III.
In both cases thus far considered the defense of the unbearable idea was brought about by the separation of the same from its affect; the idea though weakened and isolated remained in consciousness. There exists, however, a far more energetic and more successful form of defense wherein the ego misplaces the unbearable idea with its affect, and behaves as though the unbearable idea had never approached the ego. But at the moment when this is brought about the person suffers from a psychosis which can only be classified as an “hallucinatory confusion.” A single example will explain this assertion. A young girl gives her first impulsive love to a man who she firmly believed reciprocated her love. As a matter of fact she was mistaken; the young man had other motives for visiting her. It was not long before she was disappointed; at first she defended herself against it by converting hysterically the corresponding experience, and thus came to believe that he would come some day to ask her in marriage; but in consequence of the imperfect conversion and the constant pressure of new painful impressions, she felt unhappy and ill. She finally expects him with the greatest tension on a definite day, it is the day of a family reunion. The day passes but he does not come. After all the trains on which he could have come have passed she suddenly merged into an hallucinatory confusion. She thought that he did come, she heard his voice in the garden, and hastened down in her night gown to receive him. For two months after she lived in a happy dream, the content of which was that he was there, that he was always with her, and that everything was as before (before the time of the painfully defended disappointment). The hysteria and depression were thus conquered; during her sickness she never mentioned anything about the last period of doubt and suffering; she was happy as long as she was left undisturbed, and frenzied only when a regulation of her environment prevented her from accomplishing something which she thought quite natural as a result of her blissful dream. This psychosis, unintelligible as it was in its time, was revealed ten years later through hypnotic analysis.
The fact to which I call attention is this: That the content of such an hallucinatory psychosis consists in directly bringing into prominence that idea which was threatened by the motive of the disease. One is therefore justified in saying that through its flight into the psychosis the ego defended the unbearable idea; the process through which this has been brought about withdraws itself from self perception as well as from the psychological-clinical analysis. It is to be considered as the expression of a higher grade of pathological disposition, and can perhaps be explained as follows: The ego tears itself away from the unbearable idea, but as it hangs inseparably together with a part of reality, the ego while accomplishing this performance also detaches itself wholly or partially from reality. The latter is, in my opinion the condition under which hallucinatory vividness is decreed to
## particular ideas, and hence after very successful defense the person
finds himself in a hallucinatory confusion.
I have but very few analyses of such psychoses at my disposal; but I believe that we deal with a very frequently employed type of psychic illness. For analogous examples such as the mother who becoming sick after the loss of her child continues to rock in her arms a piece of wood, or the jilted bride who in full dress expects her bridegroom, can be seen in every insane asylum.
It will perhaps not be superfluous to mention that the three forms of defense here considered, and hence the three forms of disease to which this defense leads may be united in the same person. The simultaneous occurrence of phobias and hysterical symptoms, so frequently observed in praxis, really belongs to those moments which impede a pure separation of hysteria from other neuroses and urge the formation of the “mixed neuroses.” To be sure the hallucinatory confusion is not frequently compatible with the continuation of hysteria and not as a rule with obsessions; but on the other hand it is not rare that a defense psychosis should episodically break through the course of a hysteria or mixed neurosis.
In conclusion I will mention in few words the subsidiary idea of which I have made use in this discussion of the defense neuroses. It is the idea that there is something to distinguish in all psychic functions (amount of affect, sum of excitement), that all qualities have a quantity though we have no means to measure the same—it is something that can be increased, diminished, displaced, and discharged, and that extends over the memory traces of the ideas perhaps like an electric charge over the surface of the body.
This hypothesis, which also underlies our theory of “ab-reaction” (“Preliminary Communication”), can be used in the same sense as the physicist uses the assumption of the current of electric fluid. It is preliminarily justified through its usefulness in the comprehension and elucidation of diverse psychic states.
## CHAPTER VI.
ON THE RIGHT TO SEPARATE FROM NEURASTHENIA A DEFINITE SYMPTOM-COMPLEX AS “ANXIETY NEUROSIS” (ANGSTNEUROSE).
It is difficult to assert anything of general validity concerning neurasthenia as long as this term is allowed to express all that for which Beard used it. I believe that neuropathology can only gain by an attempt to separate from the actual neurosis all those neurotic disturbances the symptoms of which are on the one hand more firmly connected among themselves than to the typical neurasthenic symptoms, such as headache, spinal irritation, dyspepsia with flatulence and constipation, and which on the other hand show essential differences from the typical neurasthenic neurosis in their etiology and mechanism. If we accept this plan we will soon gain quite a uniform picture of neurasthenia. We will soon be able to differentiate—sharper than we have hitherto succeeded—from the real neurasthenia the different pseudoneurasthenias, such as the organically determined nasal reflex neurosis, the neurotic disturbances of cachexias and arteriosclerosis, the early stages of progressive paralysis, and of some psychoses. Furthermore, following the proposition of Moebius, some status nervosi of hereditary degenerates will be set aside and we will also find reasons for ascribing some of the neuroses which are now called neurasthenia to melancholia, especially those of an intermittent or periodic nature. But we force the way into the most marked changes if we decide to separate from neurasthenia that symptom-complex which I shall hereafter describe and which especially fulfills the conditions formulated above. The symptoms of this complex are clinically more related to one another than to the real neurasthenic symptoms, that is, they frequently appear together and substitute one another in the course of the disease, and both the etiology as well as the mechanism of this neurosis differs basically from the etiology and the mechanism of the real neurasthenia which remains after such a separation.
I call this symptom-complex “anxiety neurosis” (Angstneurose) because the sum of its components can be grouped around the main symptom of anxiety, because each individual symptom shows a definite relation to anxiety. I believed that I was original in this conception of the symptoms of anxiety neurosis until an interesting lecture by E. Hecker[41] fell into my hands. In this lecture I found the description of the same interpretation with all the desired clearness and completeness. To be sure, Hecker does not separate the equivalents or rudiments of the attack of anxiety from neurasthenia as I intend to do; but this is apparently due to the fact that neither here nor there has he taken into account the diversity of the etiological determinants. With the knowledge of the latter difference every obligation to designate the anxiety neurosis by the same name as the real neurasthenia disappears, for the only object of arbitrary naming is to facilitate the formulation of general assertions.
I. CLINICAL SYMPTOMATOLOGY OF ANXIETY NEUROSIS.
What I call “anxiety neurosis” can be observed in complete or rudimentary development, either isolated or in combination with other neuroses. The cases which are in a measure complete, and at the same time isolated, are naturally those which especially corroborate the impression that the anxiety neurosis possesses clinical independence. In other cases we are confronted with the task of selecting and separating from a symptom-complex which corresponds to a “mixed neurosis,” all those symptoms which do not belong to neurasthenia, hysteria, etc., but to the anxiety neurosis.
The clinical picture of the anxiety neurosis comprises the following symptoms:
1. _General Irritability._—This is a frequent nervous symptom, common as such to many nervous states. I mention it here because it constantly occurs in the anxiety neurosis and is of theoretical significance. For increased irritability always points to an accumulation of excitement or to an inability to bear accumulation, hence to an absolute or relative accumulation of excitement. The expression of this increased irritability through an auditory hyperesthesia is especially worth mentioning; it is an over sensitiveness for noises, which symptom is certainly to be explained by the congenital intimate relationship between auditory impressions and fright. Auditory hyperesthesia is frequently found as a cause of insomnia, of which more than one form belongs to anxiety neurosis.
2. _Anxious Expectation._—I can not better explain the condition that I have in mind, than by this name and by some appended examples. A woman, for example, who suffers from anxious expectation thinks of influenza-pneumonia whenever her husband who is afflicted with a catarrhal condition has a coughing spell; and in her mind she sees a passing funeral procession. If on her way home she sees two persons standing together in front of her house she can not refrain from the thought that one of her children fell out of the window; if she hears the bell ring she thinks that someone is bringing her mournful tidings, etc.; yet in none of these cases is there any special reason for exaggerating a mere possibility.
The anxious expectation naturally reflects itself constantly in the normal, and embraces all that is designated as “uneasiness and a tendency to a pessimistic conception of things,” but as often as possible it goes beyond such a plausible uneasiness, and it is frequently recognized as a part of constraint even by the patient himself. For one form of anxious expectation, namely, that which refers to one’s own health, we can reserve the old name of hypochondria. Hypochondria does not always run parallel with the height of the general anxious expectation; as a preliminary stipulation it requires the existence of paresthesias and annoying somatic sensations. Hypochondria is thus the form preferred by the genuine neurasthenics whenever they merge into the anxiety neurosis, a thing which frequently happens.
As a further manifestation of anxious expectation we may mention the frequent tendency observed in morally sensitive persons to pangs of conscience, scrupulosity, and pedantry, which varies as it were, from the normal to its aggravation as doubting mania.
Anxious expectation is the most essential symptom of the neurosis; it also clearly shows a part of its theory. It can perhaps be said that we have here a quantum of freely floating anxiety which controls the choice of ideas by expectation and is forever ready to unite itself with any suitable ideation.
3. This is not the only way in which the anxiousness, usually latent but constantly lurking in consciousness, can manifest itself. On the contrary it can also suddenly break into consciousness without being aroused by the issue of an idea, and thus provoke an attack of anxiety. Such an attack of anxiety consists of either the anxious feeling alone without any associated idea, or of the nearest interpretation of the termination of life, such as the idea of “sudden death” or threatening insanity; or the feeling of anxiety becomes mixed with some paresthesia (similar to the hysterical aura); or finally the anxious feeling may be combined with a disturbance of one or many somatic functions, such as respiration, cardiac activity, the vasomotor innervation, and the glandular activity. From this combination the patient renders especially prominent now this and now the other moment. He complains of “heartspasms,” “heavy breathing,” “profuse perspiration,” “inordinate appetite,” etc., and in his description the feeling of anxiety is put to the background or it is rather vaguely described as “feeling badly,” “uncomfortably,” etc.
4. What is interesting and of diagnostic significance is the fact that the amount of admixture of these elements in the attack of anxiety varies extraordinarily, and that almost any accompanying symptom can alone constitute the attack as well as the anxiety itself. Accordingly there are rudimentary attacks of anxiety, and equivalents for the attack of anxiety, probably all of equal significance in showing a profuse and hitherto little appreciated richness in forms. A more thorough study of these larvated states of anxiety (Hecker) and their diagnostic division from other attacks ought soon to become the necessary work for the neuropathologist.
I now add a list of those forms of attacks of anxiety with which I am acquainted. There are attacks:
(_a_) With disturbances of heart action, such as palpitation with transitory arrythmia, with longer continued tachycardia up to grave states of heart weakness, the differentiation of which from organic heart affection is not always easy; among such we have the pseudo-angina pectoris, a delicate diagnostic sphere!
(_b_) With disturbances of respiration, many forms of nervous dyspnoea, asthma-like attacks, etc. I assert that even these attacks are not always accompanied by conscious anxiety;
(_c_) Of profuse perspiration, often nocturnal;
(_d_) Of trembling and shaking which may readily be mistaken for hysterical attacks;
(_e_) Of inordinate appetite, often combined with dizziness;
(_f_) Of attack-like appearing diarrhoea;
(_g_) Of locomotor dizziness;
(_h_) Of so called congestions, embracing all that was called vasomotor neurasthenia; and,
(_i_) Of paresthesias (These are seldom without anxiety or a similar discomfort).
5. Very frequently the nocturnal frights (pavor nocturnus of adults) usually combined with anxiety, dyspnoea, perspiration, etc., is nothing other than a variety of the attack of anxiety. This disturbance determines a second form of insomnia in the sphere of the anxiety neurosis. Moreover I became convinced that even the pavor nocturnus of children evinces a form belonging to the anxiety neurosis. The hysterical tinge and the connection of the fear with the reproduction of appropriate experience or dream, makes the pavor nocturnus of children appear as something peculiar, but it also occurs alone without a dream or a recurring hallucination.
6. “_Vertigo._”—This in its lightest forms is better designated as “dizziness,” assumes a prominent place in the group of symptoms of anxiety neurosis. In its severer forms the “attack of vertigo,” with or without fear, belongs to the gravest symptoms of the neurosis. The vertigo of the anxiety neurosis is neither a rotatory dizziness nor is it confined to certain planes or lines like Menier’s vertigo. It belongs to the locomotor or coordinating vertigo, like the vertigo in paralysis of the ocular muscles; it consists in a specific feeling of discomfort which is accompanied by sensations of a heaving ground, sinking legs, of the impossibility to continue in an upright position, and at the same time there is a feeling that the legs are as heavy as lead, they shake, or give way. This vertigo never leads to falling. On the other hand, I would like to state that such an attack of vertigo may also be substituted by a profound attack of syncope. Other fainting-like states in the anxiety neurosis seem to depend on a cardiac collapse.
The vertigo attack is frequently accompanied by the worst kind of anxiety and is often combined with cardiac and respiratory disturbances. Vertigo of elevations, mountains and precipices, can also be frequently observed in anxiety neurosis; moreover, I do not know whether we are still justified in recognizing a vertigo “a stomacho laeso.”
7. On the basis of the chronic anxiousness (anxious expectation) on the one hand, and the tendency to vertiginous attacks of anxiety on the other, there develop two groups of typical phobias; the first refers to the general physiological menaces, while the second refers to locomotion. To the first group belong the fear for snakes, thunderstorms, darkness, vermin, etc., as well as the typical moral overscrupulousness, and the forms of doubting mania. Here the available fear is merely used to strengthen those aversions which are instinctively implanted in every man. But usually a compulsively acting phobia is formed only after a reminiscence is added to an experience in which this fear could manifest itself; as, for example, after the patient has experienced a storm in the open air. To attempt to explain such cases as mere continuations of strong impressions is incorrect. What makes these experiences significant and their reminiscences durable is after all only the fear which could at that time appear and can also appear today. In other words such impressions remain forceful only in persons with “anxious expectations.”
The other group contains agoraphobia with all its accessory forms, all of which are characterized by their relation to locomotion. As a determination of the phobia we frequently find a precedent attack of vertigo; I do not think that it can always be postulated. Occasionally, after a first attack of vertigo without fear, we see that though locomotion is always accompanied by the sensation of vertigo, it remains possible without any restrictions, but as soon as fear attaches itself to the attack of vertigo, locomotion fails, under the conditions of being alone, narrow streets, etc.
The relation of these phobias to the phobias of obsessions, which mechanism I discussed above,[42] is as follows: The agreement lies in the fact that here as there, an idea becomes obsessive through its connection with an available affect. The mechanism of transposition of the affect therefore holds true for both kinds of phobias. But in phobias of the anxiety neurosis this affect is (1) a monotonous one, it is always one of anxiety; (2) it does not originate from a repressed idea, and on psychological analysis it proves itself not further reducible, nor can it be attacked through psychotherapy. The mechanism of substitution does not therefore hold true for the phobias of anxiety neurosis.
