Freud - Complete Works (65 page)
I do not share this view of the
role of heredity; and since in my short paper on anxiety neurosis
it is precisely to this theme that I have paid least attention, I
will now try to make good some of what I have omitted in it and to
remove the impression that in writing my paper I had not attended
to all the relevant problems.
A Reply To Criticisms Of My Paper On Anxiety Neurosis
363
I think we can arrive at a
picture of the probably very complicated aetiological situation
which prevails in the pathology of the neuroses if we postulate the
following concepts:
(
a
)
Precondition
,
(
b
)
Specific Cause
, (
c
)
Concurrent
Causes
, and, as a term which is not equivalent to the foregoing
ones, (
d
)
Precipitating or Releasing Cause
.
In order to meet every
possibility, let us assume that the aetiological factors we are
concerned with are capable of a quantitative change - that is of
increase or decrease.
If we accept the idea of an
aetiological equation of several terms which must be satisfied if
the effect is to take place, then we may characterize as the
precipitating
or releasing cause the one which makes its
appearance last in the equation, so that it immediately precedes
the emergence of the effect. It is this chronological factor alone
which constitutes the essential nature of a precipitating cause.
Any of the other causes, too, can in a particular case play the
role of precipitating cause; and this role can change within the
same aetiological combination.
The factors which may be
described as
preconditions
are those in whose absence the
effect would never come about, but which are incapable of producing
the effect by themselves alone, no matter in what amount they may
be present. For the specific cause is still lacking.
The
specific cause
is the
one which is never missing in any case in which the effect takes
place, and which moreover suffices, if present in the required
quantity or intensity, to achieve the effect, provided only that
the preconditions are also fulfilled.
As
concurrent causes
we
may regard such factors as are not necessarily present every time,
nor able, whatever their amount, to produce the effect by
themselves alone, but which operate alongside of the preconditions
and the specific cause in satisfying the aetiological equation.
The distinctive character of the
concurrent, or auxiliary, causes seems clear; but how do we
distinguish between a precondition and a specific cause, since both
are indispensable and yet neither suffices alone to act as a
cause?
The following considerations seem
to allow us to arrive at a decision. Among the ‘
necessary
causes
' we find several which reappear in the aetiological
equations concerned in many other effects and thus exhibit no
special relationship to any one particular effect. One of these
causes, however, stands out in contrast to the rest from the fact
that it is found in no other aetiological equation, or in very few;
and this one has a right to be called the
specific
cause of
the effect concerned. Furthermore, preconditions and specific
causes are especially distinct from each other in those cases in
which the preconditions have the characteristic of being
long-standing states that are little susceptible to alteration,
while the specific cause is a factor which has recently come into
play.
A Reply To Criticisms Of My Paper On Anxiety Neurosis
364
I will try to give an example of
this complete aetiological schematic picture:
Effect
: Phthisis
pulmonum.
Precondition
: Disposition,
for the most part laid down through heredity, by the organic
constitution.
Specific Cause
: Bacillus
Kochii.
Auxilliary Causes
:
Anything that diminishes the powers - emotions as well as
suppurations or colds.
The schematic picture for the
aetiology of anxiety neurosis seems to me to be on the same
lines:
Precondition
:
Heredity.
Specific Cause
: A sexual
factor, in the sense of a deflection of sexual tension away from
the psychical field.
Auxiliary Causes
: Any
stock noxae - emotion, fright, and also physical exhaustion through
illness or over-exertion.
If I consider this aetiological
formula for anxiety neurosis in detail, I am able to add the
following remarks. Whether a special personal constitution (which
need not be produced by heredity) is absolutely necessary for the
production of an anxiety neurosis, or whether any normal person can
be made to have an anxiety neurosis by some given quantitative
increase of the specific factor - this I am not able to decide with
certainty; but I incline strongly to the latter view. -Hereditary
disposition is the most important precondition for anxiety
neurosis; but it is not an
indispensable
one, since it is
absent in a class of borderline cases. -The presence of the
specific sexual factor can, in the majority of cases, be
demonstrated with certainty. In one series of cases (congenital
ones) this factor is not separated from the precondition of
heredity, but is fulfilled with the help of it. That is to say, in
some patients this peculiarity of the
vita sexualis
-
psychical inadequacy in mastering somatic sexual tension - is
innate in the form of a stigma whereas ordinarily it is
via
that peculiarity that they acquire the neurosis. In another class
of borderline cases the specific cause is contained in a
contributory one. This is when the psychical inadequacy which I
have just mentioned is brought about by exhaustion and such causes.
All these cases fall into classes which melt into one another and
do not form separate categories. In all of them, moreover, we find
that the sexual tension undergoes the same vicissitudes; and for
most of them the distinction between precondition, specific and
auxiliary cause holds good, in conformity with the solution of the
aetiological equation which I have given above.
