Freud - Complete Works (43 page)

Studies On Hysteria

220

   If, however, this turns into
deceitfulness and actual simulation (and I think that we now err
just as far on the side of denying simulation as we used to on the
side of accepting it), that is based, not on the hysterical
disposition but, as Moebius has so aptly said, on its being
complicated by other forms of degeneracy - by innate, moral
inferiority. In just the same way the ‘malicious
hysteric’ comes into existence when someone who is innately
excitable but poor in emotion is also a victim to the egoistic
stunting of character which is so easily produced by chronic
ill-health. Incidentally, the ‘malicious hysteric’ is
scarcely commoner than the malicious patient in the later stages of
tabes.

   A surplus of excitation also
gives rise to pathological phenomena in the motor sphere. Children
having this characteristic very easily develop
tic
-like
movements. These may be started in the first instance by some
sensation in the eyes or face or by an uncomfortable article of
clothing, but they become permanent unless they are promptly
checked. The reflex paths are very easily and quickly dug in
deep.

   Nor can the possibility be
dismissed of there being purely motor convulsive attacks which are
independent of any psychical factor and in which all that happens
is that the mass of excitation accumulated by summation is
discharged, in just the same way as the mass of stimuli caused by
anatomical modifications is discharged in an epileptic fit. Here we
should have the non-ideogenic hysterical convulsion.

   We so often find adolescents who
had previously been healthy, though excitable, falling ill of
hysteria during pubertal development, that we must ask ourselves
whether that process may not create the disposition to hysteria
where it was not present innately. And in any case we must
attribute more to it than a simple raising of the quantity of
excitation. Sexual maturation impinges on the whole nervous system,
increasing excitability and reducing resistances everywhere. We are
taught this from the observation of adolescents who are not
hysterical and we are thus justified in believing that sexual
maturation also establishes the hysterical disposition in so far as
it consists precisely in this characteristic of the nervous system.
In saying this we are already recognizing sexuality as one of the
major components of hysteria. We shall see that the part it plays
in it is very much greater still and that it contributes in the
most various ways to the constitution of the illness.

   If the stigmata spring directly
from this innate breeding ground of hysteria and are not of
ideogenic origin, it is also impossible to give ideogenesis such a
central position in hysteria as is sometimes done nowadays. What
could be more genuinely hysterical than the stigmata? They are
pathognomonic findings which establish the diagnosis; and yet
precisely they seem not to be ideogenic. But if the basis of
hysteria is an idiosyncracy of the whole nervous system, the
complex of ideogenic, psychically determined symptoms is erected on
it as a building is on its foundations. And it is a building
of
several storeys
. Just as it is only possible to understand the
structure of such a building if we distinguish the plans of the
different floors, it is, I think, necessary in order to understand
hysteria for us to pay attention to the various kinds of
complication in the causation of the symptoms. If we disregard them
and try to carry through an explanation of hysteria by employing a
single causal nexus, we shall always find a very large residue of
unexplained phenomena left over. It is just as though we tried to
insert the different rooms of a many-storeyed house into the plan
of a single storey.

Studies On Hysteria

221

   Like the stigmata, a number of
other nervous symptoms - some pains and vasomotor phenomena and
perhaps purely motor convulsive attacks - are, as we have seen, not
caused by ideas but are direct results of the fundamental
abnormality of the nervous system.

   Closest to them are the ideogenic
phenomena which are simply conversions of affective excitation (
p. 181
). They arise as the consequences of
affects in people with a hysterical disposition and in the first
instance they are only an ‘abnormal expression of the
emotions’ (Oppenheim).¹ This becomes by repetition a
genuine and apparently purely somatic hysterical symptom, while the
idea that gave rise to it becomes unnoticeable (
p. 184
) or is fended off and therefore
repressed from consciousness. The most numerous and important of
the ideas that are fended off and converted have a sexual content.
They are at the bottom of a great deal of the hysteria of puberty.
Girls who are approaching maturity - and it is they who are chiefly
concerned - behave very differently towards the sexual ideas and
feelings which crowd in on them. Some girls meet them with complete
unembarrassment, among whom a few ignore and overlook the whole
subject. Others accept them like boys, and this is no doubt the
rule with peasant and working class girls. Others again, with more
or less perverse curiosity, run after anything sexual that they can
get hold of in talk or books. And lastly there are natures of a
refined organization who, though their sexual excitability is
great, have an equally great moral purity and who feel that
anything sexual is something incompatible with their ethical
standards, something dirtying and smirching.² They repress
sexuality from their consciousness, and the affective ideas with a
content of this kind which have caused the somatic phenomena are
fended off and thus become unconscious.

  
¹
This disposition is nothing else than what
Strümpell speaks of as the ‘disturbance in the
psycho-physical sphere’ which underlies hysteria.

  
²
Some observations lead us to believe that
the fear of touching, or, more properly, the fear of being dirtied,
which compels women to keep on washing their hands all the time,
very often has this derivation. Their washing is derived from the
same mental process as Lady Macbeth’s.

Studies On Hysteria

222

   The tendency towards fending off
what is sexual is further intensified by the fact that in young
unmarried women sensual excitation has an admixture of anxiety, of
fear of what is coming, what is unknown and half-suspected, whereas
in normal and healthy young men it is an unmixed aggressive
instinct. The girl senses in Eros the terrible power which governs
and decides her destiny and she is frightened by it. All the
greater, then, is her inclination to look away and to repress from
her consciousness the thing that frightens her.

