Freud - Complete Works (44 page)

Studies On Hysteria

224

   Since these states are so often
nothing less than psychoses and are yet derived immediately and
exclusively from hysteria, I cannot agree with Moebius’s
opinion that ‘apart from the deliria attached to attacks, it
is impossible to speak of an actual hysterical insanity’
(1895, 18). In many cases these states constitute an insanity of
this kind; and psychoses like these also recur in the further
course of a hysteria. It is true that essentially they are nothing
other than the psychotic stage of an attack, but since they last
for months they can nevertheless hardly be described as
attacks.

   How does one of these acute
hysterias arise? In the best known case (Case History 1) it
developed out of an accumulation of hypnoid attacks; in another
case (where there was already a complicated hysteria present) it
arose in association with a withdrawal of morphine. The process is
for the most part completely obscure and awaits clarification from
further observations.

   Accordingly, we may apply to the
hysterias which have been discussed here Moebius’s
pronouncement (ibid., 16): ‘The essential change that occurs
in hysteria is that the mental state of the hysterical patient
becomes temporarily or permanently similar to that of a hypnotized
subject.’

   The persistence in the normal
state of the symptoms that have arisen during the hypnoid one
corresponds entirely to our experiences with post-hypnotic
suggestion. But this already implies that complexes of ideas that
are inadmissible to consciousness co-exist with the trains of ideas
that pursue a conscious course, that the splitting of the mind has
taken place (
p. 206
). It seems certain
that this can happen even without a hypnoid state, from the wealth
of thoughts which have been fended off and repressed from
consciousness but not suppressed. In one way or another there comes
into existence a region of mental life - sometimes poor in ideas
and rudimentary, sometimes more or less on a par with waking
thought - our knowledge of which we owe, above all, to Binet and
Janet. The splitting of the mind is the consummation of hysteria. I
have shown above (in Section 5) how it explains the principal
characteristics of the disorder. One part of the patient’s
mind is in the hypnoid state, permanently, but with a varying
degree of vividness in its ideas, and is always prepared whenever
there is a lapse in waking thought to assume control over the whole
person (e. g. in an attack or delirium). This occurs as soon as a
powerful affect interrupts the normal course of ideas, in twilight
states and states of exhaustion. Out of this persisting hypnoid
state unmotivated ideas, alien to normal association, force their
way into consciousness, hallucinations are introduced into the
perceptual system and motor acts are innervated independently of
the conscious will. This hypnoid mind is in the highest degree
susceptible to conversion of affects and to suggestion, and thus
fresh hysterical phenomena appear easily, which without the split
in the mind would only have come about with great difficulty and
under the pressure of repeated affects. The split-off mind is the
devil with which the unsophisticated observation of early
superstitious times believed that these patients were possessed. It
is true that a spirit alien to the patient’s waking
consciousness holds sway in him; but the spirit is not in fact an
alien one, but a part of his own.

Studies On Hysteria

225

   The attempt that has been made
here to make a synthetic construction of hysteria out of what we
know of it to-day is open to the reproach of eclecticism, if such a
reproach can be justified at all. There were so many formulations
of hysteria, from the old ‘reflex theory’ to the
‘dissociation of personality’, which have had to find a
place in it. But it can scarcely be otherwise; for so many
excellent observers and acute minds have concerned themselves with
hysteria. It is unlikely that any of their formulations was without
a portion of the truth. A future exposition of the true state of
affairs will certainly, include them all and will merely combine
all the one-sided views of the subject into a corporate reality.
Eclecticism, therefore, seems to me nothing to be ashamed of.