Both kinds of phobias (or obsessions) often occur side by side, though the atypical phobias which depend on obsessions need not necessarily develop on the basis of anxiety neurosis. A very frequent, ostensibly complicated mechanism appears if the content of an original simple phobia of anxiety neurosis is substituted by another idea, the substitution is then subsequently added to the phobia. The “protective measures” originally employed in combatting the phobia are most frequently used as substitutions. Thus, for example, from the effort to provide oneself with counter evidence that one is not crazy, contrary to the assertion of the hypochondriacal phobia, there results a reasoning mania. The hesitations, doubts, and the many repetitions of the folie du doute originate from the justified doubt concerning the certainty of one’s own stream of thoughts, for, through the compulsive like idea one is surely conscious of so obstinate a disturbance, etc. It may therefore be claimed that many syndromes of compulsion neurosis, like folie du doute and similar ones, can clinically, if not notionally be attributed to anxiety neurosis.[43]
8. The digestive functions in anxiety neurosis are subject to very few but characteristic disturbances. Sensations like nausea and sickly feeling are not rare, and the symptom of inordinate appetite alone or with other congestions, may serve as a rudimentary attack of anxiety. As a chronic alteration analogous to the anxious expectations one finds a tendency to diarrhea which has occasioned the queerest diagnostic mistakes. If I am not mistaken it is this diarrhea to which Moebius[44] has recently called attention in a small article. I believe, moreover, that Peyer’s[45] reflex diarrhea which he attributes to a disease of the prostate is nothing other than the diarrhea of anxiety neurosis. The deceptive reflex relation is due to the fact that the same factors which are active in the origin of such prostatic affections also come into play in the etiology of anxiety neurosis.
The behavior of the gastro-intestinal function in anxiety neurosis shows a sharp contrast to the influence of this same function in neurasthenia. Mixed cases often show the familiar “fluctuations between diarrhea and constipation.” The desire to urinate in anxiety neurosis is analogous to the diarrhea.
9. The paresthesias which accompany the attack of vertigo or anxiety are interesting because they associate themselves into a firm sequence, similar to the sensations of the hysterical aura. But in contrast to the hysterical aura I find these associated sensations atypical and changeable. Another similarity to hysteria is shown by the fact that in anxiety neurosis a kind of conversion[46] into bodily sensations, as for example into rheumatic muscles, takes place which otherwise can be overlooked at one’s pleasure. A large number of so called rheumatics, who are moreover demonstrable as such, really suffer from an anxiety neurosis. Besides this aggravation of the sensation of pain I have observed in a number of cases of anxiety neurosis a tendency towards hallucinations which could not be explained as hysterical.
10. Many of the so called symptoms which accompany or substitute the attack of anxiety also appear in a chronic manner. They are then still less discernible, for the anxious feeling accompanying them appears more indistinct than in the attack of anxiety. This especially holds true for the diarrhea, vertigo, and paresthesias. Just as the attack of vertigo can be substituted by an attack of syncope, so can the chronic vertigo be substituted by the continuous feeling of feebleness, lassitude, etc.
II. THE OCCURRENCE AND ETIOLOGY OF ANXIETY NEUROSIS.
In some cases of anxiety neurosis no etiology can readily be ascertained. It is noteworthy that in such cases it is seldom difficult to demonstrate a marked hereditary taint.
Where we have reason to assume that the neurosis is acquired we can find by careful and laborious examination that the etiologically effective moments are based on a series of injuries and influences from the sexual life. These at first appear to be of a varied nature but easily display the common character which explains their homogeneous effect on the nervous system. They are found either alone or with other banal injuries to which a reinforcing effect can be attributed. This sexual etiology of anxiety neurosis can be demonstrated so preponderately often that I venture for the purpose of this brief communication to set aside all cases of a doubtful or different etiology.
For the more precise description of the etiological determinations under which anxiety neurosis occurs, it will be advisable to treat separately those occurring in men and those occurring in women. Anxiety neurosis appears in women—disregarding their predisposition—in the following cases:
(_a_) As virginal fear or anxiety in adults. A number of unequivocal observations showed me that an anxiety neurosis, which is almost typically combined with hysteria, can be evoked in maturing girls, at the first encounter with the sexual problem, that is at the sudden revelation of the things hitherto veiled, by either seeing the sexual act, or by hearing or reading something of that nature;
(_b_) As fear in the newly married. Young women who remain anesthetic during the first cohabitation not seldom merge into an anxiety neurosis which disappears after the anesthesia is displaced by the normal sensation. As most young women remain undisturbed through such a beginning anesthesia, the production of this fear requires determinants which I will mention;
(_c_) As fear in women whose husbands suffer from ejaculatio precox or from diminished potency; and,
(_d_) In those whose husbands practice coitus interruptus or reservatus. These cases go together, for on analyzing a large number of examples one can easily be convinced that they only depend on whether the woman attained gratification during coitus or not. In the latter case one finds the determinant for the origin of anxiety neurosis. On the other hand the woman is spared from the neurosis if the husband afflicted by ejaculatio precox can repeat the congress with better results immediately thereafter. The congressus reservatus by means of the condom is not injurious to the woman if she is quickly excited and the husband is very potent; in other cases the noxiousness of this kind of preventive measure is not inferior to the others. Coitus interruptus is almost regularly injurious; but for the woman it is injurious only if the husband practices it regardlessly, that is, if he interrupt coitus as soon as he comes near ejaculating without concerning himself about the determination of the excitement of his wife. On the other hand if the husband waits until his wife is gratified, the coitus has the same significance for the latter as a normal one; but then the husband becomes afflicted with an anxiety neurosis. I have collected and analyzed a number of cases which furnished the material for the above statements.
(_e_) As fear in widows and intentional abstainers, not seldom in typical combination with obsessions; and,
(_f_) As fear in the climacterium during the last marked enhancement of the sexual desire.
The cases (_c_), (_d_), and (_e_), contain the determinants under which the anxiety neurosis originates in the female sex, most frequently and most independently, of hereditary predisposition. I will endeavor to demonstrate in these—curable, acquired—cases of anxiety neurosis that the discovered sexual injuries really represent the etiological moments of the neurosis. But before proceeding I will mention the sexual determinants of anxiety neurosis in men. I would like to formulate the following groups, every one of which finds its analogy in women:
(_a_) Fear of the intentional abstainers; this is frequently combined with symptoms of defense (obsessions, hysteria). The motives which are decisive for intentional abstinence carry along with them the fact that a number of hereditarily burdened eccentrics, etc., belong to this category.
(_b_) Fear in men with frustrated excitement (during the engagement period), persons who out of fear for the consequences of sexual relations satisfy themselves with handling or looking at the woman. This group of determinants which can moreover be transferred to the other sex—engagement periods, relations with sexual forbearance—furnish the purest cases of the neurosis.
(_c_) Fear in men who practice coitus interruptus. As observed above, coitus interruptus injures the woman if it is practiced regardless of the woman’s gratification; it becomes injurious to the man, if in order to bring about the gratification in the woman be voluntarily controls the coitus by delaying the ejaculation. In this manner we can understand why it is that in couples who practice coitus interruptus it is usually only one of them who becomes afflicted. Moreover the coitus interruptus only rarely produces in man a pure anxiety neurosis, usually it is a mixture of the same with neurasthenia.
(_d_) Fear in men in the senium. There are men who show a climacterium like women, and merge into an anxiety neurosis at the time when their potency diminishes and their libido increases.
Finally I must add two more cases holding true for both sexes:
(_e_) Neurasthenics merge into anxiety neurosis in consequence of masturbation as soon as they refrain from this manner of sexual gratification. These persons have especially made themselves unfit to bear abstinence.
What is important for the understanding of the anxiety neurosis is the fact that any noteworthy development of the same occurs only in men who remain potent, and in non-anesthetic women. In neurasthenics, who on account of masturbation have markedly injured their potency, anxiety neurosis as a result of abstinence occurs but rarely and limits itself usually to hypochondria and light chronic dizziness. The majority of women are really to be considered as “potent”; a real impotent, that is, a real anesthetic woman, is also inaccessible to anxiety neurosis, and bears strikingly well the injuries cited.
How far we are perhaps justified in assuming constant relations between individual etiological moments and individual symptoms from the complex of anxiety neurosis, I do not care to discuss here.
(_f_) The last of the etiological determinants to be mentioned seems, in the first place, really not to be of a sexual nature. Anxiety neurosis originates in both sexes through the moment of overwork, exhaustive exertion, as for instance, after sleepless nights, nursing the sick, and even after serious illnesses.
The main objection against my formulation of a sexual etiology of the anxiety neurosis will probably be to the purport that such abnormal relations of the sexual life can be found so very often that wherever one will look for them they will be found near at hand. Their occurrence, therefore, in the cases cited of anxiety neurosis does not prove that the etiology of the neurosis was revealed in them. Moreover, the number of persons practicing coitus interruptus, etc., is incomparably greater than the number of those who are burdened with anxiety neurosis, and the overwhelming number of the first are quite well in spite of this injury.
To this I can answer that we certainly ought not to expect a rarely occurring etiological moment in the conceded enormous frequency of the neurosis, and especially anxiety neurosis; furthermore, that it really fulfills a postulate of pathology if on examining an etiology the etiological moments can be more frequently demonstrated than their effects, for, for the latter still other determinants (predisposition, summation of the specific etiology, reinforcement through other banal injuries) could be demanded; and furthermore, that the detailed analysis of suitable cases of anxiety neurosis show quite unequivocally the significance of the sexual moment. I shall, however, here confine myself to the etiological moment of coitus interruptus, and I will render prominent obvious individual experiences.
1. As long as the anxiety neurosis in young women is not yet constituted but appears in fragments which again spontaneously disappear, it can be shown that every such turn of the neurosis depends on a coitus with lack of gratification. Two days after this influence, and in persons of little resistance the day after, there regularly appears the attack of anxiety or vertigo to which all the other symptoms of the neurosis attach themselves, only to separate again on rarer marriage relations. An unexpected journey of the husband, a sojourn in the mountains causing a separation of the married couple, does good; the benefit from a course of gynecological treatment is due to the fact that during its continuation the marriage relations are stopped. It is noteworthy that the success of a local treatment is only transitory, the neurosis reappears while in the mountains if the husband joins his wife for his own vacation, etc. If, in a not as yet constituted neurosis, a physician aware of this etiology causes a substitution of the coitus interruptus by normal relations there results a therapeutic proof of the assertion here formulated. The anxiety is removed and does not return unless there be a new or similar cause.
2. In the anamnesis of many cases of anxiety neurosis we find in both men and women a striking fluctuation in the intensity of the appearances in both the coming and going of the whole condition. This year was almost wholly good, the following was terrible, etc.; on one occasion the improvement occurred after a definite treatment which, however, failed to produce a response at the next attack. If we inform ourselves about the number and the sequence of the children, and compare this marriage chronicle with the peculiar course of the neurosis, the result of the simple solution shows that the periods of improvement or well being corresponded with the pregnancies of the woman during which, naturally, the occasions for preventive relations were unnecessary. The treatment which benefited the husband, be it Father Kneip’s or the hydrotherapeutic institute, was the one which he has taken after he found his wife was pregnant.
3. From the anamnesis of the patients we often find that the symptoms of the anxiety neurosis are relieved at a certain time by another neurosis, perhaps a neurasthenia which has supplanted it. It can then be regularly demonstrated that shortly before this change of the picture there occurred a corresponding change in the form of a sexual injury.
Whereas such experiences, which can be augmented at pleasure, plainly obtrude upon the physician the sexual etiology for a certain category of cases, other cases which would have otherwise remained incomprehensible can at least without gainsaying be solved and classified by the key of the sexual etiology. We refer to those numerous cases in which everything exists that has been found in the former category, such as the appearance of anxiety neurosis on the one hand, and the specific moment of the coitus interruptus on the other, but yet something else slips in, namely, a long interval between the assumed etiology and its effect, and perhaps other etiological moments of a non-sexual nature. We have here, for example, a man who was seized with an attack of palpitation on hearing of his father’s death, and who since that time suffered from an anxiety neurosis. The case cannot be understood, for up to that time this man was not nervous. The death of the father, well advanced in years, did not occur under any peculiar circumstances, and it must be admitted that the natural expected death of an aged father does not belong to those experiences which are wont to make a healthy adult sick. The etiological analysis will perhaps seem clearer if I add that out of regard for his wife this man practiced coitus interruptus for eleven years. At all events the manifestations are precisely the same as those appearing in other persons after a short sexual injury of this nature, and without the intervention of another trauma. The same judgment may be pronounced in the case of a woman who merges into an anxiety neurosis after the death of her child, or in the case of the student who becomes disturbed by an anxiety neurosis while preparing for his final state examination. I find that here, as there, the effect is not explained by the reported etiology. One must not necessarily “overwork” himself studying, and a healthy mother is wont to react to the death of her child with normal grief. But, above all, I would expect that the overworked student would acquire a cephalasthenia, and the mother in our example a hysteria. That both became afflicted with anxiety neurosis causes me to attach importance to the fact that the mother lived for eight year in marital coitus interruptus, and that the student entertained for three years a warm love affair with a “respectable” girl whom he was not allowed to impregnate.
These examples tend to show that where the specific sexual injury of the coitus interruptus is in itself unable to provoke an anxiety neurosis it at least predisposes to its acquisition. The anxiety neurosis then comes to light as soon as the effect of another banal injury enters into the latent effect of the specific moment. The former can quantitatively substitute the specific moment but not supplant it qualitatively. The specific moment always remains that which determines the form of neurosis. I hope to be able to prove to a greater extent this proposition for the etiology of the neurosis.
Furthermore, the last discussions contain the, not in itself, improbable assumption that a sexual injury like coitus interruptus asserts itself through summation. The time required before the effect of this summation becomes visible depends upon the predisposition of the individual and the former burdening of his nervous system. The individuals who bear coitus interruptus manifestly without disadvantage really become predisposed by it to the disturbance—anxiety neurosis—which can at any time burst forth spontaneously or after a banal, otherwise inadequate, trauma, just as the chronic alcoholic finally develops a cirrhosis or another disease by summation, or under the influence of a fever he merges into a delirium.
III. ADDENDA TO THE THEORY OF ANXIETY NEUROSIS.
The following discussions claim nothing but the value of a first tentative experiment, which judgment should not influence the acceptance of the facts mentioned above. The estimation of this “Theory of Anxiety Neurosis” is rendered still more difficult by the fact that it merely corresponds to a fragment of a more comprehensive representation of the neuroses.
