Freud - Complete Works (69 page)

   There are cases in which one can
observe how the obsession is transferred from the idea or from the
affect on to the protective measure; others in which the obsession
oscillates periodically between the symptom of the return of the
repressed and the symptom of the secondary defence; and yet other
cases in which no obsessional idea is constructed at all, but,
instead, the repressed memory is at once represented by what is
apparently a primary measure of defence. Here we reach at one bound
the stage which elsewhere only completes the course run by the
obsessional neurosis after the defensive struggle has taken place.
Severe cases of this disorder end in the ceremonial actions
becoming fixated, or in a general state of doubting mania, or in a
life of eccentricity conditioned by phobias.

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394

   The fact that the obsessional
ideas and everything derived from them meet with no belief is no
doubt because at their first repression the defensive symptom of
conscientiousness
has been formed and that that symptom,
too, acquires an obsessional force. The subject’s certainty
of having lived a moral life throughout the whole period of his
successful defence makes it impossible for him to believe the
self-reproach which his obsessional idea involves. Only
transitorily, too, on the appearance of a new obsessional idea and
occasionally in melancholic states of exhaustion of the ego, do the
pathological symptoms of the return of the repressed compel belief.
The ‘obsessional’ character of the psychical formations
which I have described here has quite generally nothing to do with
attaching belief to them. Nor is it to be confused with the factor
which is described as the ‘strength’ or
‘intensity’ of an idea. Its essence is rather
indissolubility by psychical activity that is capable of being
conscious; and this attribute undergoes no change, whether the idea
to which the obsession attaches is stronger or weaker, or less or
more intensely ‘illuminated’, or ‘cathected with
energy’ and so on.

   The cause of this invulnerability
of the obsessional idea and its derivatives is, however, nothing
more than its connection with the repressed memory from early
childhood. For if we can succeed in making that connection
conscious - and psychotherapeutic methods already appear able to do
so - the obsession, too, is resolved.

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395

III

ANALYSIS OF A CASE OF CHRONIC PARANOIA
¹

   For a considerable time I have
harboured a suspicion that paranoia, too - or classes of cases
which fall under the heading of paranoia - is a psychosis of
defence; that is to say, that, like hysteria and obsessions, it
proceeds from the repression of distressing memories and that its
symptoms are determined in their form by the content of what has
been repressed. Paranoia must, however, have a special method or
mechanism of repression which is peculiar to it, in the same way as
hysteria effects repression by the method of conversion into
somatic innervation, and obsessional neurosis by the method of
substitution
(viz. by displacement along the lines of
certain categories of associations). I had observed several cases
which favoured this interpretation, but had found none which proved
it; until, a few months ago, I had an opportunity, through the
kindness of Dr. Josef Breuer, of undertaking the psycho-analysis
for therapeutic purposes of an intelligent woman of thirty-two, in
whose case a diagnosis of chronic paranoia could not be questioned.
I am reporting in these pages, without waiting further, some of the
information I have been able to obtain from this piece of work,
because I have no prospect of studying paranoia except in very
isolated instances, and because I think it possible that my remarks
may encourage a psychiatrist better placed than I am in this matter
to give its rightful place to the factor of ‘defence’
in the discussion as to the nature and psychical mechanism of
paranoia which is being carried on so actively just now. I have, of
course, on the strength of the following single observation, no
intention of saying more than: ‘This case is a psychosis of
defence and there are most probably others in the class of
"paranoia" which are equally so.’

  
¹
(
Footnote added
1924:) More
correctly, no doubt,
dementia paranoides
.

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396

   Frau P., thirty-two years of age,
has been married for three years and is the mother of a child of
two. Her parents were not neurotic; but her brother and sister are
to my knowledge, like her, neurotic. It is doubtful whether she may
not, at one time in her middle twenties, have become temporarily
depressed and confused in her judgement. In recent years she was
healthy and capable, until, six months after the birth of her
child, she showed the first signs if her present illness. She
became uncommunicative and distrustful, showed aversion to meeting
her husband’s brothers and sisters and complained that the
neighbours in the small town in which she lived were behaving
differently towards her from how they did before and were rude and
inconsiderate to her. By degrees these complaints increased in
intensity, although not in definiteness. She thought people had
something against her, though she had no idea what; but there was
no doubt that everyone - relatives and friends - had ceased to
respect her and were doing all they could to slight her. She had
racked her brains, she said, to find the reason for this, but had
no idea. A little time later she complained that she was being
watched and that people were reading her thoughts and knew
everything that was going on in her house. One afternoon she
suddenly had the idea that she was being watched while she was
undressing in the evening. From that time on she took the most
precautionary measures when she undressed; she got into bed in the
dark and did not begin to take off her things till she was under
the bedclothes. Since she avoided all contact with other people,
ate poorly and was very depressed, she was sent in the summer of
1895 to a hydropathic establishment. There, fresh symptoms appeared
and those she already had increased in strength. Already in the
spring of that year, when she was alone one day with her housemaid,
she had suddenly had a sensation in her lower abdomen, and had
thought to herself that the girl had at that moment had an improper
idea. This sensation grew more frequent during the summer and
became almost continual. She felt her genitals ‘as one feels
a heavy hand’. Then she began to see images which horrified
her - hallucinations of naked women, especially of the lower part
of a woman’s abdomen with pubic hairs, and occasionally of
male genitals as well. The image of the abdomen with hair and the
physical sensation in her own abdomen usually occurred together.
The images became very tormenting, for they happened regularly when
she was in the company of a woman, and it made her think that she
was seeing the woman in an indecent state of nakedness, but that
simultaneously the woman was having the same picture of her (!). At
the same time as these visual hallucinations - which vanished again
for several months after their first appearance in the hydropathic
establishment - she began to be pestered by voices which she did
not recognize and which she could not account for. When she was in
the street, they said: ‘That’s Frau P.- There she goes!
Where’s she going to?’ Every one of her movements and
actions was commented on; and at times she heard threats and
reproaches. All these symptoms became worse when she was in company
or in the street. For that reason she refused to go out; she said
that eating disgusted her; and her state of health rapidly
deteriorated.