   But how far we still are to-day
from the possibility of any such complete understanding of
hysteria! With what uncertain strokes have its outlines been drawn
in these pages, with what clumsy hypotheses have the gaping lacunas
been concealed rather than bridged! Only one consideration is to
some extent consoling: that this defect attaches, and must attach,
to all physiological expositions of complicated psychical
processes. We must always say of them what Theseus in
A
Midsummer Night’s Dream
says of tragedy: ‘The best
in this kind are but shadows.’ And even the weakest is not
without value if it honestly and modestly tries to hold on to the
outlines of the shadows which the unknown real objects throw upon
the wall. For then, in spite of everything, the hope is always
justified that there may be some degree of correspondence and
similarity between the real processes and our idea of them.

Studies On Hysteria

226

IV

THE PSYCHOTHERAPY OF HYSTERIA

(FREUD)

Studies On Hysteria

227

IV

THE PSYCHOTHERAPY OF HYSTERIA

(FREUD)

In our ‘Preliminary Communication’
we reported how, in the course of our investigation into the
aetiology of hysterical symptoms, we also came upon a therapeutic
method which seemed to us of practical importance. For ‘we
found, to our great surprise at first, that
each individual
hysterical symptom immediately and permanently disappeared when we
had succeeded in bringing clearly to light the memory of the event
by which it was provoked and in arousing its accompanying affect,
and when the patient had described that event in the greatest
possible detail and had put the affect into words
’. (
p. 9.
)

   We further endeavoured to explain
the way in which our psychotherapeutic method works. ‘
It
brings to an end the operative force of the idea which was not
abreacted in the first instance, by allowing its strangulated
affect to find a way through to speech; and it subjects it to
associative corrected by introducing it into normal consciousness
(under light hypnosis) or by removing it through the
physician’s suggestion, as is done in somnambulism
accompanied by amnesia
.’ (
p. 19.
)

   I will now try to give a
connected account of how far this method carries us, of the
respects in which it achieves more than other methods, of the
technique by which it works and of the difficulties it meets with.
Much of the substance of this is already contained in the case
histories printed in the earlier portion of this book, and I shall
not be able to avoid repeating myself in the account which
follows.

(1)

   For my own part, I too may say
that I can still hold by what is contained in the
‘Preliminary Communication’. None the less I must
confess that during the years which have since passed - in which I
have been unceasingly concerned with the problems touched upon in
it - fresh points of view have forced themselves on my mind. These
have led to what is in part at least a different grouping and
interpretation of the factual material known to me at that time. It
would be unfair if I were to try to lay too much of the
responsibility for this development upon my honoured friend Dr.
Josef Breuer. For this reason the considerations which follow stand
principally under my own name.

Studies On Hysteria

228

   When I attempted to apply to a
comparatively large number of patients Breuer’s method of
treating hysterical symptoms by an investigation and abreaction of
them under hypnosis, I came up against two difficulties, in the
course of dealing with which I was led to an alteration both in my
technique and in my view of the facts. (1) I found that not
everyone could be hypnotized who exhibited undoubted hysterical
symptoms and who, it was highly probable, was governed by the same
psychical mechanism. (2) I was forced to take up a position on the
question of what, after all, essentially characterizes hysteria and
what distinguishes it from other neuroses.

   I will put off until later my
account of how I got over the first of these two difficulties and
what I have learnt from it, and I will begin by describing the
attitude I adopted in my daily practice towards the second problem.
It is very hard to obtain a clear view of a case of neurosis before
one has submitted it to a thorough analysis - an analysis which
can, in fact, only be brought about by the use of Breuer’s
method; but a decision on the diagnosis and the form of therapy to
be adopted has to be made before any such thorough knowledge of the
case has been arrived at. The only course open to me, therefore,
was to select for cathartic treatment such cases as could be
provisionally diagnosed as hysteria, which exhibited one or more of
the stigmata or characteristic symptoms of hysteria. It then
sometimes happened that in spite of the diagnosis of hysteria the
therapeutic results turned out to be very scanty and that even
analysis brought nothing significant to light. On other occasions
again, I tried applying Breuer’s method of treatment to
neuroses which no one could have mistaken for hysteria, and I found
that in that manner they could be influenced and indeed cleared up.
I had this experience, for instance, with obsessional ideas,
genuine obsessional ideas of the Westphal type, in cases without a
single trait which recalled hysteria. Consequently, the psychical
mechanism revealed by the ‘Preliminary
Communication’  could not be pathognomonic for hysteria.
Nor could I resolve, merely for the sake of preserving that
mechanism as a criterion of it, to lump all these other neuroses in
with hysteria. I eventually found a way out of all these emerging
doubts by the plan of treating all the other neuroses in question
in the same way as hysteria. I determined to investigate their
aetiology and the nature of their psychical mechanism in every case
and to let the decision as to whether the diagnosis of hysteria was
justified depend upon the outcome of that investigation.