The facts hitherto expressed concerning the anxiety neurosis already contain some starting points for an insight into the mechanism of this neurosis. In the first place it contains the assumption that we deal with an accumulation of excitement, and then the very important fact that the anxiety underlying the manifestations of the neurosis is not of psychic derivation. Such, for example, would exist if we found as a basis for the anxiety neurosis a justified fright happening once or repeatedly which has since supplied the source of the preparedness for the anxiety neurosis. But this is not the case; a former fright can perhaps cause a hysteria or a traumatic neurosis but never an anxiety neurosis. As the coitus interruptus is rendered so prominent among the causes of anxiety neurosis I have thought at first that the source of the continuous anxiety was perhaps the repeated fear during the sexual
## act lest the technique will fail and conception follow. But I have found
that this state of mind of the man or woman during the coitus interruptus plays no part in the origin of anxiety neurosis, that the women who are really indifferent to the possibilities of conception are just as exposed to the neurosis as those who are trembling at the possibility of it, it all depends on which person suffers the loss of sexual gratification.
Another starting point presents itself in the as yet unmentioned observation that in a whole series of cases the anxiety neurosis goes along with the most distinct diminution of the sexual libido or the psychic desire, so that on revealing to the patients that their affliction depends on “insufficient gratification,” they regularly reply that this is impossible as just now their whole desire is extinguished. The indications that we deal with an accumulation of excitement, that the anxiety which probably corresponds to such accumulated excitement is of somatic origin, so that somatic excitement becomes accumulated, and furthermore, that this somatic excitement is of a sexual nature, and that it is accompanied by a decreased psychic participation in the sexual processes—all these indications, I say, favor the expectation that the mechanism of the anxiety neurosis is to be found in the deviation of the somatic sexual excitement from the psychic, and in the abnormal utilization of this excitement occasioned by the former.
This conception of the mechanism of anxiety neurosis will become clearer if one accepts the following view concerning the sexual process in man. In the sexually mature male organism, the somatic sexual excitement is—probably continuously—produced, and this becomes a periodic stimulus for the psychic life. To make our conceptions clearer we will add that this somatic sexual excitement manifests itself as a pressure on the wall of the seminal vesicle which is provided with nerve endings. This visceral excitement thus becomes continuously increased, but not before attaining a certain height is it able to overcome the resistances of the intercalated conduction as far as the cortex, and manifest itself as psychic excitement. Then the group of sexual ideas existing in the psyche becomes endowed with energy and results in a psychic state of libidinous tension which is accompanied by an impulse to remove this tension. Such psychic unburdening is possible only in one way which I wish to designate as specific or adequate action. This adequate action for the male sexual impulse consists of a complicated spinal reflex-act which results in the unburdening of those nerve endings, and of all psychically formed preparations for the liberation of this reflex. Anything else except the adequate action would be of no avail, for after the somatic sexual excitement has once reached the liminal value, it continuously changes into psychic excitement; that must by all means occur which frees the nerve endings from their heavy pressure, and thus abolish the whole somatic excitement existing at the time and allow the subcortical conduction to reestablish its resistance.
I will desist from presenting in a similar manner more complicated cases of the sexual process. I will merely formulate the statement that this scheme can essentially be transferred to the woman despite the problem of the perplexity, artificial retardation, and stunting of the female sexual impulse. In the woman, too, it can be assumed that there is a somatic sexual excitement and a state in which this excitement becomes psychic, evoking libido and the impulse to specific action which is accompanied by the sensual feeling. But we are unable to state what analogy there may be in the woman to the unburdening of the seminal vesicles.
We can bring into the bounds of this representation of the sexual process the etiology of actual neurasthenia as well as of the anxiety neurosis. Neurasthenia always originates whenever the adequate (action) unburdening is replaced by a less adequate one, like the normal coitus under the most favorable conditions, by a masturbation or spontaneous pollution; while anxiety neurosis is produced by all moments which impede the psychic elaboration of the somatic sexual excitement. The manifestations of anxiety neurosis are brought about by the fact that the somatic sexual excitement diverted from the psyche expends itself subcortically in not at all adequate reactions.
I will now attempt to test the etiological determinants suggested before in order to see whether they show the common character formulated by me. As the first etiological moment for the man, I have mentioned intentional abstinence. Abstinence consists in foregoing the specific
## action which results from the libido. Such foregoing may have two
consequences, namely that the somatic excitement accumulates, and then, what is more important, is the fact that it becomes diverted to another route where there is more chance for discharge than through the psyche. It will then finally diminish the libido and the excitement will manifest itself subcortically as anxiety. Where the libido does not become diminished, or the somatic excitement is expended in pollutions, or where it really becomes exhausted in consequence of repulsion, everything else except anxiety neurosis is formed. In this manner abstinence leads to anxiety neurosis. But abstinence is also the active process in the second etiological group of frustrated excitement. The third case, that of the considerate coitus reservatus, acts through the fact that it disturbs the psychic preparedness for the sexual discharge by establishing beside the subjugation of the sexual affect, another distracting psychic task. Through this psychic distraction, too, the libido gradually disappears and the further course is then the same as in the case of abstinence. The anxiety in old age (climacterium of men) requires another explanation. Here the libido does not diminish, but just as in the climacterium of women, such an increase takes place in the somatic excitement that the psyche shows itself relatively insufficient for the subjugation of the same.
The subsummation of the etiological determinants in the woman, under the aspect mentioned, does not afford any greater difficulties. The case of the virginal fear is especially clear. Here the group of ideas with which the somatic sexual excitement should combine are not as yet sufficiently developed. In anesthetically newly married the anxiety appears only if the first cohabitations awakened a sufficient amount of somatic excitement. Where the local signs of such excitability (like spontaneous feelings of excitement, desire to micturate, etc.) are lacking, the anxiety, too, stays away. The case of ejaculatio precox or coitus interruptus is explained similarly to that in the man by the fact that the libido gradually disappears in the psychically ungratified act, whereas the excitement thereby evoked is subcortically expended. The formation of an estrangement between the somatic and psychic in the discharge of the sexual excitement succeeds quicker in the woman than in the man and is more difficult to remove. The case of widowhood or voluntary abstinence, as well as the case of climacterium adjusts itself in the woman as in the man, but in the case of abstinence there surely is in addition the intentional repression of the sexual ideas, for an abstinent woman struggling with temptation must often decide to suppress it. The abhorrence perceived by an elderly woman during her menopause against the immensely increased libido can have a similar effect.
The two etiological determinants mentioned last can also be classified without any difficulty.
The tendency to anxiety of the masturbator who becomes neurasthenic is explained by the fact that these persons so easily merge into the state of abstinence after they have for long been accustomed to afford a discharge, to be sure an incorrect one, for every little quantity of somatic excitement. Finally the last case, the origin of anxiety neurosis through a severe illness, overwork, exhaustive nursing, etc., in addition to the efficacy of coitus interruptus readily permits a free interpretation. Through deviation the psyche becomes here insufficient for the subjugation of the somatic sexual excitement, a task which continuously devolves upon it. We know how deeply the libido can sink under the same conditions, and we have here a nice example of a neurosis which although not of a sexual etiology still evinces a sexual mechanism.
The conception here developed represents the symptoms of anxiety neurosis in a measure as a substitute for the omitted specific action to the sexual excitement. As a further corroboration of this I recall that also in normal coitus the excitement expends itself in respiratory acceleration, palpitation, perspiration, congestion, etc. In the corresponding attack of anxiety of our neurosis we have before us the dyspnoea, the palpitation, etc., of the coitus in an isolated and aggravated manner.
It can still be asked why the nervous system merges into a peculiar affective state of anxiety under the circumstances of psychic inadequacy for the subjugation of the sexual excitement? A hint to the answer is as follows: The psyche merges into the affect of fear when it perceives itself unable to adjust an externally approaching task (danger) by corresponding reaction; it merges into the neurosis of anxiety when it finds itself unable to equalize the endogenously originated (sexual) excitement. The psyche, therefore, behaves as if projecting this excitement externally. The affect and the neurosis corresponding to it stand in close relationship to each other; the first is the reaction to an exogenous, the latter the reaction to an analogous endogenous excitement. The affect is a rapidly passing state, the neurosis is chronic because the exogenous excitement acts like a stroke happening but once, while the endogenous acts like a constant force. The nervous system reacts in the neurosis against an inner source of excitement just as it does in the corresponding affect against an analogous external one.
IV. THE RELATIONS TO OTHER NEUROSES.
A few observations still remain to be mentioned on the relations of the anxiety neurosis to the other neuroses in reference to occurrence and inner relationship.
The purest cases of anxiety neurosis are also usually the most pronounced. They are found in potent young individuals with a uniform etiology, and where the disease is not of long standing.
To be sure, the symptoms of anxiety are found more frequently as a simultaneous and common occurrence with those of neurasthenia, hysteria, compulsive ideas, and melancholia. If on account of such clinical mixtures one hesitates in recognizing anxiety neurosis as an independent unity, he will also have to abandon the laboriously acquired separation of hysteria and neurasthenia.
For the analysis of the “mixed neuroses” I can advocate the following proposition: Where a mixed neurosis exists, an involvement of many specific etiologies can be demonstrated.
Such a multiplicity of etiological moments determining a mixed neurosis can only come about accidentally, if the activities of a newly formed injury are added to those already existing. Thus, for example, a woman who was at all times a hysteric begins to practice coitus reservatus at a certain period of her married life, and adds an anxiety neurosis to her hysteria; a man who had masturbated and become neurasthenic, becomes engaged and excites himself with his fiancée so that a fresh anxiety neurosis allies itself to his neurasthenia.
The multiplicity of etiological moments in other cases is not accidental, one of them has brought the other into activity. Thus a woman, with whom her husband practices coitus reservatus without regard to her gratification, finds herself forced to finish the tormenting excitement following such an act with masturbation, as a result of which she shows an anxiety neurosis with symptoms of neurasthenia. Under the same noxiousness another woman has to contend with lewd pictures against which she wishes to defend herself, and in this way the coitus interruptus will cause her to acquire obsessions along with the anxiety neurosis. Finally a third woman, as a result of coitus interruptus loses her affection for her husband and forms another which she secretly guards, and as a result she evinces a mixture of hysteria and anxiety neurosis.
In a third category of mixed neuroses the connection of the symptoms is of a still more intimate nature, as the same etiological determinants regularly and simultaneously evoke both neuroses. Thus, for example, the sudden sexual explanation which we have found in virginal fear always produces hysteria, too; most causes of intentional abstinence connect themselves in the beginning with actual obsessions; and it seems to me that the coitus interruptus of men can never provoke a pure anxiety neurosis, but always a mixture of the same with neurasthenia, etc.
It follows from this discussion that the etiological determinants of the occurrence must moreover be distinguished from the specific etiological moments of neurasthenia. The first moments, as for example the coitus interruptus, masturbation, and abstinence, are still ambiguous, and can each produce different neuroses; and it is only the etiological moments abstracted from them, like the inadequate unburdening, psychic insufficiency, and defense with substitution, that have an unambiguous and specific relation to the etiology of the individual great neuroses.
In its intrinsic property, anxiety neurosis shows the most interesting agreements and differences when compared with the other great neuroses,
## particularly when compared with neurasthenia and hysteria. With
neurasthenia it shares one main character, namely, that the source of excitement, the cause of the disturbance, lies in the somatic rather than in the psychic sphere as in the case of hysteria and compulsion neurosis. For the rest we can recognize a kind of contrast between the symptoms of neurasthenia and anxiety neurosis, which can be expressed in the catchwords, accumulation and impoverishment of excitement. This contrast does not hinder the two neuroses from combining with each other, but shows itself in the fact that the most extreme forms in both cases are also the purest.
When compared with hysteria anxiety neurosis shows in the first place a number of agreements in the symptomatology the valuation of which is still unsettled. The appearance of the manifestations as persistent symptoms or attacks, the aura-like grouped paresthesias, the hyperesthesias and pressure points can be found in certain substitutes for the anxiety attack, as in dyspnoea and palpitation, the aggravation of the perhaps organically determined pains (by conversion)—these and other joint features lead to the supposition that some things which are ascribed to hysteria can with full authority be fastened to anxiety neurosis. But if we enter into the mechanism of both neuroses, as far as it can at present be penetrated, we find aspects which make it appear that the anxiety neurosis is really the somatic counterpart to hysteria. Here as there we have accumulation and excitement—on which is perhaps based the similarity of the aforementioned symptoms—; here as there we have a psychic insufficiency which results from abnormal somatic processes; and here as there we have instead of a psychic elaboration a deviation of the excitement into the somatic. The difference only lies in the fact that the excitement, in which displacement the neurosis manifests itself, is purely somatic (somatic sexual excitement) in anxiety neurosis, while in hysteria it is psychic (evoked through a conflict). Hence it is not surprising that hysteria and anxiety neurosis lawfully combine with each other, as in the “virginal fear” or in the “sexual hysteria,” and that hysteria simply borrows a number of symptoms from anxiety neurosis, etc. This intimate relationship between anxiety neurosis and hysteria furnishes us with a new argument for demanding the separation of anxiety neurosis from hysteria, for if this be denied, one will also be unable to maintain the so painstakingly acquired distinction between neurasthenia and hysteria, so indispensable for the theory of the neuroses.
## CHAPTER VII.
FURTHER OBSERVATIONS ON THE DEFENSE NEUROPSYCHOSES.
Under the caption of “Defense Neuropsychoses” I have comprised hysteria, obsessions, as well as certain cases of acute hallucinatory confusion.[47] All these affections evince one common aspect in the fact that their symptoms originated through the psychic mechanism of (unconscious) defense, that is, through the attempt to repress an unbearable idea which appeared in painful contrast to the ego of the patient. I was also able to explain and exemplify by cases reported in the preceding chapters in what sense this psychic process of “defense” or “repression” is to be understood. I have also discussed the laborious but perfectly reliable method of psychoanalysis of which I make use in my examinations, and which at the same time serves as a therapy.
My experiences during the last two years have strengthened my predilection for making the defense the essential point in the psychic mechanism of the mentioned neuroses, and on the other hand have permitted me to give a clinical foundation to the psychological theory. To my surprise I have discovered some simple but sharply circumscribed solutions for the problem of the neuroses which I shall provisionally briefly report in the following pages. It would be inconsistent with this manner of reporting to add to the assertions the required proofs, but I hope to be able to fulfill this obligation in a comprehensive discussion.