A Reply To Criticisms Of My Paper On Anxiety Neurosis
365
When I consult my experience on
this point, I cannot find that there is any antithetic relation as
regards anxiety neurosis between hereditary disposition and the
specific sexual factor. On the contrary, the two aetiological
factors support and supplement each other. The sexual factor is
usually only operative in those who have an innate hereditary taint
as well; heredity alone is usually not able to produce an
anxiety neurosis, but waits for the occurrence of a sufficient
amount of the specific sexual noxa. The discovery of the hereditary
element does not, therefore, exempt us from searching for a
specific factor. On its discovery, incidentally, all our
therapeutic interest as well depends. For what can we do
therapeutically about heredity as an aetiological element? It
has always been there in the patient and will continue to be there
until the end of his life. Taken by itself, it cannot help us to
understand the episodic onset of a neurosis or the cessation of a
neurosis as a result of treatment. It is nothing but a
precondition
of the neurosis - an inexpressibly important
precondition, it is true, but nevertheless one which has been
over-estimated, to the detriment of therapy and theoretical
comprehension. To be convinced by the contrasting state of affairs,
one has only to think of the cases of nervous diseases that run in
families (such as chorea chronica, Thomsen’s disease, and so
on), in which heredity unites in itself all the aetiological
preconditions.
In conclusion, I should like to
repeat the few statements in which I am accustomed, as a first
approximation to the truth, to express the mutual relationships
between the various aetiological factors:
(1) Whether a neurotic illness
occurs at all
depends upon a quantitative factor - upon the
total load on the nervous system as compared with the
latter’s capacity for resistance. Everything which can keep
this quantitative factor below a certain threshold-value, or can
bring it back to that level, has a therapeutic effect, since by so
doing it keeps the aetiological equation unsatisfied.
What is to be understood by the
‘total load’ and by the ‘capacity for
resistance’ of the nervous system, could no doubt be more
clearly explained on the basis of certain hypotheses regarding the
function of the nerves.
(2) What
dimensions
the neurosis attains depends in the first instance on the amount of
the hereditary taint. Heredity acts like a multiplier introduced
into an electric circuit, which increases the deviation of the
needle many times over.
(3) But what
form
the
neurosis assumes - what direction the deviation takes - is solely
determined by the specific aetiological factor arising from sexual
life.
Although I am aware of the many
still unsolved difficulties of the subject, I hope that, on the
whole, my hypothesis of an anxiety neurosis will prove more
fruitful for an understanding of the neuroses than
Löwenfeld’s attempt to account for the same facts by
postulating ‘
a combination of neurasthenic and hysterical
symptoms in the form of an attack
.’
VIENNA
,
beginning of May
1895.
366
HEREDITY AND THE AETIOLOGY OF THE NEUROSES
(1896)
367
Intentionally left blank
368
HEREDITY AND THE AETIOLOGY OF THE NEUROSES
I am addressing in particular the disciples of
J.-M. Charcot, in order to put forward some objections to the
aetiological theory of the neuroses which was handed on to us by
our teacher.
The role attributed in that
theory to nervous heredity is well known: it is the sole true and
indispensable cause of neurotic affections, and the other
aetiological influences can aspire only to the name of
agents
provocateurs
. Such was the opinion laid down by the great man
himself and by his pupils, M M. Guinon, Gilles de la Tourette,
Janet and others, in regard to the major neurosis, hysteria; and I
believe the same view is held in France and in most other places in
regard to the other neuroses, though, where these states analogous
to hysteria are concerned, it has not been promulgated in so solemn
and decided a manner.
I have long entertained doubts on
this subject, but I have had to wait to find corroborative facts in
my daily experience as a doctor. My objections are now of a double
order: factual arguments and arguments derived from speculation. I
will begin with the former, arranging them according to the
importance I ascribe to them.
I
(
a
) Affections which
are fairly often remote from the domain of neuropathology, and
which do not necessarily depend on a disease of the nervous system,
have sometimes been regarded as nervous and as showing the presence
of a hereditary neuropathic tendency. This has been so with true
facial neuralgias and with many headaches which were thought to be
nervous but which arose rather from post-infectious pathological
changes and suppuration in the pharyngo-nasal cavities. I feel
convinced that the patients would benefit if we were more often to
hand over the treatment of these affections to the rhinological
surgeons.
Heredity And The Aetiology Of The Neuroses
369
(
b
) All the nervous
affections found in a patient’s family, without consideration
of their frequence or severity, have been accepted as a basis for
charging him with a hereditary nervous taint. Does not this way of
looking at things imply drawing a sharp line between families which
are clear of all nervous predisposition and families which are
subject to them to an unlimited extent? And do not the facts argue
in favour of the contrary view that there are transitions and
degrees in nervous disposition and that no family escapes it
altogether?