Studies On Hysteria

229

   Thus, starting out from
Breuer’s method, I found myself engaged in a consideration of
the aetiology and mechanism of the neuroses in general. I was
fortunate enough to arrive at some serviceable findings in a
relatively short time. In the first place I was obliged to
recognize that, in so far as one can speak of determining causes
which lead to the
acquisition
of neuroses, their aetiology
is to be looked for in
sexual
factors. There followed the
discovery that different sexual factors, in the most general sense,
produce different pictures of neurotic disorders. And it then
became possible, in the degree to which this relation was
confirmed, to venture on using aetiology for the purpose of
characterizing the neuroses and of making a sharp distinction
between the clinical pictures of the various neuroses. Where the
aetiological characteristics coincided regularly with the clinical
ones, this was of course justified.

   In this manner I found that
neurasthenia presented a monotonous clinical picture in which, as
my analyses showed, a ‘psychical mechanism’ played no
part. There was a sharp distinction between neurasthenia and
‘obsessional neurosis’, the neurosis of obsessional
ideas proper. In this latter one I was able to recognize a
complicated psychical mechanism, an aetiology similar to that of
hysteria and an extensive possibility of reducing it by
psychotherapy. On the other hand, it seemed to me absolutely
necessary to detach from neurasthenia a complex of neurotic
symptoms which depend on a quite different and indeed at bottom a
contrary
aetiology. The component symptoms of this complex
are united by a characteristic which has already been recognized by
Hecker (1893). For they are either symptoms or equivalents and
rudiments of
manifestations of anxiety
; and for this reason
I have given to this complex which is to be detached from
neurasthenia the name of ‘anxiety neurosis’. I have
maintained that it arises from, an accumulation of physical
tension, which is itself once more of sexual origin. This neurosis,
too, has no psychical mechanism, but it invariably influences
mental life, so that ‘anxious expectation’, phobias,
hyperaesthesia to pains, etc., are among its regular
manifestations. This anxiety neurosis, in my sense of the term, no
doubt coincides in part with the neurosis which, under the name of
‘hypochondria’, finds a place in not a few descriptions
alongside hysteria and neurasthenia. But I cannot regard the
delimitation of hypochondria in any of the works in question as
being the correct one, and the applicability of its name seems to
me to be prejudiced by the fixed connection of that term with the
symptom of ‘fear of illness’.

   After I had in this way fixed the
simple pictures of neurasthenia, anxiety neurosis and obsessional
ideas, I went on to consider the cases of neurosis which are
commonly included under the diagnosis of hysteria. I reflected that
it was not right to stamp a neurosis as a whole as hysterical
because a few hysterical signs were prominent in its complex of
symptoms. I could well understand this practice, since after all
hysteria is the oldest, best-known and most striking of the
neuroses under consideration; but it was an abuse, for it put down
to the account of hysteria so many traits of perversion and
degeneracy. Whenever a hysterical sign, such as an anaesthesia or a
characteristic attack, was found in a complicated case of psychical
degeneracy, the whole condition was described as one of
‘hysteria’, so that it is not surprising that the worst
and the most contradictory things were found together under this
label. But just as it was certain that
this
diagnosis was
incorrect, it was equally certain that we ought also to separate
out the various neuroses; and since we were acquainted with
neurasthenia, anxiety neurosis, etc., in a pure form, there was no
longer any need to overlook them in the combined picture.