I. THE “SPECIFIC” ETIOLOGY OF HYSTERIA.
That the symptoms of hysteria become comprehensible only through a reduction to “traumatically” effective experiences, and that these psychic traumas refer to the sexual life has already been asserted by Breuer and me in former publications. What I have to add today as a uniform result of thirteen analyzed cases of hysteria concerns, on the one hand, the nature of these sexual traumas, and on the other, the period of life in which they occurred. An experience occurring at any period of life, touching in any way the sexual life, and then becoming pathogenic through the liberation and suppression of a painful affect is not sufficient for the causation of hysteria. It must on the contrary belong to the sexual traumas of early childhood (the period of life before puberty), and its content must consist in a real irritation of the genitals (coitus-like processes).
This specific determination of hysteria—sexual passivity in pre-sexual periods—I have found fulfilled in all analyzed cases of hysteria (among which were two men). To what extent the determination of the accidental etiological moment diminishes the requirement of the hereditary predisposition needs only be intimated. We can, moreover, understand the disproportionately greater frequency of hysteria in the female sex, as even in childhood this sex is more subject to sexual assaults.
The objection most frequently advanced against this result may be to the purport, that sexual assaults on little children occur too frequently to give an etiological value to its verification, or that such experiences must remain ineffectual just because they concern a sexually undeveloped being; and that one must moreover be careful not to obtrude upon the patient through the examination such alleged reminiscences or believe in the romances which they themselves fabricate. To the latter objections I hold out the request that no one should really judge with great certainty this obscure realm unless he has made use of the only method which can clear it up (the method of psychoanalysis for bringing to consciousness the hitherto unconscious[48]). The essential point in the first doubts is settled by the observation that it really is not the experiences themselves that act traumatically, but their revival as reminiscences after the individual has entered into sexual maturity.
My thirteen cases of hysteria were throughout of the graver kind, they were all of long duration, and some had undergone a lengthy and unsuccessful asylum treatment. Every one of the infantile traumas which the analysis revealed for these severe cases had to be designated as marked sexual injuries; some of them were indeed abominable. Among the persons who were guilty of such serious abuse we have in the first place nurses, governesses, and other servants to whom children are left much too carelessly, then in regrettable frequency come the teachers; but in seven of the thirteen cases we dealt with innocent childish offenders, mostly brothers who for years entertained sexual relations with their younger sisters. The course of events always resembled some of the cases which could with certainty be tracked, namely, that the boy had been abused by a person of the feminine sex, thus awakening in him prematurely the libido, and that after a few years he repeated in sexual aggression on his sister the same procedures to which he himself was subjected.
I must exclude active masturbation from the list of sexual injuries of early childhood as being pathogenic for hysteria. That it is so very frequently found associated with hysteria is due to the fact that masturbation in itself is more frequently the result of abuse or seduction than one supposes. It not seldom happens that both members of a childish pair later in life become afflicted by defense neuroses, the brother by obsessions and the sister by hysteria, which naturally gives the appearance of a familial neurotic predisposition. This pseudo-heredity is now and then solved in a surprising manner. I have had under observation a brother, sister, and a somewhat older cousin. The analysis which I have undertaken with the brother showed me that he suffered from reproaches for being the cause of his sister’s malady; he himself was corrupted by his cousin, concerning whom it was known in the family that he fell a victim to his nurse.
I can not definitely state up to what age sexual damage occurs in the etiology of hysteria, but I doubt whether sexual passivity can cause repression after the eighth and tenth year unless qualified for it by previous experiences. The lower limit reaches as far as memory in general, that is, to the delicate age of one and one half or two years! (two cases). In a number of my cases the sexual trauma (or the number of traumas) occurred during the third and fourth year of life. I myself would not lend credence to this peculiar discovery if it were not for the fact that the later development of the neurosis furnished it with full trustworthiness. In every case there are a number of morbid symptoms, habits and phobias which are only explainable by returning to those youthful experiences, and the logical structure of the neurotic manifestation makes it impossible to reject the faithfully retained memories of childhood. Except through psychoanalysis it is of no avail to ask a hysterical patient about these infantile traumas; their remains can only be found in the morbid symptoms and not in conscious memory.
All the experiences and excitements which prepare the way for, or occasion the outburst of, hysteria in the period of life after puberty evidently act through the fact that they awaken the memory remnants of those infantile traumas which do not become conscious but lead to the liberation of affect and repression. It is quite in harmony with this rôle of the later traumas not to be subject to the strict limitation of the infantile traumas, but that both in intensity and quality they can vary from an actual sexual assault to a mere approximation of the sexual, such as perceiving the sexual acts of others, or receiving information concerning sexual processes.[49]
In my first communication on the defense neuropsychoses I failed to explain how the exertion of a hitherto healthy individual to forget such traumatic happenings would result in the real intentional repression, and thus open the door for the defense neurosis. It can not depend on the nature of the experience, as other persons remain unaffected despite the same motives. Hysteria cannot therefore be fully explained by the effect of the trauma, and we are forced to admit that the capacity for hysteria already existed before the trauma.
This indefinite hysterical predisposition can now wholly or partially be substituted by the posthumous effect of the infantile sexual trauma. The “repression” of the memory of a painful sexual experience of maturer years can take place only in persons in whom this experience can bring into activity the memory remnants of an infantile trauma.[50]
The prerequisite of obsessions is also a sexual infantile experience, but of a different nature than that of hysteria. The etiology of both defense neuropsychoses now shows the following relation to the etiology of both simple neuroses, neurasthenia and anxiety neurosis. As I have shown above, both the latter neuroses are the direct results of the sexual noxas alone, while both defense neuroses are the direct results of sexual noxas which acted before the appearance of sexual maturity, that is, they are the results of the psychic memory remnants of these noxas. The actual causes producing neurasthenia and anxiety neurosis simultaneously play the rôle of inciting causes of the defense neuroses, and on the other hand, the specific causes of the defense neuroses, the infantile traumas, may simultaneously prepare the soil for the later developing neurasthenia. Finally it not seldom happens that the existence of a neurasthenia or anxiety neurosis is only preserved by continued recollection of an infantile trauma rather than by actual sexual injuries.
II. THE ESSENCE AND MECHANISM OF COMPULSION NEUROSIS.
Sexual experiences of early childhood have the same significance in the etiology of the compulsion neurosis as in hysteria, still we no longer deal here with sexual passivity but with pleasurably accomplished aggressions, and with pleasurably experienced participation in sexual acts, that is, we deal here with sexual activity. It is due to this difference in the etiological relations that the masculine sex seems to be preferred in the compulsion neurosis.
In all my cases of compulsion neurosis I have found besides a subsoil of hysterical symptoms which could be traced to a pleasurable action of sexual passivity from a precedent scene. I presume that this coincidence is a lawful one, and that premature sexual aggression always presupposes an experience of seduction. But I am unable to present as yet a complete description of the etiology of the compulsion neurosis. I only believe that the final determination as to whether a hysteria or compulsion neurosis should originate on the basis of infantile traumas depends on the temporal relation of the development of the libido.
The essence of the compulsion neurosis may be expressed in the following simple formula: Obsessions are always transformed _reproaches_ returning from consciousness which always refer to a pleasurably accomplished sexual action of childhood. In order to elucidate this sentence it will be necessary to describe the typical course of compulsion neurosis.
In a first period—period of childish immorality—the events containing the seeds of the later neurosis take place. In the earliest childhood there appear at first the experiences of sexual seduction which later makes the repression possible, and this is followed by the actions of sexual aggressions against the other sex which later manifest themselves as actions of reproach.
This period is brought to an end by the appearance of the—often self ripened—sexual “maturity.” A reproach then attaches itself to the memory of that pleasurable action, and the connection with the initial experience of passivity makes it possible—often only after conscious and recollected effort—to repress it and replace it by a primary symptom of defense. The third period, that of apparent healthiness but really of successful defense, begins with the symptoms of scrupulousness, shame and diffidence.
The next period, the disease is characterized by the return of the repressed reminiscences, hence, by the failure of the defense; but it remains undecided whether the awakening of the same is more frequently accidental and spontaneous, or whether it appears in consequence of actual sexual disturbances, that is, as additional influences of the same. But the revived reminiscences and the reproaches formed from them never enter into consciousness unchanged, but what becomes conscious as an obsession and obsessive affect and substitutes the pathogenic memory in the conscious life, are compromise formations between the repressed and the repressing ideas.
In order to describe clearly and probably convincingly the processes of repression, the return of the repression, and the formation of the pathological ideas of compromise, we would have to decide upon very definite hypotheses concerning the substratum of the psychic occurrence and consciousness. As long as we wish to avoid it we will have to rest content with the following rather figuratively understood observations. Depending on whether the memory content of the reproachful action alone forces an entrance into consciousness or whether it takes with it the accompanying reproachful affect, we have two forms of compulsion neurosis. The first represents the typical obsessions, the content of which attracts the patient’s attention; only an indefinite displeasure is perceived as an affect, whereas, for the content of the obsession the only suitable affect would be one of reproach. The content of the obsession is doubly distorted when compared to the content of the infantile compulsive act. First, something actual replaces the past experience, and second, the sexual is substituted by an analogous non-sexual experience. These two changes are the results of the constant tendency to repression still in force which we will attribute to the “ego.” The influence of the revived pathogenic memory is shown by the fact that the content of the obsession is still partially identical with the repressed, or can be traced to it by a correct stream of thought. If, with the help of the psychoanalytic method, we reconstruct the origin of one individual obsession we find that one actual impression instigated two diverse streams of thought, and that the one which passed over the repressed memory, though incapable of consciousness and correction, proves to be just as correctly formed logically as the other. If the results of the two psychic operations disagree, the contradiction between the two may never be brought to logical adjustment, but as a compromise between the resistance and the pathological result of thought an apparently absurd obsession enters into consciousness beside the normal result of the thought. If both streams of thought yield the same result, they reinforce each other so that the normally gained result of thought now behaves psychically like an obsession. Wherever neurotic compulsion manifests itself psychically it originates from repression. The obsessions have, as it were, a psychical course of compulsion which is due, not to their own validity, but to the source from which they originate, or to the source which furnishes a part of their validity.
A second form of compulsion neurosis results if the repressed reproach and not the repressed content of memory forces a replacement in the conscious psychic life. Through a psychic admixture, the affect of the reproach can change itself into any other affect of displeasure, and if this occurs there is nothing to hinder the substituting affect from becoming conscious. Thus, the reproach (of having performed in childhood some sexual actions) may be easily transformed into shame (if some one else becomes aware of it), into hypochondriacal anxiety (because of the physical harmful consequences of those reproachful acts), into social anxiety (fearing punishment from others), into religious anxiety, into delusions of observation (fear of betraying those actions to others), into fear of temptations (justified distrust in one’s own moral ability of resistance), etc. Besides, the memory content of the reproachful
## action may also be represented in consciousness, or it may be altogether
concealed, which makes the diagnosis very difficult. Many cases which on superficial examination are taken as ordinary (neurasthenic) hypochondria often belong to this group of compulsive affects; the very frequently so called “periodic neurasthenia” or “periodic melancholia” especially seem to be explained by compulsive affects or obsessions, a recognition not unimportant therapeutically.
Beside these compromise symptoms which signify the return of the repression and hence a failure of the originally achieved defense, the compulsion neurosis forms a series of other symptoms of a totally different origin. The ego really tries to defend itself against those descendants of the initial repressed reminiscence, and in this conflict of defense it produces symptoms which may be comprehended as “secondary defense.” These are throughout “protective measures” which have performed good service in the struggle carried on against the obsessions and the obsessing affects. If these helps in the conflict of the defense really succeed in repressing anew the symptoms of return obtruding themselves on the ego, the compulsion then transmits itself on the protective measures themselves and produces a third form of the “compulsion neurosis,” the compulsive action. These are never primary, they never contain anything else but a defense, never an aggression. Psychic analysis shows that despite their peculiarity they can always be fully explained by reduction to the compulsive reminiscence which they oppose.[51]
The secondary defense of the obsessions can be brought about by a forcible deviation to other thoughts of possibly contrary content; hence, in case of success there is a compulsive reasoning, regularly concerning abstract and transcendental subjects, because the repressed ideas always occupied themselves with the sensuous. Or the patient tries to become master of every compulsive idea through logical labor and by appealing to his conscious memory; this leads to compulsive thinking and examination and to doubting mania. The priority of the perception before the memory in these examinations at first induce and then force the patient to collect and preserve all objects with which he comes in contact. The secondary defense against the compulsive affects results in a greater number of defensive measures which are capable of being transformed into compulsive actions. These can be grouped according to their tendency. We may have measures of penitence (irksome ceremonial and observation of numbers), of prevention (diverse phobias, superstition, pedantry, aggravation of the primary symptom of scrupulousness), measures of fear of betrayal (collecting papers and shyness), and measures of becoming unconscious (dipsomania). Among these compulsive acts and impulses the phobias play the greatest part as limitations of the patient’s existence.
There are cases in which we can observe how the compulsion becomes transferred from the idea or affect to the measure, and other cases in which the compulsion oscillates between the returning symptoms of secondary defense. But there are also cases in which no obsessions are really formed, but the repressed reminiscence immediately becomes replaced by the apparent primary defensive measure. Here that stage is attained at a bound which otherwise ends the course of the compulsion neurosis only after the conflict of the defense. Grave cases of this affection end either with a fixation of ceremonial actions, general doubting mania, or in an existence of eccentricity conditioned by phobias.
That the obsessions and everything derived from them are not believed is probably due to the fact that the defense symptom of scrupulousness was formed during the first repression and gained compulsive validity. The certainty of having lived morally throughout the whole period of the successful defense makes it impossible to give credence to the reproach which the obsession really involves. Only transitorily during the appearance of a new obsession, and now and then in melancholic exhaustive states of the ego do the morbid symptoms of the return also enforce the belief. The “compulsion” of the psychic formations here described has in general nothing to do with the recognition through belief, and is not to be mistaken for that moment which is designated as “strength” or “intensity” of an idea. Its main characteristic lies in its inexplicableness through psychic activities of conscious ability, and this character undergoes no change whether the idea to which the compulsion is attached is stronger or weaker, more or less intensively “elucidated,” “supplied with energy,” etc.
The reason for the unassailableness of the obsession or its derivative is due only to its connection with the repressed memory of early childhood, for as soon as we succeed in making it conscious, for which the psychotherapeutic methods already seem quite sufficient, the compulsion, too, becomes detached.