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397

   I gathered all this from her when
she came to Vienna for treatment with me in the winter of 1895. I
have set it out at length because I want to convey the impression
that what we are dealing with here really is a quite frequent form
of chronic paranoia - a conclusion with which the details of her
symptoms and behaviour which I have still to describe will be found
to tally. At that time she concealed from me the delusions which
served to interpret her hallucinations, or else the delusions had
in fact not yet occurred to her. Her intelligence was undiminished;
the only unusual thing I learnt was that she had repeatedly made
appointments with her brother, who lived in the neighbourhood, in
order to confide something important to him, but had never told him
anything. She never spoke about her hallucinations, and towards the
end she no longer said much either about the slights and
persecutions of which she was subjected.

   What I have to report about this
patient concerns the aetiology of the case and the mechanism of the
hallucinations. I discovered the aetiology when I applied
Breuer’s method, exactly as in a case of hysteria - in the
first instance for the investigation and removal of the
hallucinations. In doing so, I started out from the assumption that
in this case of paranoia, just as in the two other defence neuroses
with which I was familiar, there must be unconscious thoughts and
repressed memories which could be brought into consciousness in the
same way as they were in those neuroses, by overcoming a certain
resistance. The patient at once confirmed my expectation, for she
behaved in analysis exactly like, for instance, a hysterical
patient; with her attention on the pressure of my hand,¹ she
produced thoughts which she could not remember having had, which at
first she did not understand and which were contrary to her
expectations. The presence of significant unconscious ideas was
thus demonstrated in a case of paranoia as well, and I was able to
hope that I might trace the compulsion of paranoia, too, to
repression. The only peculiarity was that the thoughts which arose
from the unconscious were for the most part heard inwardly or
hallucinated by the patient, in the same way as her voices.

  
¹
Cf. my
Studies on
Hysteria
.

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398

   Concerning the origin of the
visual hallucinations, or at least of the vivid images, I learned
the following. The image of the lower part of a woman’s
abdomen almost always coincided with the physical sensation in her
own abdomen; but the latter was much more constant and often
occurred without the image. The first images of a woman’s
abdomen had appeared in the hydropathic establishment a few hours
after she had in fact seen a number of naked women at the baths; so
they turned out to be simple reproductions of a real impression. It
was therefore to be presumed that these impressions had been
repeated only because great interest was attached to them. She told
me that she had felt ashamed for these women; she herself had been
ashamed to be seen naked for as long as she could remember. Since I
was obliged to regard the shame as something obsessional, I
concluded, in accordance with the mechanism of defence, that an
experience must have been repressed here about which she had
not
felt ashamed. So I requested her to let the memories
emerge which belonged to the theme of feeling ashamed. She promptly
reproduced a series of scenes going back from her seventeenth to
her eighth year, in which she had felt ashamed of being naked in
her bath in front of her mother, her sister and the doctor; but the
series ended in a scene at the age of six, in which she was
undressing in the nursery before going to bed, without feeling any
shame in front of her brother who was there. On my questioning her,
it transpired that scenes like this had occurred often and that the
brother and sister had for years been in the habit of showing
themselves to one another naked before going to bed. I now
understood the meaning of her sudden idea that she was being
watched as she was going to bed. It was an unaltered piece of the
old memory which involved self-reproach, and she was now making up
for the shame which she had omitted to feel as a child.

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399

   My conjecture that we had to do
with an affair between children, as is so often found in the
aetiology of hysteria, was strengthened by the further progress of
the analysis, which at the same time yielded solutions of
individual details that frequently recurred in the clinical picture
of the paranoia. The patient’s depression began at the time
of a quarrel between her husband and her brother, as a result of
which the latter no longer came to the house. She had always been
very fond of this brother and she missed him very much at that
time. Besides this she spoke of a certain moment in her illness at
which for the first time ‘everything became clear to
her’ - that is, at which she became convinced of the truth of
her suspicion that she was despised by everyone and deliberately
slighted. This certainty came to her during a visit from her
sister-in law who, in the course of conversation, let fall the
words: ‘If anything of that sort happens to me, I treat it
in a light vein.’ At first Frau P. took this remark
unsuspectingly; but later, after the visitor had left, it seemed to
her that the words had contained a reproach, as if
she
was
in the habit of taking serious things lightly; and from that moment
on she was certain that she was the victim of general slander. When
I questioned her as to what made her feel justified in applying the
words to herself, she answered that it was the tone of voice in
which her sister-in-law had spoken that had (although, it is true,
only subsequently) convinced her of it. This is a detail which is
characteristic of paranoia. I now obliged her to remember what her
sister-in-law had been saying
before
the remark she
complained of, and it emerged that the sister-in-law had related
how in her parents’ home there had been all sorts of
difficulties with her
brothers
, and had added the wise
comment: ‘In every family all sorts of things happen that one
would like to draw a veil over. But if anything of the kind happens
to
me
, I take it lightly.’ Frau P. now had to admit
that her depression was attached to the statements made by her
sister-in-law
before
her last remark. Since she had
repressed both the statements which might have awakened a memory of
her relations with her brother, and had only retained the
insignificant last one, it was with it that she was obliged to
connect her feeling that her sister-in-law was making a reproach
against her; and since its
content
offered no basis for
this, she turned from the content to the
tone
in which the
words had been spoken. This is probably a typical piece of evidence
that the misinterpretations of paranoia are based on a
repression.