   Marriage brings fresh sexual
traumas. It is surprising that the wedding night does not have
pathogenic effects more frequently, since unfortunately what it
involves is so often not an erotic seduction but a violation. But
indeed it is not rare to find in young married women hysterias
which can be traced back to this and which vanish if in the course
of time sexual enjoyment emerges and wipes out the trauma. Sexual
traumas also occur in the later course of many marriages. The case
histories from whose publication we have been obliged to refrain
include a great number of them - perverse demands made by the
husband, unnatural practices, etc. I do not think I am exaggerating
when I assert that
the great majority of severe neuroses in
women have their origin in the marriage bed
.¹

   Certain sexual noxae, which
consist essentially in insufficient satisfaction (
coitus
interruptus, ejaculatio praecox
, etc.), result according to the
discovery of Freud (1895
b
) not in hysteria but in an anxiety
neurosis. I am of opinion, however, that even in such cases the
excitation of the sexual affect is quite frequently converted into
hysterical somatic phenomena.

   It is self-evident and is also
sufficiently proved by our observations that the non-sexual affects
of fright, anxiety and anger lead to the development of hysterical
phenomena. But it is perhaps worth while insisting again and again
that the sexual factor is by far the most important and the most
productive of pathological results. The unsophisticated
observations of our predecessors, the residue of which is preserved
in the term ‘hysteria’, came nearer the truth than the
more recent view which puts sexuality almost last, in order to save
the patients from moral reproaches. The sexual needs of hysterical
patients are no doubt just as variable in degree from individual to
individual as in healthy people and are no stronger than in them;
but the former fall ill from them, and, for the most part,
precisely owing to struggling against them, owing to their
defence
against sexuality.

   Alongside sexual hysteria we must
at this point recall hysteria due to fright - traumatic hysteria
proper - which constitutes one of the best known and recognized
forms of hysteria.

   In what may be called the same
stratum as the phenomena which arise from the conversion of
affective excitation are to be found those which owe their origin
to suggestion (mostly auto-suggestion) in individuals who are
innately suggestible. A high degree of suggestibility - that is to
say, the unrestricted preponderance of ideas that have been freshly
aroused - is not among the essential features of hysteria. It can,
however, be present as a complication in people with a hysterical
disposition, in whom this very idiosyncracy of the nervous system
makes possible the somatic realization of supervalent
[‘Überwertig’] ideas. Moreover, it is for the most
part only
affective
ideas which are realized in somatic
phenomena by suggestion, and consequently the process may often be
regarded as a conversion of the accompanying affect of fright or
anxiety.

   These processes - the conversion
of affect, and suggestion - remain identical even in the
complicated forms of hysteria which we must now consider. They
merely find more favourable conditions in such cases: it is
invariably through one of these two processes that
psychically-determined hysterical phenomena come into being.

  
¹
It is a most unfortunate thing that
clinical medicine ignores one of the most important of all the
pathogenic factors or at least only hints at it delicately. This is
certainly a subject in which the acquired knowledge of experienced
physicians should be communicated to their juniors, who as a rule
blindly overlook sexuality - at all events so far as their patients
are concerned.

Studies On Hysteria

223

   The third constituent of the
hysterical disposition, which appears in some cases in addition to
those that have been already discussed, is the hypnoid state, the
tendency to auto-hypnosis (
p. 192
).
This state favours and facilitates in the greatest degree both
conversion and suggestion; and in this way it erects, as we might
say, on the top of the minor hysterias, the higher storey of major
hysteria. The tendency to auto-hypnosis is a state which is to
begin with only temporary and which alternates with the normal one.
We may attribute to it the same increase of mental influence on the
body that we observe in artificial hypnosis. This influence is all
the more intense and deep-going here in that it is acting upon a
nervous system which even outside hypnosis is abnormally
excitable.¹ We cannot tell how far and in what cases the
tendency to auto-hypnosis is an innate property of the organism. I
have expressed the view above (
pp. 195‑196
) that it develops from
reveries that are charged with affect. But there can be no doubt
that innate disposition plays a part in this as well. If this view
is correct, it will be clear here once again how great an influence
on the development of hysteria is to be ascribed to sexuality. For,
apart from sick-nursing, no psychical factor is so well-calculated
to produce reveries charged with affect as are the longings of a
person in love. And over and above this the sexual orgasm itself,
with its wealth of affect and its restriction of consciousness, is
closely akin to hypnoid states.

   The hypnoid element is most
clearly manifested in hysterical attacks and in those states which
can be described as acute hysteria and which, it seems, play such
an important part in the development of hysteria (
p. 213
). These are obviously psychotic
states which persist for a long time, often for several months and
which it is frequently necessary to describe as hallucinatory
confusion. Even if the disturbance does not go as far as this, a
great variety of hysterical phenomena emerge in it, a few of which
actually persist after it is over. The psychical content of these
states consists partly in precisely the ideas which have been
fended off in waking life and repressed from consciousness. (Cf.
the ‘hysterical deliria in saints and nuns, continent women
and well-brought-up children’.)

  
¹
It is tempting to identify the disposition
to hypnosis with innate abnormal excitability; for artificial
hypnosis, too, exhibits ideogenic changes in secretion and local
blood-supply, formation of vesicles, etc This seems to be the view
held by Moebius. But in my opinion it would involve us in a vicious
circle. The miraculous workings of hypnosis are, so far as I can
see, only observable in hysterical patients. What we should be
doing would be first to assign the phenomena of hysteria to
hypnosis, and then to assert that hypnosis is the cause of those
phenomena.