III. ANALYSIS OF A CASE OF CHRONIC PARANOIA.
For some length of time I entertained the idea that paranoia also—or the group of cases belonging to paranoia—is a defense psychosis, that is, like hysteria and obsessions it originates from the repression of painful reminiscences, and that the form of its symptoms is determined by the content of the repression. A special way or mechanism of repression must be peculiar to paranoia perhaps just as in hysteria which brings about the repression by way of conversion into bodily innervation, and perhaps like obsessions in which a substitution is accomplished (displacement along certain associative categories). I observed many cases which seemed to favor this interpretation, but I had not found any which demonstrated it until a few months ago when, through the kindness of Dr. J. Breuer, I subjected to psychoanalysis, with therapeutic aims, an intelligent woman of 32, whom no one will be able to refuse to designate as a chronic paranoiac. I report here some explanations gained in this work, because I have no prospects of studying paranoia except in very isolated examples, and because I think it possible that these observations may instigate a psychiatrist for whom conditions are more favorable, to give due justice to the moment of defense in the present animated discussion on the nature and psychic mechanism of paranoia. It is of course far from my thoughts to wish to show from the following single observation anything but that this case is a defense psychosis, and that in the group of “paranoia” there may be still others of a similar nature.
Mrs. P. thirty-two years old, married three years. She is the mother of a two-year-old child, and does not descend from nervous parents; but her sister and brother whom I know, are also neurotic. It was doubtful whether she was not transitorily depressed and mistaken in her judgment in the middle of her twentieth year. During the last years she was healthy and capacitated until she evinced the first symptoms of the present illness, six months after the birth of her child. She became secluded and suspicious, showing a disinclination towards social relations with the relatives of her husband, and complained that the neighbors in the little town now behaved towards her in a rather impolite and regardless manner. Gradually these complaints grew in intensity, she thought that there was something against her, though she had no notion what it could be. But there was no doubt that all the relatives and friends denied her respect, and did everything to aggravate her. She was trying very hard to find out whence this came but could not discover anything. Some time later she complained that she was watched, that her thoughts were guessed, and that everything that happened in her house was known. One afternoon she suddenly conceived the thought that she was watched during the evening while undressing. Since then she applied while undressing the most complicated precautionary measures. She slipped into her bed in the darkness and undressed only under cover. As she avoided all social relations, and took but little nourishment, and was very depressed, she was sent in the summer of 1895 to a hydrotherapeutic institute. There new symptoms appeared and reinforced those already existing. As early as the spring, while she was alone with the servant girl, she suddenly perceived a sensation in her lap, and thought that the servant girl then had an unseemly thought. This sensation became more frequent in the summer, it was almost continuous, and she felt her genitals “as if one feels a heavy hand.” She then began to see pictures which frightened her; they were hallucinations of female nakedness, especially an exposed woman’s lap with hair; occasionally she also saw male genitals. The picture of the hairy lap and the organic sensation in the lap usually came conjointly. The pictures became very aggravating, as she regularly perceived them when she was in the company of a woman, and the thought accompanying them was that she sees the woman in an indecent exposure, and that in the same moment the woman sees the same picture of her (!) Simultaneously with these visual hallucinations, which, after their first appearance in the asylum, disappeared again for many months, she began to be troubled with voices which she did not recognize and could not explain. When she was in the street she heard, “This is Mrs. P.—Here she goes.—Where does she go?”. Every one of her movements and actions were commented upon. Occasionally she heard threats and reproaches. All these symptoms became worse when she was in society, or even in the street; she therefore hesitated about going out; she also stated that she experienced nausea for food, and as a result she became reduced in vitality.
I obtained this from her when she came under my care in the winter of 1895. I present this case in detail in order to make the impression that we really deal here with a very frequent form of chronic paranoia, which diagnosis will agree with the details of the symptoms and their behavior to be mentioned later. At that time she either concealed from me the delusions for the interpretation of the hallucinations or they really had not as yet occurred. Her intelligence was undiminished. It was reported to me as peculiar that she had a number of rendezvous with her brother who lived in the neighborhood, in order to confide something to him, but this she never told him. She never spoke about her hallucinations, and towards the end she did not say much about the aggravations and persecutions from which she suffered. What I have to report about this patient concerns the etiology of the case and the mechanism of the hallucinations. I discovered the etiology by applying Breuer’s method exactly as in hysteria, for the investigation and removal of the hallucinations. I started with the presupposition that just as in the two other defense neuroses known to me this paranoia must contain unconscious thoughts and repressed reminiscences which have to be brought to consciousness, in the same manner as in the others, by overcoming a certain resistance. The patient immediately corroborated this expectation by behaving during the analysis exactly like a hysteric, and under attention to the pressure of my hand she reproduced thoughts which she could not remember having had, which she at first could not understand, and which contradicted her expectations. The occurrence of important unconscious ideas was therefore also demonstrated in a case of paranoia, and I could hope to reconduct the compulsion of paranoia to repression. It was only peculiar that the assertions which originated in the unconscious were usually heard inwardly or hallucinated by her as her voices.
Concerning the origin of the visual hallucinations, or at least the vivid pictures, I discovered the following: The picture of the female lap occurred almost always together with the organic sensation in the lap. The latter, however, was more constant and often occurred without the picture.
The first pictures of feminine laps appeared in the hydrotherapeutic institute a few hours after she had actually seen a number of women naked in the bath house. They were therefore only simple reproductions of a real impression. It may be assumed that these impressions repeated themselves because something of great interest was connected with them. She stated that she was at that time ashamed of these women, and that since she recalled it she is ashamed of having been seen naked. Having been obliged to look upon this shame as something compulsive, I concluded that according to the mechanism of defense an experience must have here been repressed in which she was not ashamed, and I requested her to allow those reminiscences to emerge which belonged to the theme of shame. She promptly reproduced a series of scenes from her seventeenth to her eighth year, during which while bathing before her mother, her sister, and her physician she was ashamed of her nakedness. This series, however, reached back to a scene in her sixth year when she undressed in the children’s room before going to sleep without feeling ashamed of her brother who was present. On questioning her it was found that there were a number of such scenes, and that for years the brothers and sisters were in the habit of showing themselves naked to one another before retiring. I now understood the significance of the sudden thought of being watched on going to sleep. It was an unchanged fragment of the old reproachful reminiscence, and she was now trying to make up in shame what she lost as a child.
The supposition that we dealt here with an amour of childhood so frequent in the etiology of hysteria was strengthened by the further progress of the analysis which also showed simultaneous solutions for individual frequently recurring details in the picture of paranoia. The beginning of her depression commenced at the time of a disagreement between her husband and her brother on account of which the latter no longer visited her. She was always much attached to this brother and missed him very much at this time. Besides this she spoke about a moment in the history of her disease during which for the first time “everything became clear,” that is, during which she became convinced that her assumption about being generally despised and intentionally annoyed was true. She gained this assurance during a visit of her sister-in-law, who in the course of conversation dropped the words, “If such a thing should happen to me I would not mind it.” Mrs. P. at first took this utterance unsuspectingly, but when her visitor left her it seemed to her that these words contained a reproach meaning that she was in the habit of taking serious matters lightly, and since that hour she was sure that she was a victim of common slander. On asking her why she felt justified in referring those words to herself she answered that the tone in which her sister-in-law spoke convinced her of it—to be sure subsequently—This is really a characteristic detail of paranoia. I now urged her to recall her sister-in-law’s conversation before the accusing utterance, and it was found that she related that in her father’s home there were all sorts of difficulties with the brothers, and added the wise remark, “In every family many things happen which one would rather keep under cover, and that if such a thing should happen to her she would take it lightly.” Mrs. P. had to acknowledge that her depression was connected with the sentences before the last utterance. As she repressed both sentences which could recall her relations with her brother, and retained only the last meaningless one, she was forced to connect with it the feeling of being reproached by her sister-in-law; but, inasmuch as the contents of this sentence offered absolutely no basis for such assumption she disregarded it and laid stress on the tone with which the words were pronounced. It is probably a typical illustration for the fact that the misinterpretations of paranoia depend on repression.
In a most surprising manner it also explains her peculiar behavior in making appointments with her brother and then refusing to tell him anything. Her explanation was that she thought that if she only looked at him he must understand her suffering, as he knew the cause of it. As this brother was really the only person who could know anything about the etiology of her disease it followed that she acted from a motive which, though she did not consciously understand, seemed perfectly justified as soon as a new sense was put on it from the unconscious.
I then succeeded in causing her to reproduce different scenes the culminating points of which were the sexual relations with her brother at least from her sixth to her tenth year. During this work of reproduction the organic sensation in the lap “joined in the discussion,” precisely as regularly observed in the analysis of memory remnants of hysterical patients. The picture of a naked female lap (but now reduced to childish proportions and without hair) immediately appeared or stayed away in accordance with the occurrence of the scene in question in full light or in darkness. The disgust for eating, too, was explained by a repulsive detail of these actions. After we had gone through this series, the hallucinatory sensations and pictures disappeared without having thus far returned.[52]
I have thus learned that these hallucinations were nothing other than fragments from the content of the repressed experiences of childhood, that is, symptoms of the return of the repressed material.
I now turned to the analysis of the voices. Here it must before all be explained why such indifferent remarks as, “Here goes Mrs. P.—She now looks for apartments, etc.” could be so painfully perceived, and how these harmless sentences managed to become distinguished by hallucinatory enforcement. To begin with, it was clear that these “voices” could not be hallucinatory reproduced reminiscences like the pictures and sensations, but rather thoughts which “became loud.”
She heard the voices for the first time under the following circumstances. With great tension she read the pretty story, “The Heiterethei” by O. Ludwig, and noticed that while reading she was preoccupied with incoming thoughts. Immediately after she took a walk on the highway and suddenly while passing a peasant’s cottage the voices told her, “That is how the house of the Heiterethei looked! Here is the well, and here is the bush! How happy she was in all her poverty!” The voices then repeated whole paragraphs of what she had just read, but it remained incomprehensible why house, bush, and well of the Heiterethei, and just such indifferent and most irrelevant passages of the romance should have obtruded themselves upon her attention with pathological strength. The analysis showed that while reading she at the same time entertained extraneous thoughts, and that she was excited by totally different passages of the book. Against this material analogy between the couple of the romance and herself and her husband, the reminiscence of intimate things of her married life and family secrets, against all these there arose a repressive resistance because they were connected with her sexual shyness by very simple and demonstrable streams of thought, and finally resulted in the awakening of old experiences of childhood. In consequence of the censorship exercised by the repression the harmless and idyllic passages connected with the objectionable ones by contrast and vicinity, became reinforced in consciousness, enabling them to become audible. For example, the first repressed thought referred to the slander to which the secluded heroine was subjected by her neighbors. She readily found in this an analogy to herself. She, too, lived in a small place, had no intercourse with anybody and considered herself despised by her neighbors. The suspicion against the neighbors was founded on the fact that in the beginning of her married life she was obliged to content herself with a small apartment. The wall of the bedroom, near which stood the nuptial bed of the young couple, adjoined the neighbors’ room. With the beginning of her marriage there awakened in her a great sexual shyness. This was apparently due to an unconscious awakening of some reminiscences of childhood of having played husband and wife. She was very careful lest the neighbors might hear through the adjacent wall either words or noises and this shyness changed into suspicion against the neighbors.
The voices therefore owed their origin to the repression of thoughts which in the last analysis really signified reproaches on the occasion of an experience analogous to the infantile trauma; they were accordingly symptoms of the return of the repression, but at the same time they were results of a comparison between the resistance of the ego and the force of the returning repression which in this case produce a distortion beyond recognition. On other occasions when analyzing voices in Mrs. P. the distortion was less marked, still the words heard always showed a character of diplomatic uncertainty. The annoying allusion was generally deeply hidden, the connection of the individual sentences was masked by a strange expression, unusual forms of speech, etc., characteristics generally common to the auditory hallucinations of paranoiacs, and in which I noticed the remnant of the compromise distortion. The expression, “There goes Mrs. P., she is looking for apartments in the street,” signified, for example, the threat that she will never recover, for I promised her that after the treatment she would be able to return to the little city where her husband was employed. She rented temporary quarters in Vienna for a few months.
On some occasions Mrs. P. also perceived more distinct threats, for example, concerning the relatives of her husband, the restrained expression of which still continued to contrast with the grief which such voices caused her. Considering all that we otherwise know of paranoiacs I am inclined to assume a gradual relaxation of that resistance which weakens the reproaches so that finally the defense fails completely and the original reproach, the insulting word, which one wanted to save himself returns in unchanged form. I do not, however, know whether this is a constant course, whether the censor of the expressions of reproach can not from the beginning stay away, or persist to the end.
It is left for me to utilize the explanations gained in this case of paranoia for the comparison of paranoia with compulsion neurosis. Here, as there, the repression was shown to be the nucleus of the psychic mechanism, and in both cases the repression is a sexual experience of childhood. The origin of every compulsion in this paranoia is in the repression, and the symptoms of paranoia allow a similar classification as the one found justified in compulsion neurosis. Some symptoms also originate from the primary defense among which are all delusions of distrust, suspicion and persecution by others. In the compulsion neurosis the initial reproach became repressed through the formation of the primary symptom of defense, self-distrust, moreover, the reproach was recognized as justified, and for the purpose of adjustment the validity acquired by the scrupulousness during the normal interval now guards against giving credence to the returning reproach in the form of an obsession. By the formation of the defense symptom of distrust in others, the reproach in paranoia is repressed in a way which may be designated as projection; the reproach is also deprived of recognition, and as a retaliation there is no protection against the returning reproaches contained in the delusions.
The other symptoms in my case of paranoia are therefore to be designated as symptoms of the return of the repression, and as in the compulsion neurosis they show the traces of the compromise which alone permits an entrance into consciousness. Such are the delusions of being observed while undressing, the visual hallucinations, the perceptual hallucinations and the hearing of voices. The memory content existing in the delusion mentioned is almost unchanged and appears only uncertain through utterance. The return of the repression into visual pictures comes nearer to the character of hysteria than to the character of compulsion neurosis; still, hysteria is wont to repeat its memory symbols without modification, whereas the paranoiac memory hallucination undergoes a distortion similar to those in compulsion neurosis. An analogous modern picture takes the place of the one repressed (instead of a child’s lap it was the lap of a woman upon which the hairs were
## particularly distinct because they were absent in the original
impression). Quite peculiar to paranoia but no further elucidated in this comparison is the fact that the repressed reproaches return as loud thoughts, this must yield to a double distortion: (1) a censor, which either leads to a replacement through other associated thoughts or to a concealment by indefinite expressions, and (2) the reference to the modern which is merely analogous to the old.