(
c
) Our opinion of the
aetiological role of heredity in nervous illnesses ought decidedly
to be based on an impartial statistical examination and not on a
petitio principi
. Until such an examination has been made we
ought to believe that the existence of acquired nervous disorders
is just as possible as that of hereditary ones. But if there can be
nervous disorders that are acquired by people without a
predisposition, it can no longer be denied that the nervous
affections met with in our patient’s relatives may partly
have arisen in that way. It will then no longer be possible to
quote them as conclusive evidence of the hereditary disposition
imputed to the patient by reason of his family history, for a
retrospective diagnosis of the illnesses of ancestors or absent
members of a family can only very rarely be successfully made.
(
d
) Those who are
adherents of M. Fournier and M. Erb in the matter of the part
played by syphilis in the aetiology of tabes dorsalis and
progressive paralysis have learned that powerful aetiological
influences must be recognized whose collaboration is indispensable
for the pathogenesis of certain illnesses which could not be
produced by heredity alone. Nevertheless M. Charcot remained to the
very last (as I know from a private letter I had from him) strictly
opposed to Fournier’s theory, which is, however, gaining
ground every day.
(
e
) There is no doubt that
certain nervous disorders can develop in people who are perfectly
healthy and whose family is above reproach. This is a matter of
daily observation in cases of Beard’s neurasthenia; if
neurasthenia were restricted to people who were predisposed, it
would never have attained the importance and extent with which we
are familiar.
Heredity And The Aetiology Of The Neuroses
370
(
f
) In nervous pathology
there is
similar heredity
and what is known as
dissimilar
heredity
. No objection can be made to the former; it is in fact
a very remarkable thing that in the disorders which depend on
similar heredity (Thomsen’s disease, Friedreich’s
disease, the myopathies, Huntington’s chorea, etc.) we never
come across a trace of any other accessory aetiological influence.
But dissimilar heredity, which is much more important than the
other, leaves gaps which would have to be filled before a
satisfactory solution of aetiological problems could be reached.
Dissimilar heredity consists in the fact that the members of the
same family are found to be affected by the most various nervous
disorders, functional and organic, without its being possible to
discover any law determining the replacement of one illness by
another or the order of their succession through the generations.
Alongside of the sick members of these families there are others
who remain healthy; and the theory of dissimilar heredity does not
tell us why one person tolerates the same hereditary load without
succumbing to it or why another person, who is sick, should choose
this particular nervous affection from among all the illnesses
which make up the great family of nervous diseases instead of
choosing another one - hysteria instead of epilepsy or insanity,
and so on. Since there is no such thing as chance in neurotic
pathogenesis any more than anywhere else, it must be allowed that
it is not heredity that presides over the choice of the particular
nervous disorder which is to develop in the predisposed member of a
family, but that there are grounds for suspecting the existence of
other aetiological influences, of a less incomprehensible nature,
which would then deserve to be called the
specific aetiology
of such and such a nervous affection. Without the existence of this
special aetiological factor, heredity could have done nothing; it
would have lent itself to the production of another nervous
disorder if the specific aetiology in question had been replaced by
some other influence.
Heredity And The Aetiology Of The Neuroses
371
II
There has been too little
research into these specific and determining causes of nervous
disorders, for the attention of physicians has remained dazzled by
the grandiose prospect of the aetiological precondition of
heredity. Those causes nevertheless deserve to be made the object
of industrious study. Although their pathogenic power is in general
only accessory to that of heredity, great practical interest
attaches to the knowledge of this specific aetiology; it will allow
our therapeutic efforts a path of access, whereas hereditary
disposition, which is something fixed in advance for the patient
from his birth, brings our efforts to a halt with its
unapproachable power.
I have been engaged for years in
researches into the aetiology of the major neuroses (functional
nervous states analogous to hysteria) and it is the result of those
studies that I propose to describe to you in the following pages.
To avoid any possible misunderstanding I shall begin by making two
remarks on the nosography of the neuroses and on the aetiology of
the neuroses in general.
I was obliged to begin my work
with a nosographic innovation. I found reason to set alongside of
hysteria the obsessional neurosis (
Zwangsneurose
) as a
self-sufficient and independent disorder, although the majority of
the authorities place obsessions among the syndromes constituting
mental degeneracy or confuse them with neurasthenia. I for my part,
by examining the psychical mechanism of obsessions, had learnt that
they are connected with hysteria more closely than one might
suppose.
