke his secret aloud to the reeds. We
meet the same urge as one of the basic factors of a major
historical institution - the Roman Catholic confessional. Telling
things is a relief; it discharges tension even when the person to
whom they are told is not a priest and even when no absolution
follows. If the excitation is denied this outlet it is sometimes
converted into a somatic phenomenon, just as is the excitation
belonging to traumatic affects. The whole group of hysterical
phenomena that originate in this way may be described, with Freud,
as
hysterical phenomena of retention
.

   The account that we have hitherto
given of the mechanism by which hysterical phenomena originate is
open to the criticism that it is too schematic and simplifies the
facts. In order that a healthy person who is not initially
neuropathic may develop a genuine hysterical symptom, with its
apparent independence of the mind and with a somatic existence in
its own right, there must always be a number of concurrent
circumstances.

   The following case will serve as
an example of the complicated nature of the process. A
twelve-year-old boy, who had previously suffered from
pavor
nocturnis
and whose father was highly neurotic, came home from
school one day feeling unwell. He complained of difficulty in
swallowing and headache. The family doctor assumed that the cause
was a sore throat. But the condition did not improve even after
several days. The boy refused food and vomited when it was pressed
on him. He moved about listlessly, without energy or enjoyment; he
wanted to lie in bed all the time and was very much run down
physically. When I saw him five weeks later, he gave the impression
of being a shy and shut-in child, and I became convinced that his
condition had a psychical basis. On being questioned closely, he
brought up a trivial explanation - a severe reproof given by his
father - which had clearly not been the real cause of his illness.
Nor could anything be learnt from his school. I promised that I
would extract the information later under hypnosis. This, however,
turned out to be unnecessary. In response to strong appeals from
his clever and energetic mother, he burst into tears and told the
following story. While he was on his way home from school he had
gone into a urinal, and a man had held out his penis to him and
asked him to take it into his mouth. He had run away in terror, and
nothing else had happened to him. But he was ill from that instant.
As soon as he had made his confession he recovered completely. - In
order to produce the anorexia, the difficulty in swallowing and the
vomiting, several factors were required: the boy’s innate
neurotic nature, his severe fright, the irruption of sexuality in
its crudest form into his childish temperament and, as the
specifically determining factor, the idea of disgust. The illness
owed its persistence to the boy’s silence, which prevented
the excitation from finding its normal outlet.

   In all other cases, as in this
one, there must be a convergence of several factors before a
hysterical symptom can be generated in anyone who has hitherto been
normal. Such symptoms are invariably ‘overdetermined’,
to use Freud’s expression.

   It may be assumed that an
overdetermination of this sort is also present when the same affect
has been called out by a series of several provoking causes. The
patient and those about him attribute the hysterical symptom only
to the last cause, though that cause has as a rule merely brought
to light something that had already been almost accomplished by
other traumas.

Studies On Hysteria

190

   A girl of seventeen ¹ had
her first hysterical attack (which was followed by a number of
others) when a cat jumped on her shoulder in the dark. The attack
seemed simply to be the result of fright. Closer investigation
showed, however, that the girl, who was particularly good-looking
and was not properly looked after, had recently had a number of
more or less brutal attempts made on her, and had herself been
sexually excited by them. (Here we have the factor of disposition.)
A few days before, a young man had attacked her on the same dark
staircase and she had escaped from him with difficulty. This was
the actual psychical trauma, which the cat did no more than make
manifest. But it is to be feared that in many such cases the cat is
regarded as the
causa efficiens
.

   In order for the repetition of an
affect to bring about a conversion in this way, it is not always
necessary that there should be a number of
external
provoking causes; the renewal of the affect in
memory
is
often also enough, if the recollection is repeated rapidly and
frequently, immediately after the trauma and before its affect has
become weakened. This is enough if the affect was a very powerful
one. Such is the case in traumatic hysteria, in the narrower sense
of the word. During the days following a railway accident, for
instance, the subject will live through his frightful experiences
again both in sleeping and waking, and always with the renewed
affect of fright, till at last, after this period of
‘psychical working-out [
élaboration
]’ (in
Charcot’s phrase ) or of ‘incubation’, conversion
into a somatic phenomenon takes place. (Though there is another
factor concerned which we shall have to discuss later.)

   As a rule, however, an affective
idea is promptly subjected to ‘wearing away’, to all
the influences touched on in our ‘Preliminary
Communication’, which deprive it little by little of its
quota of affect. Its revival causes an ever-diminishing amount of
excitation, and the recollection thus loses the capacity to
contribute to the production of a somatic phenomenon. The
facilitation of the abnormal reflex disappears and the
status
quo ante
is thereupon re-established.

  
¹
I have to thank Herr Assistent Dr. Paul
Karplus for this case.

Studies On Hysteria

191

   The ‘wearing-away’
influences, however, are all of them effects of association, of
thinking, of corrections by reference to other ideas. This process
of correction becomes impossible if the affective idea is withdrawn
from ‘associative contact’. When this happens the idea
retains its whole quota of affect. Since at every renewal the whole
sum of excitation of the original affect is liberated once more,
the facilitation of the abnormal reflex that was started at the
time is finally completed; or, if the facilitation was already
complete, it is maintained and stabilized. The phenomenon of
hysterical conversion is in this way permanently established.