The third group of symptoms found in compulsion neurosis, the symptoms of the secondary defense, cannot exist as such in paranoia, for no defense asserts itself against the returning symptoms which really find credence. As a substitute for this we find in paranoia another source of symptom formation; the delusions (symptoms of return) reaching consciousness through the compromise demand a great deal of the thinking work of the ego until they can be unconditionally accepted. As they themselves are not to be influenced the ego must adapt itself to them, and hence the combining delusional formation, the delusion of interpretation which results in the transformation of the ego, corresponds here to the symptoms of secondary defense of compulsion neurosis. In this respect my case was imperfect as it did not at that time show any attempt at interpretation, this only appeared later. I do not doubt, however that if psychoanalysis were also applied to that stage of paranoia, another important result would be established. It would probably be found that even the so called weakness of memory in paranoiacs is purposeful, that is, it depends on the repression and serves its purpose. Subsequently even those nonpathogenic memories which stand in opposition to the transformation of the ego become repressed and replaced; this the symptoms of return imperatively demand.
## CHAPTER VIII.
ON PSYCHOTHERAPY.[53]
_Gentlemen_:
It is almost eight years since, at the request of your deceased chairman, Prof. v. Reder, I had the pleasure of speaking in your midst on the subject of hysteria. Shortly before (1895) I had published the “Studien über Hysterie” together with Dr. J. Breuer, and on the basis of a new knowledge for which we are thankful to this investigator, I have attempted to introduce a new way of treating the neurosis. Fortunately, I can say that the endeavors of our “Studies” have met with success, and that the ideas which they advocate concerning the effects of psychic traumas through the restraint of affects and the conception of the hysterical symptom as a result of a displacement of excitement from the psychic to the physical—ideas for which we have created the terms “ab-reaction” and “conversion”—are today generally known and understood. At least in German-speaking countries there are no descriptions of hysteria which do not to a certain extent take cognizance of them, and no colleague who does not at least partially follow this theory. And yet as long as they were new these theories and these terms must have sounded strange enough!
I can not say the same thing about the therapeutic procedure which we have proposed to our colleagues together with our theory. It still struggles for recognition. This may have its special reasons. The technique of the procedure was at that time still rudimentary. I was unable to give those indications to the medical reader of the book which would enable him to perform such a treatment. But surely there were other causes of a general nature. To many physicians psychotherapy even today appears as a product of modern mysticism, and in comparison to our physico-chemical remedies the application of which is based on physiological insight, psychotherapy appears quite unscientific and unworthy of the interest of a natural philosopher. You will therefore allow me to present to you the subject of psychotherapy, and to point out to you what part of this verdict can be designated as unjust or erroneous.
In the first place let me remind you that psychotherapy is not a modern therapeutic procedure. On the contrary it is one of the oldest remedies used in medicine. In Lëwenfeld’s instructive work (Lehrbuch der gesamten Psychotherapie) you can find the methods employed in primitive and ancient medicine. Most of them were of a psychotherapeutic nature. In order to cure a patient he was transferred into a state of “credulous expectation” which acts in a similar manner even today. Even after the doctors found other remedial agents psychotherapeutic endeavors never disappeared from this or that branch of medicine.
Secondly, I call your attention to the fact that we doctors really can not abandon psychotherapy if only because another very much to be considered party in the treatment—namely the patient—has no intention of abandoning it. You know how much we owe to the Nancy school (Liébault, Bernheim) for these explanations. Without our intention, an independent factor from the patient’s psychic disposition enters into the activity of every remedial agent introduced by the doctor, acting mostly in a favorable sense but often also in an inhibiting sense. We have learned to apply to this factor the word “suggestion,” and Moebius taught us that the failures of some of our remedies are to be ascribed to the disturbing influences of this very powerful moment. You doctors, all of you, constantly practice psychotherapy, even when you do not know it, or do not intend it, but it has one disadvantage, you leave entirely to the patient the psychic factor of your influence. It then becomes uncontrollable, it can not be divided into doses and can not be increased. Is it not a justified endeavor of the doctor to become master of this factor, to make use of it intentionally, to direct and enforce it? It is nothing other than that, that scientific psychotherapy expects of you.
In the third place, gentlemen, I wish to refer you to the well known experience, namely, that certain maladies and particularly the psychoneuroses, are more accessible to psychic influences than to any other medications. It is no modern talk but a dictum of old physicians that these diseases are not cured by the drug, but by the doctor, to wit, by the personality of the physician in so far as it exerts a psychic influence. I am well aware, gentlemen, that you like very much the idea which the aesthete Vischer, in his parody on Faust (Faust, der Tragödie, III Teil) endowed with a classical expression: “I know that the physical often acts on the moral.”
But would it not be more adequate and frequently more correct to influence the moral part of the person with the moral, that is, with psychic means?
There are many ways and means of psychotherapy. All methods are good which produce the aim of the therapy. Our usual consolation, “You will soon be well again,” with which we are so generous to our patients, corresponds to one of the psychotherapeutic methods, only that on gaining a profounder insight into the neuroses we are not forced to limit ourselves to this consolation alone. We have developed the technique of hypnotic suggestion, of psychotherapy through diversion, through practice, and through the evocation of serviceable affects. I do not disdain any of them, and would practice them all under suitable conditions. That I have in reality restricted myself to a single therapeutic procedure, to the method called by Breuer “cathartic,” which I prefer to call “analytic,” is simply due to subjective motives which guided me. Having participated in the elaboration of this therapy I feel it a personal duty to devote myself to its investigation, and to the final development of its technique. I maintain that the analytic method of psychotherapy is one which acts most penetratingly, and carries farthest; through it one can produce the most prolific changes in the patient. If I relinquish for a moment the therapeutic point of view, I can assert that it is the most interesting, and that it alone teaches us something concerning the origin and the connection of the morbid manifestations. Owing to insights which it opens for us into the mechanism of the psychic malady, it can even lead us beyond itself, and show us the way to still other kinds of therapeutic influences.
Allow me now to correct some errors, and furnish some explanations concerning this cathartic or analytic method of psychotherapy.
(_a_) I notice that this method is often mistaken for the hypnotic suggestive treatment. I notice this by the fact that quite frequently colleagues whose confidant I am not by any means, send patients to me, refractory patients of course, with the request that I should hypnotize them. Now, for eight years I have not practiced hypnotism (individual cases excluded) as a therapeutic aim, and hence I used to return the patients with the advice that he who relies on hypnosis should do it himself. In truth, the greatest possible contrast exists between the suggestive and the analytic technique, that contrast which the great Leonardo da Vinci has expressed for the arts in the formulæ per via di porre and per via di levare. Said Leonardo, “the art of painting works per via di levare, that is to say, places little heaps of paint where they have not been before on the uncolored canvas; sculpturing, on the other hand, goes per via di levare, that is to say, it takes away from the stone as much as covers the surface of the statue therein contained.” Quite similarly, gentlemen, the suggestive technique acts per via di porre, it does not concern itself about the origin, force, and significance of the morbid symptoms, but puts on something, to wit, the suggestion which it expects will be strong enough to prevent the pathogenic idea from expression. On the other hand the analytic therapy does not wish to put on anything, or introduce anything new, but to take away, and extract, and for this purpose it concerns itself with the genesis of the morbid symptoms, and the psychic connection of the pathogenic idea the removal of which is its aim. This manner of investigation has considerably furthered our understanding. I have so early given up the technique of suggestion, and with it hypnosis, because I despaired of making the suggestion as strong and persistent as would be necessary for a lasting cure. In all grave cases I noticed that the suggestions which were put on crumbled off again, and then the disease, or one replacing it, reappeared. Besides, I charge this technique with concealing from us the psychic play of forces, for example, it does not permit us to recognize the resistance with which the patients adhere to their malady, with which they also strive against the recovery, and which alone can give us an understanding of their behavior in life.
(_b_) It seems to me that a very widespread mistake among my colleagues is the idea that the technique of the investigation for the causes of the disease and the removal of the manifestations by this investigation is easy and self-evident. I concluded this from the fact that of the many who interest themselves in my therapy and express a definite opinion on the same, no one has yet asked me how I do it. There can only be one reason for it, they believe there is nothing to ask, that it is a matter of course. I occasionally also hear with surprise that in this or that division of the hospital a young interne is requested by his chief to undertake a “psychoanalysis” with a hysterical woman. I am convinced that he would not entrust him with the examination of an extirpated tumor without previously assuring himself that he is acquainted with the histological technique. Likewise I am informed that this or that colleague has made appointments with a patient for psychic treatment, whereas I am certain that he does not know the technique of such a treatment. He must, therefore, expect that the patient will bring him her secrets, or he seeks salvation in some kind of a confession or confidence. I should not wonder if the patient thus treated would rather be harmed than benefited. The mental instrument is really not at all easy to play. On such occasions I can not help but think of the speech of a world-renowned neurotic, who really never came under a doctor’s treatment, and only lived in the fancy of the poet. I mean Prince Hamlet of Denmark. The king has sent the two courtiers, Rosencrantz and Guildenstern, to investigate him and rob him of his secret. While he defended himself, pipes were brought on the stage. Hamlet took a pipe and requested one of his tormentors to play on it, saying that it is as easy to play as lying. The courtier hesitated because he knew no touch of it, and as he could not be moved to attempt to play the pipe, Hamlet finally burst forth: “Why, look you now, how unworthy a thing you make of me! You would play upon me; you would seem to know my stops; you would pluck out the heart of my mystery; you would sound me from my lowest note to the top of my compass; and there is much music, excellent voice, in this little organ, yet you cannot make it speak. ’Sblood! do you think I am easier to be played on than a pipe? Call me what instrument you will, though you can fret me, you cannot play upon me.” (Act III, Scene 2.)
(_c_) You will have surmised from some of my observations that the analytic cure contains qualities which keep it away from the ideal of a therapy. Tuto, cito, iucunde; the investigation and examination does not really mean rapidity of success, and the allusion to the resistance has prepared you for the expectation of inconveniences. Certainly the psychoanalytic method lays high claims on the patient as well as the physician. From the first it requires the sacrifice of perfect candor, it takes up much of his time, and is therefore also expensive; for the physician it also means the loss of much time, and due to the technique which he has to learn and practice, it is quite laborious. I even find it quite justified to employ more suitable remedies as long as there is a prospect to achieve something with them. It comes to this point only: if we gain by the more laborious and cumbersome procedure considerably more than by the short and easy one, the first is justified despite everything. Just think, gentlemen, by how much the Finsen therapy of lupus is more inconvenient and expensive than the formerly used cauterization and scraping, and yet it means a great progress, merely because it achieves more, it actually cures the lupus radically. I do not really wish to carry through the comparison, but psychoanalysis can claim for itself a similar privilege. In reality I could develop and test my therapeutic method in grave and in the gravest of cases only; my material at first consisted of patients who tried everything unsuccessfully, and had spent years in asylums. I hardly gained enough experience to be able to tell you how my therapy behaves in those lighter, episodically appearing diseases which we see cured under the most diverse influences, and also spontaneously. The psychoanalytic method was created for patients who are permanently incapacitated, and its triumph is to make a gratifying number of such, permanently capacitated. Against this success all expense is insignificant. We can not conceal from ourselves what we were wont to disavow to the patient, namely, that the significance of a grave neurosis for the individual subjected to it is not less than any cachexia or any of the generally feared maladies.
(_d_) In view of the many practical limitations which I have encountered in my work, I can hardly definitely enumerate the indications and contraindications of this treatment. However, I will attempt to discuss with you a few points:
1. The former value of the person should not be overlooked in the disease, and you should refuse a patient who does not possess a certain degree of education, and whose character is not in a measure reliable. We must not forget that there are also healthy persons who are good for nothing, and that if they only show a mere touch of the neurosis, one is only too much inclined to blame the disease for incapacitating such inferior persons. I maintain that the neurosis does not in any way stamp its bearer as a dégéneré, but that frequently enough it is found in the same individual associated with the manifestations of degeneration. The analytic psychotherapy is therefore no procedure for the treatment of neuropathic degeneration, on the contrary it is limited by it. It is also not to be applied in persons who are not prompted by their own suffering to seek the treatment, but subject themselves to it by order of their relatives. The characteristic feature upon which the usefulness of the psychoanalytic treatment depends, the educability, we will still have to consider from another point of view.
2. If one wishes to take a safe course he should limit his selection to persons of a normal state, for, in psychoanalytic procedures, it is from the normal that we seize upon the morbid. Psychoses, confusional states, and marked (I might say toxic) depressions, are unsuitable for analysis, at least as it is practiced today. I do not think it at all impossible that with the proper changes in the procedure it will be possible to disregard this contraindication, and thus claim a psychotherapy for the psychoses.
3. The age of the patient also plays a part in the selection for the psychoanalytic treatment. Persons near or over the age of fifty lack, on the one hand, the plasticity of the psychic processes upon which the therapy depends—old people are no longer educable—and on the other hand, the material which has to be elaborated, and the duration of the treatment is immensely increased. The earliest age limit is to be individually determined; youthful persons, even before puberty, are excellent subjects for influence.
4. One should not attempt psychoanalysis when it is a question of rapidly removing a threatening manifestation, as, for example, in the case of an hysterical anorexia.
You have now gained the impression that the sphere of application of the analytic psychotherapy is a very limited one, for you really heard me enumerate nothing but contraindications. Nevertheless, there remain sufficient cases and morbid states, such as all chronic forms of hysteria with remnant manifestations, the extensive realms of compulsive states, abulias, etc., on which this therapy can be tried.
It is pleasing that particularly the worthiest and highest developed persons can thus be most helped. Where the analytic psychotherapy has accomplished but little one can cheerfully assert that any other treatment would have certainly resulted in nothing.
(_e_) You will surely wish to ask me about the possibility of doing harm through the application of psychoanalysis. To this I will reply that if you will judge justly you will meet this procedure with the same critical good-feeling as you have met our other therapeutic methods, and doing this you will have to agree with me that a rationally executed analytic treatment entails no dangers for the patient. One who, like a layman, is accustomed to ascribe to the treatment everything occurring during the disease, will probably judge differently. It is really not so long since our hydrotherapeutic asylums met with similar opposition. Thus one who was advised to go to such an asylum became thoughtful because he had an acquaintance who entered the asylum as nervous and there become insane. As you surmise we deal with cases of initial general paresis who in the first stages could still be sent to hydrotherapeutic asylums, and who there merged into the irresistible course leading to manifest insanity. For the layman the water was the cause and author of this sad transformation. Where it is a question of unfamiliar influences, even doctors are not free from such mistaken judgment. I recall having once attempted to treat a woman by psychotherapy who passed a great part of her existence by alternating between mania and melancholia. I began to treat her at the end of a melancholia and everything seemed to go well for two weeks, but in the third week she was again merging into a mania. It was surely a spontaneous alteration of the morbid picture, for two weeks is no time in which anything can be accomplished by psychotherapy, but the prominent—now deceased—physician who saw the case with me could not refrain from remarking that this decline must have been due to the psychotherapy. I am quite convinced that he would have been more critical under different conditions.