Studies On Hysteria

230

   The following view, therefore,
seemed to be the more probable one. The neuroses which commonly
occur are mostly to be described as ‘mixed’.
Neurasthenia and anxiety neuroses are easily found in pure forms as
well, especially in young people. Pure forms of hysteria and
obsessional neurosis are rare; as a rule these two neuroses are
combined with anxiety neurosis. The reason why mixed neuroses occur
so frequently is that their aetiological factors are so often
intermixed, sometimes only by chance, sometimes as a result of
causal relations between the processes from which the aetiological
factors of the neuroses are derived. There is no difficulty in
tracing this out and demonstrating it in detail. As regards
hysteria, however, it follows that that disorder can scarcely be
segregated from the nexus of the sexual neuroses for the purposes
of study, that as a rule it represents only a single side, only one
aspect, of a complicated case of neurosis, and that it is only in
marginal cases that it can be found and treated in isolation. We
may perhaps say in a number of instances:
a potiori fit
denominatio
[i.e. it has been given its name from its more
important feature].

   I will now examine the case
histories that have been reported here, with a view to seeing
whether they speak in favour of my opinion that hysteria is not an
independent clinical entity.

   Breuer’s patient, Anna O.,
seems to contradict my opinion and to be an example of a pure
hysterical disorder. This case, however, which has been so fruitful
for our knowledge of hysteria, was not considered at all by its
observer from the point of view of a sexual neurosis, and is now
quite useless for this purpose. When I began to analyse the second
patient, Frau Emmy von N., the expectation of a sexual neurosis
being the basis of hysteria was fairly remote from my mind. I had
come fresh from the school of Charcot, and I regarded the linking
of hysteria with the topic of sexuality as a sort of insult - just
as the women patients themselves do. When I go through my notes on
this case to-day there seems to me no doubt at all that it must be
looked on as a case of severe anxiety neurosis accompanied by
anxious expectation and phobias - an anxiety neurosis which
originated from sexual abstinence and had become combined with
hysteria. Case 3, that of Miss Lucy R., can perhaps best be
described as a marginal case of pure hysteria. It was a short
hysteria which ran an episodic course and had an unmistakable
sexual aetiology, such as would correspond to an anxiety neurosis.
The patient was an over-mature girl with a need to be loved, whose
affections had been too hastily aroused through a misunderstanding.
The anxiety neurosis, however, did not become visible, or it
escaped me. Case 4, Katharina, was nothing less than a model of
what I have described as ‘virginal anxiety’. It was a
combination of anxiety neurosis and hysteria. The former created
the symptoms, while the latter repeated them and operated with
them. Incidentally, it was a case typical of a large number of
neuroses in young people that are described as
‘hysteria’. Case 5, that of Fräulein Elisabeth von
R., was once again not investigated as a sexual neurosis. I was
only able to express, without confirming it, a suspicion that a
spinal neurasthenia may have been its basis.

   I must add, though, that in the
meantime pure hysterias have become even rarer in my experience. If
it was possible for me to bring together these four cases as
hysterias and if in reporting them I was able to overlook the
points of view that were of importance as regards sexual neuroses,
the reason is that these histories date some distance back, and
that I did not at that time as yet submit such cases to a
deliberate and searching investigation of their neurotic sexual
foundation. And if, instead of these four, I did not report
twelve
cases whose analysis provides a confirmation of the
psychical mechanism of hysterical phenomena put forward by us, this
reticence was necessitated by the very circumstance that the
analysis revealed these cases as being simultaneously sexual
neuroses, although certainly no diagnostician would have refused
them the name of hysteria. But an elucidation of these sexual
neuroses would overstep the bounds of the present joint
publication.

Studies On Hysteria

231