Hysteria and obsessional neurosis
form the first group of the major neuroses studied by me. The
second contains Beard’s neurasthenia, which I have divided up
into two functional states separated by their aetiology as well as
by their symptomatic appearance -
neurasthenia
proper and
the
anxiety neurosis
(
Angstneurose
), a name which, I
may say in passing, I am not pleased with myself. I gave my
detailed reasons for making this separation, which I consider
necessary, in a paper published in 1895.
As regards the aetiology of the
neuroses, I think it should be recognized in theory that
aetiological influences, differing among themselves in their
importance and in the manner in which they are related to the
effect they produce, can be grouped in three classes: (1)
Preconditions
, which are indispensable for producing the
disorder concerned but which are of a general nature and are
equally met with in the aetiology of many other disorders; (2)
Concurrent Causes
, which share the character of
preconditions in that they function in the causation of other
disorders as well as in that of the disorder under consideration,
but which are not indispensable for the production of the latter;
and (3)
Specific Causes
, which are as indispensable as the
preconditions, but are of a limited nature and appear only in the
aetiology of the disorder for which they are specific.
In the pathogenesis of the major
neuroses, then, heredity fulfils the role of a
precondition
,
powerful in every case and even indispensable in most cases. It
could not do without the collaboration of the specific causes; but
the importance of hereditary disposition is proved by the fact that
the same specific causes acting on a healthy individual produce no
manifest pathological effect, whereas in a predisposed person their
action causes the neurosis to come to light, whose development will
be proportionate in intensity and extent to the degree of the
hereditary precondition.
Thus the action of heredity is
comparable to that of a multiplier in an electric circuit, which
exaggerates the visible deviation of the needle, but which cannot
determine its direction.
There is yet another thing to be
noted in the relations between the hereditary precondition and the
specific causes of neuroses. Experience shows - what one might have
guessed in advance - that in these questions of aetiology one
should not neglect the relative quantities, so to speak, of the
aetiological influences. But one could not have guessed the
following fact, which seems to arise from my observations: namely
that heredity and the specific causes can replace each other as
regards quantity, that the same pathological effect will be
produced by the coincidence of a very serious specific aetiology
with a moderate disposition or of a severely loaded nervous
heredity with a slight specific influence. And we shall simply be
meeting not unexpected extreme instances in this series if we come
upon cases of neurosis in which we shall look in vain for an
appreciable degree of hereditary disposition, provided that what is
lacking is made up for by a powerful specific influence.
Heredity And The Aetiology Of The Neuroses
372
As
concurrent
(or
auxiliary)
causes
of neuroses may be enumerated all the
stock agents met with elsewhere: emotional disturbance, physical
exhaustion, acute illnesses, intoxications, traumatic accidents,
intellectual overwork, etc. I maintain that none of these, not even
the last, enters into the aetiology of the neuroses regularly or
necessarily, and I am aware that to declare this opinion is to put
oneself in direct opposition to a theory which is looked upon as
universally accepted and irreproachable. Since Beard declared that
neurasthenia was the fruit of our modern civilization, he has only
met with believers; but I find it impossible to accept this view. A
laborious study of the neuroses has taught me that the specific
aetiology of the neuroses has escaped Beard’s notice.
I have no desire to depreciate
the aetiological importance of these stock agents. Since they are
very various, occur very frequently and are most often named by
patients themselves, they become more prominent than the specific
causes of the neuroses - an aetiology which is either hidden or
unknown. Fairly frequently they fulfil the function of
agents
provocateurs
which render manifest a neurosis that has
previously been latent; and a practical interest attaches to them,
for a consideration of these stock causes may offer lines of
approach to a therapy which does not aim at a radical cure and is
content with repressing the illness to its former state of
latency.
But it is not possible to
establish any constant and close relation between one of these
stock causes and one or other form of nervous affection. Emotional
disturbance, for instance, is found equally in the aetiology of
hysteria, obsessions and neurasthenia, as well as in that of
epilepsy, Parkinson’s disease, diabetes and many others.
Heredity And The Aetiology Of The Neuroses
373
Stock concurrent causes can
replace the specific aetiology in respect of quantity, but can
never take its place entirely. There are numerous cases in which
all the aetiological influences are represented by the hereditary
precondition and the specific cause, stock causes being absent. In
the other cases indispensable aetiological factors are not in
themselves sufficient in quantity to bring about an outbreak of
neurosis; a state of apparent health may be maintained for a long
time, though it is in reality a state of predisposition to
neurosis. It is then enough for a stock cause to come into action
as well, and the neurosis becomes manifest. But it must be clearly
pointed out that under these conditions the nature of the stock
cause which supervenes is a matter of complete indifference -
whether it is an emotion, a trauma, an infectious illness or
anything else. The pathological effect will not be modified
according to this variation; the nature of the neurosis will always
be dominated by the pre-existing specific cause.