(_f_) In conclusion, gentlemen, I must say to myself that it will not do to lay claim to your attention so long in favor of the analytic psychotherapy without telling you of what this treatment consists, and on what it is based. To be sure I can only indicate it as I have to be brief. This therapy is founded on the understanding that unconscious ideas—or rather the unconsciousness of certain psychic processes—are the main causes of a morbid symptom. We share this conviction with the French school (Janet) which moreover by gross schematization reduces the hysterical symptom to an unconscious idée fixe. Do not fear now that we will thus merge too far into the obscurest philosophy. Our unconscious is not quite the same as that of the philosophers and what is more, most philosophers wish to know nothing of the “psychical unconscious.” But if you will put yourselves in our position, you will understand that the interpretation of this unconscious, in patients’ psychic life, into the conscious, must result in a correction of their deviation from the normal, and in an abrogation of the compulsion controlling their psychic life. For the conscious will reaches as far as the conscious psychic processes and every psychic compulsion is substantiated by the unconscious. You need never fear that the patient will be harmed by the emotion produced in the entrance of his unconscious into consciousness, for you can theoretically readily understand that the somatic and affective activity of the emotion which became conscious can never become as great as those of the unconscious. For we only control all our emotions by directing upon them our highest psychic activities which are connected with consciousness.
We can still choose another point of view for the understanding of the psychoanalytic treatment. The revealing and interpreting of the unconscious takes place under constant resistance on the part of the patient. The emerging of the unconscious is connected with displeasure and owing to this displeasure it is continuously repulsed by the patient. It is upon this conflict in the patient’s psychic life that you encroach, and if you succeed in prevailing upon him to accept something, for motives of better insight, which he has thus far repulsed (repressed) on account of the automatic adjustment of displeasure, you have achieved in him a piece of educational work. For it is really an education if you can induce a person to leave his bed early in the morning despite his unwillingness to do so. As such an after training for the overcoming of inner resistances you can conceive the psychoanalytic treatment in quite a general manner. But in no sphere of the nervous patients is such an after training so essential as in the psychic elements of their sexual life. For nowhere have culture and education produced as much harm as here, and it is here, as experience will show you, that the controlling etiologies of the neuroses are found. The other etiological element, the constitutional contribution, is really given to us as something immutable. But this gives rise to an important demand on the doctor. Not only must he be of unblemished character—“morality is really a matter of course” as the principal person in Th. Vischer’s “Auch Einer” used to say—but he must have overcome in his own personality the mixture of lewdness and prudishness with which so many others are wont to meet the sexual problems.
This is perhaps the place for another observation. I know that the emphasis which I laid on the sexual rôle in the origin of the psychoneuroses has become widely known. But I also know that restriction and nearer determinations are of little use with the great public; the multitude has little room in its memory, and generally retains from a statement the bare nucleus, thus creating for itself an easily remembered extreme. The same might also have happened to some physicians when the faint notion that they have of my theory is that I trace back the neurosis in the last place to sexual privation. Of such there is surely no dearth under the vital conditions of our society. But if that supposition were true would it not seem obvious that in order to avoid the roundabout way of the psychic treatment and tend directly towards the cure, we should directly recommend sexual participation as the remedy? I really do not know what could induce me to suppress these conclusions if they were justified. But the state of affairs is different. The sexual need or privation is merely one of the factors playing a part in the mechanism of the neurosis, and if it alone existed the result would not be a disease but a dissipation. The other equally indispensable factor, which one is only too ready to forget, is the sexual repugnance of neurotics, their inability to love; it is that psychic feature which I have designated as “repression.” It is only from the conflict between the two strivings that the neurotic malady originates, and it is for this reason that the advice for sexual
## participation in the psychoneuroses can really only seldom be designated
as good.
Allow me to conclude with this guarded remark. Let us hope that with an interest for psychotherapy, purified of all hostile prejudice, you will help us to do some good in the treatment of the severe cases of psychoneuroses.
## CHAPTER IX.
MY VIEWS ON THE RÔLE OF SEXUALITY IN THE ETIOLOGY OF THE NEUROSES.[54]
I am of the opinion that my theory on the etiological significance of the sexual moment in the neuroses can be best appreciated by following its development. I will by no means make any effort to deny that it passed through an evolution during which it underwent a change. My colleagues can find the assurance in this admission that this theory is nothing other than the result of continued and painstaking experiences. In contradistinction to this whatever originates from speculation can certainly appear complete at one go and continue unchanged.
Originally the theory had reference only to the morbid pictures comprehended as “neurasthenia,” among which I found two types which occasionally appeared pure, and which I described as “actual neurasthenia” and “anxiety neurosis.” For it was always known that sexual moments could play a part in the causation of these forms, but they were found neither regularly effective, nor did one think of conceding to them a precedence over other etiological influences. I was above all surprised at the frequency of coarse disturbances in the vita sexualis of nervous patients. The more I was in quest of such disturbances, during which I remembered that all men conceal the truth in things sexual, and the more skilful I became in continuing the examination despite the incipient negation, the more regularly such disease-forming moments were discovered in the sexual life, until it seemed to me that they were but little short of universal. But one must from the first be prepared for similar frequent occurrences of sexual irregularities under the stress of the social relations of our society, and one could therefore remain in doubt as to what part of the deviation from the normal sexual function is to be considered as a morbid cause. I could therefore only place less value on the regular demonstration of sexual noxas than on other experiences which appeared to me to be less equivocal. It was found that the form of the malady, be it neurasthenia or anxiety neurosis, shows a constant relation to the form of the sexual injury. In the typical cases of neurasthenia we could always demonstrate masturbation or accumulated pollutions, while in anxiety neurosis we could find such factors as coitus interruptus, “frustrated excitement,” etc. The moment of insufficient discharge of the generated libido seemed to be common to both. Only after this experience, which is easy to gain and very often confirmed, had I the courage to claim for the sexual influences a prominent place in the etiology of the neurosis. It also happened that the mixed forms of neurasthenia and anxiety neurosis occurring so often, showed the admixture of the etiologies accepted for both, and that such a bipartition in the form of the manifestations of the neurosis seemed to accord well with the polar characters of sexuality (male and female).
At the same time, while I assigned to sexuality this significance in the origin of the simple neurosis, I still professed for the psychoneuroses (hysteria and obsessions) a purely psychological theory in which the sexual moment was no differently considered than any other emotional sources. Together with J. Breuer, and in addition to observations which he has made on his hysterical patients fully a decade before, I have studied the mechanism of the origin of hysterical symptoms by the awakening of memories in hypnotic states. We obtained information which permitted us to cross the bridge from Charcot’s traumatic hysteria to the common non-traumatic hysteria. We reached the conception that the hysterical symptoms are permanent results of psychic traumas, and that the amount of affect belonging to them was pushed away from conscious elaboration by special determinations, thus forcing an abnormal road into bodily innervation. The terms “strangulated affect,” “conversion,” and “ab-reaction,” comprise the distinctive characteristics of this conception.
In the close relations of the psychoneuroses to the simple neuroses, which can go so far that the diagnostic distinction is not always easy for the unpracticed, it could happen that the cognition gained from one sphere has also taken effect in the other. Leaving such influences out of the question, the deep study of the psychic traumas also leads to the same results. If by the “analytic” method we continue to trace the psychic traumas from which the hysterical symptoms are derived, we finally reach to experiences which belong to the patient’s childhood, and concern his sexual life. This can be found even in such cases where a banal emotion of a non-sexual nature has occasioned the outburst of the disease. Without taking into account these sexual traumas of childhood we could neither explain the symptoms, find their determination intelligible, nor guard against their recurrence. The incomparable significance of sexual experiences in the etiology of the psychoneuroses seems therefore firmly established, and this fact remains until today one of the main supports of the theory.
If we represent this theory by saying that the course of the life long hysterical neurosis lies in the sexual experiences of early childhood which are usually trivial in themselves, it surely would sound strange enough. But if we take cognizance of the historical development of the theory, and transfer the main content of the same into the sentence: hysteria is the expression of a special behavior of the sexual function of the individual, and that this behavior was already decisively determined by the first effective influences and experiences of childhood, we will perhaps be poorer in a paradox but richer in a motive for directing our attention to a hitherto very neglected and most significant aftereffect of infantile impressions in general.
As I reserve the question whether the etiology of hysteria (and compulsion neurosis) is to be found in the sexual infantile experiences for a later more thorough discussion, I now return to the construction of the theory expressed in some small preliminary publications in the years 1895–1896.[55] The bringing into prominence of the assumed etiological moments permitted us at the time to contrast the common neuroses which are maladies with an actual etiology, with the psychoneuroses which etiology was in the first place to be sought in the sexual experiences of remote times. The theory culminates in the sentence: In a normal vita sexualis no neurosis is possible.
If I still consider today this sentence as correct it is really not surprising that after ten years labor on the knowledge of these relations I passed a good way beyond my former point of view, and that I now think myself in a position to correct by detailed experience the imperfections, the displacements, and the misconceptions, from which this theory then suffered. By chance my former rather meagre material furnished me with a great number of cases in which infantile histories, sexual seduction by grown-up persons or older children, played the main rôle. I overestimated the frequency of these (otherwise not to be doubted) occurrences, the more so because I was then in no position to distinguish definitely the deceptive memories of hysterical patients concerning their childhood, from the traces of the real processes, whereas, I have since then learned to explain many a seduction fancy as an attempt at defense against the reminiscence of their own sexual
## activity (infantile masturbation). The emphasis laid on the “traumatic”
element of the infantile sexual experience disappeared with this explanation, and it remained obvious that the infantile sexual
## activities (be they spontaneous or provoked) dictate the course of the
later sexual life after maturity. The same explanation which really corrects the most significant of my original errors perforce also changed the conception of the mechanism of the hysterical symptoms. These no longer appeared as direct descendants of repressed memories of sexual infantile experiences, but between the symptoms and the infantile impressions there slipped in the fancies (confabulations of memory) of the patients which were mostly produced during the years of puberty and which on the one hand, are raised from and over the infantile memories, and on the other, are immediately transformed into symptoms. Only after the introduction of the element of hysterical fancies did the structure of the neurosis and its relation to the life of the patient become transparent. It also resulted in a veritable surprising analogy between these unconscious hysterical fancies and the romances which became conscious as delusions in paranoia.
After this correction the “infantile sexual traumas” were in a sense supplanted by the “infantilism of sexuality.” A second modification of the original theory was not remote. With the accepted frequency of seduction in childhood there also disappeared the enormous emphasis of the accidental influences of sexuality to which I wished to shift the main rôle in the causation of the disease without, however, denying constitutional and hereditary moments. I even hoped to solve thereby the problem of the selection of the neurosis, that is, to decide by the details of the sexual infantile experience, the form of the psychoneurosis into which the patient may merge. Though with reserve I thought at that time that passive behavior during these scenes results in the specific predisposition for hysteria, while active behavior results in compulsion neurosis. This conception I was later obliged to disclaim completely though some facts of the supposed connection between passivity and hysteria, and activity and compulsion neurosis, can be maintained to some extent. With the disappearance of the accidental influences of experiences, the elements of constitution and heredity had to regain the upper hand, but differing from the view generally in vogue I placed the “sexual constitution” in place of the general neuropathic predisposition. In my recent work, “Three Contributions to the Sexual Theory.”[56] I have attempted to discuss the varieties of this sexual constitution, the components of the sexual impulse in general, and its origin from the contributory sources of the organism.
Still in connection with the changed conception of the “sexual infantile traumas,” the theory continued to develop in a course which was already indicated in the publications of 1894–1896. Even before sexuality was installed in its proper place in the etiology, I had already stated as a condition for the pathogenic efficaciousness of an experience that the latter must appear to the ego as unbearable and thus evoke an exertion for defense. To this defense I have traced the psychic splitting—or as it was then called the splitting of consciousness—of hysteria. If the defense succeeded, the unbearable experience with its resulting affect was expelled from consciousness and memory; but under certain conditions the thing expelled which was now unconscious, developed its activity, and with the aid of the symptoms and their adhering affect it returned into consciousness, so that the disease corresponded to a failure of the defense. This conception had the merit of entering into the play of the psychic forces, and hence approximate the psychic processes of hysteria to the normal instead of shifting the characteristic of the neurosis into an enigmatic and no further analyzable disturbance.
Further inquiries among persons who remained normal furnished the unexpected result, that the sexual histories of their childhood need not differ essentially from the infantile life of neurotics, and that especially the rôle of seduction is the same in the former, so the accidental influences receded still more in comparison to the moments of “repression” (which I began to use instead of “defense”). It really does not depend on the sexual excitements which an individual experiences in his childhood but above all on his reactions towards these experiences, and whether these impressions responded with “repression” or not. It could be shown that spontaneous sexual manifestations of childhood were frequently interrupted in the course of development by an act of repression. The sexual maturity of neurotic individuals thus regularly brings with it a fragment of “sexual repression” from childhood which manifests itself in the requirements of real life. Psychoanalyses of hysterical individuals show that the malady is the result of the conflict between the libido and the sexual repression, and that their symptoms have the value of a compromise between both psychic streams.
Without a comprehensive discussion of my conception of repression I could not explain any further this part of the theory. It suffices to refer here to my “Three Contributions to the Sexual Theory,” where I have made an attempt to throw some light on the somatic processes in which the essence of sexuality is to be sought. I have stated there that the constitutional sexual predisposition of the child is more irregularly multifarious than one would expect, that it deserves to be called “polymorphous-perverse,” and that from this predisposition the so called normal behavior of the sexual functions results through a repression of certain components. By referring to the infantile character of sexuality, I could form a simple connection among normal, perversions, and neurosis. The normal resulted through the repression of certain partial impulses and components of the infantile predisposition, and through the subordination of the rest under the primacy of the genital zones for the service of the function of procreation. The perversions corresponded to disturbances of this connection due to a superior compulsive like development of some of the partial impulses, while the neurosis could be traced to a marked repression of the libidinous strivings. As almost all perversive impulses of the infantile predisposition are demonstrable as forces of symptom formation in the neurosis, in which, however, they exist in a state of repression, I could designate the neurosis as the “negative” of the perversion.
I think it worth emphasizing that with all changes my ideas on the etiology of the psychoneuroses still never disavowed or abandoned two points of view, to wit, the estimation of sexuality and infantilism. In other respects we have in place of the accidental influences the constitutional moments, and instead of the pure psychologically intended defense we have the organic “sexual repression.” Should anybody ask where a cogent proof can be found for the asserted etiological significance of sexual factors in the psychoneuroses, and argue that since an outburst of these diseases can result from the most banal emotions, and even from somatic causes, a specific etiology in the form of special experiences of childhood must therefore be disavowed; I mention as an answer for all these arguments the psychoanalytic investigation of neurotics as the source from which the disputed conviction emanates. If one only makes use of this method of investigation he will discover that the symptoms represent the whole or a partial sexual manifestation of the patient from the sources of the normal or perverse partial impulses of sexuality. Not only does a good part of the hysterical symptomatology originate directly from the manifestations of the sexual excitement, not only are a series of erogenous zones in strengthening infantile attributes raised in the neurosis to the importance of genitals, but even the most complicated symptoms become revealed as the converted representations of fancies having a sexual situation as a content. He who can interpret the language of hysteria can understand that the neurosis only deals with the repressed sexuality. One should, however, understand the sexual function in its proper sphere as circumscribed by the infantile predisposition. Where a banal emotion has to be added to the causation of the disease, the analysis regularly shows that the sexual components of the traumatic experience, which are never missing, have exercised the pathogenic effect.
We have unexpectedly advanced from the question of the causation of the psychoneuroses to the problem of its essence. If we wish to take cognizance of what we discovered by psychoanalysis we can only say that the essence of these maladies lies in disturbances of the sexual processes, in those processes in the organism which determine the formation and utilization of the sexual libido. We can hardly avoid perceiving these processes in the last place as chemical, so that we can recognize in the so called actual neuroses the somatic effects of disturbances in the sexual metabolism, while in the psychoneuroses we recognize besides the psychic effects of the same disturbances. The resemblance of the neuroses to the manifestations of intoxication and abstinence following certain alkaloids, and to Basedow’s and Addison’s diseases, obtrudes itself clinically without any further ado, and just as these two diseases should no more be described as “nervous diseases,” so will the genuine “neuroses” soon have to be removed from this class despite their nomenclature.
Everything that can exert harmful influences in the processes serving the sexual function therefore belongs to the etiology of the neurosis. In the first place we have the noxas directly affecting the sexual functions insofar as they are accepted as injuries by the sexual constitution which is changeable through culture and breeding. In the second place, we have all the different noxas and traumas which may also injure the sexual processes by injuring the organism as a whole. But we must not forget that the etiological problem in the neuroses is at least as complicated as in the causation of any other disease. One single pathogenic influence almost never suffices, it mostly requires a multiplicity of etiological moments reinforcing one another, and which can not be brought in contrast to one another. It is for that reason that the state of neurotic illness is not sharply separated from the normal. The disease is the result of a summation, and the measure of the etiological determinations can be completed from any one part. To seek the etiology of the neurosis exclusively in heredity or in the constitution would be no less one sided than to attempt to raise to the etiology the accidental influences of sexuality alone, even though the explanations show that the essence of this malady lies only in a disturbance of the sexual processes of the organism.
## CHAPTER X.
HYSTERICAL FANCIES AND THEIR RELATIONS TO BISEXUALITY.[57]
The delusional formations of paranoiacs containing the greatness and sufferings of their own ego, which manifest themselves quite typically in almost monotonous forms are universally familiar. Furthermore, through numerous communications we became acquainted with the peculiar organizations by means of which certain perverts put into operation their sexual gratifications, be it in fancy or reality. On the other hand it may sound rather novel to some to hear that quite analogous psychic formations regularly appear in all psychoneuroses, especially in hysteria, and that these so called hysterical fancies show important relations to the causation of the neurotic symptoms.
Of the same source and of the normal prototype are all these fantastic creations, so called reveries of youth, which have already gained a certain consideration in the literature, though not a sufficient one.[58] They are perhaps equally frequent in both sexes; in girls and women they seem to be wholly of an erotic nature, while in men they are of an erotic or ambitious nature. Yet even in men the significance of the erotic moment is not to be put in the second place, for on examining more closely the reveries of men we generally learn that all these heroic acts are accomplished, that all these successes are acquired in order to please a woman and to be preferred to other men.[59] These fancies are wish gratifications which emanate from privation and longing. They are justly named “day dreams” for they give the key for the understanding of night dreams in which the nucleus of the dream formation is produced by just such complicated, disfigured day fancies which are misunderstood by the conscious psychic judgment.[60]
These day dreams are garnished with great interest, are cautiously nurtured, and coyly guarded, as if they were numbered among the most intimate estates of personality. On the street, however, the day dreamer can be readily recognized by a sudden, as if absent minded smile, by talking to himself, or by a running-like acceleration of his gait wherein he designates the acme of the imaginary situation.
All hysterical attacks which I have been thus far able to examine proved to be such involuntary incursions of day dreams. Observation leaves no doubt that such fancies may exist as unconscious or conscious and whenever they become unconscious they may also become pathogenic, that is, they may express themselves in symptoms and attacks. Under favorable conditions it is possible for consciousness to seize such unconscious fancies. One of my patients whose attention I have called to her fancies narrated that once while in the street she suddenly found herself in tears, and rapidly reflecting over the cause of her weeping the fancy became clear to her. She fancied herself in delicate relationship with a piano virtuoso familiar in the city, but whom she did not know personally. In her fancy she bore him a child (she was childless), and he then deserted her, leaving her and her child in misery. At this passage of the romance she burst into tears.
The unconscious fancies are either from the first unconscious, having been formed in the unconscious, or what is more frequently the case they were once conscious fancies, day dreams, and were then intentionally forgotten, merging into the unconscious by “repression.” Their content then either remained the same or underwent a transformation, so that the present unconscious fancy represents a descendant of the once conscious one. The unconscious fancy stands in a very important relation to the sexual life of the person, it is really identical with that fancy which helped it towards sexual gratification during a period of masturbation. The masturbating act (in the broader sense the onanistic) then consisted of two parts, the evocation of the fancy, and the active performance of self gratification at the height of the same. This combination is familiarly in itself a soldering.[61] Originally this action was a purely auto-erotic undertaking for the pleasure obtained from a certain so called erogenous part of the body. Later this action blended with a wish presentation from the sphere of the object loved, and served for a
## partial realization of the situation in which this fancy culminated. If,
then, the person forgoes in this manner the masturbo-fantastic gratification, the action remains undone, the fancy, however, changes from a conscious to an unconscious one. If no other manner of sexual gratification occurs, if the person remains abstinent and does not succeed in sublimating his libido, that is, in diverting the sexual excitement to a higher aim, we then have the conditions for the refreshment of the unconscious fancy; it grows exuberantly and with all the force of the desire for love at least a fragment of its content becomes a morbid symptom.
The unconscious fancies are then the nearest psychical first steps of a whole series of hysterical symptoms. The hysterical symptoms are nothing other than unconscious fancies brought to light by “conversion,” and insofar as they are somatic symptoms they are frequently enough taken from the spheres of the sexual feelings and motor innervations which originally accompanied the former still conscious fancies. In this way the disuse of onanism is really made retrograde, and the final aim of the whole pathological process, the restoration of the primary sexual gratification, though it never becomes perfect, in a manner always achieves a certain approximation.
The interest of him who studies hysteria turns directly from the symptoms to the fancies from which the former originate. The technique of psychoanalysis gives the means of finding out from the symptoms the unconscious fancies, and then of bringing them back to the patient’s consciousness. In this way it was found that the unconscious fancies of hysterics perfectly correspond in content to the consciously performed gratification situations of perverts. Those who lack examples of such nature need only recall the historical managements of the Roman Caesars whose frenzies were naturally only conditioned by the unrestricted fullness of the fancy creators. The delusional formations of paranoiacs are of the same nature, they are fancies which directly become conscious, and which are borne by the masochistic-sadistic components of the sexual impulse. Complete counterparts of these can also be found in certain unconscious fancies of hysterics. It is a familiar, practically significant fact that hysterics express their fancies not as symptoms but in conscious realization, and in this way they feign and commit murders, assaults, and sexual aggressions.
All that can be found out about the sexuality of the psychoneurotic can be ascertained by the psychoanalytic examination which leads from the obtrusive symptoms to the hidden unconscious fancies; herein, too, is the fact, the communication of which will be put in the foreground of this short preliminary publication.
Probably in view of the difficulties which prevent the effort of the unconscious fancies from expressing themselves, the relation between the fancies to the symptoms is not simple but rather manifoldly complicated.[62] As a rule, that is, in a fully developed and a long standing neurosis, a symptom does not correspond to an individual unconscious fancy, but to a number of such, and indeed it is not arbitrary but in lawful combination. To be sure in the beginning of the disease all these complications are not developed.
For the sake of general interest I pass over the connection of this communication and insert a series of formulæ which strive to progressively exhaust the nature of hysteria. They do not contradict one another but correspond partly to more complete and sharper conceptions, and partly to the use of different points of view.
1. The hysterical symptom is the memory symbol of certain efficacious (traumatic) impressions and experiences.
2. The hysterical symptom is the compensation by conversion for the associative return of the traumatic experience.
3. The hysterical symptom—like all other psychic formations—is the expression of a wish realization.
4. The hysterical symptom is the realization of an unconscious fancy serving as a wish fulfilment.
5. The hysterical symptom serves as a sexual gratification, and represents a part of the sexual life of the individual (corresponding to one of the components of his sexual impulse).
6. The hysterical symptom, in a fashion, corresponds to the return of the sexual gratification which was real in infantile life but had been repressed since then.
7. The hysterical symptom results as a compromise between two opposing affects or impulse incitements, one of which strives to bring to realization a partial impulse, or a component of the sexual constitution, while the other strives to suppress the same.
8. The hysterical symptom may undertake the representation of diverse unconscious non-sexual incitements, but can not lack the sexual significance.
It is the seventh among these determinations which expresses most exhaustively the essence of the hysterical symptom as a realization of an unconscious fancy, and it is the eighth which properly designates the significance of the sexual moment. Some of the preceding formulæ are contained as first steps in this formula.
In view of these relations between symptoms and fancies one can readily reach from the psychoanalysis of the symptoms to the knowledge of the components of the sexual impulse controlling the individual, just as I have shown in the “Three Contributions to the Sexual Theory.” But in some cases this examination gives rather unexpected results. It shows that many symptoms can not be solved by one unconscious sexual fancy or by a series of fancies in which the most significant and most primitive is of a sexual nature, but in order to solve the symptom two sexual fancies are required, one of the masculine and one of the feminine character, so that one of these fancies arises from a homosexual impulse. The axiom pronounced in formula seven is in no way effected by this novelty, so that a hysterical symptom necessarily corresponds to a compromise between a libidinous and a repressed emotion, but besides that, it can correspond to a union of two libidinous fancies of contrary sex characters.
I refrain from giving examples for this axiom. Experience has taught me that short analyses compressed into the form of an abstract can never make the demonstrable impression for which they were intended. The communication of fully analyzed cases must be reserved for another place.
I therefore content myself in formulating the axiom and in elucidating its significance:
9. An hysterical symptom is the expression, on the one hand, of a masculine, and on the other hand of a feminine unconscious sexual fancy.
I expressly observe that I am unable to adjudge to this axiom the similar general validity that I claimed for the other formulæ. As far as I can see it is met neither in all symptoms of a single case, nor in all cases. On the contrary it is not difficult to find cases in which the contrary sexual emotions have found separate symptomatic expression, so that the symptoms of hetero- and homosexuality can be as sharply distinguished from each other as the fancies hidden behind them. Nevertheless, the relation claimed in the ninth formula occurs frequently enough, and wherever it is found it is of sufficient significance to merit a special formulation. It seems to me to signify the highest stage of complexity to which the determination of hysterical symptoms can reach, and can only be expected in a long standing neurosis and where a great amount of organization has occurred.[63]
The demonstrable bisexual significance of hysterical symptoms occurring in many cases is indeed an interesting proof for the assertion formulated by me that the supposed bisexual predisposition of man can be especially recognized in psychoneurotics by means of psychoanalysis.[64] Quite an analogous process from the same sphere is that in which the masturbator in his conscious fancies attempts to live through in his imagination the fancied situations of both the man and the woman. Other counterparts are found in certain hysterical crises in which the patients play both rôles lying at the basis of sexual fancies; thus, for example, one of the cases under my observation presses his garments to his body with one arm (as woman), and with the other arm he attempts to tear them off (as man). This contradictory simultaneity determines most of the incomprehensibility of the situation otherwise so plastically represented in the attack, and is excellently suited for the concealment of the effective unconscious fancy.
In psychoanalytical treatment it is very important to be prepared for the bisexual significance of a symptom. It should not be at all surprising or misleading when a symptom remains apparently undiminished in spite of the fact that one of its sexual determinants is already solved. Perhaps it is still supported by the unsuspected contrary sexual. Furthermore, during the treatment of such cases we can observe how the patient makes use of this convenience. During the analysis of the one sexual significance he continually switches his thoughts into the sphere of the contrary significance just as if onto a neighboring track.
-----
Footnote 1:
Studien über Hysterie von Jos. Breuer und Sigm. Freud. Leipzig und Wien, Franz Deuticke, 1895. 2nd ed., 1909.
Footnote 2:
Sammlung kleiner Schriften zur Neurosenlehre, Vols. I. and II. Leipzig und Wien, Deuticke, 1906, and 1909.
Footnote 3:
Bleuler, Freudsche Mechanismen in der Symptomatologie der Psychosen, Psychiatrisch-Neurolog. Wochenschrift, 1906, Nrs. 35 and 36.
Footnote 4:
Jung, The Psychology of Dementia Præcox, Nervous and Mental Disease Monograph Series, Nr. 3.
Footnote 5:
Riklin, Psychiatrisch-Neurolog. Wochenschrift, 1905, Nr. 46.
Footnote 6:
Brill, Psychological Factors in Dementia Præcox, Journal of Abnormal Psychology, Vol. III, Nr. 4, and A Case of Schizophrenia, American Journal of Insanity, Vol. LXVI, No. 1.
Footnote 7:
Freud, Deuticke, 1909.
Footnote 8:
Freud, Karger, 1907.
Footnote 9:
Freud, Deuticke, 1905.
Footnote 10:
Written in collaboration with Dr. Joseph Breuer.
Footnote 11:
The possibility of such a therapy was clearly recognized by Delboeuf and Binet, as is shown by the accompanying quotations: Delboeuf, Le magnétisme animal, Paris, 1889: “On s’expliquerait des lors comment le magnétiseur aide à guérison. Il remet le sujet dans l’état où le mal s’est manifesté et combat par la parole le même mal, mais renaissant.” (Binet, Les altérations de la personnalité, 1892, p. 243): “... peut-être verra-t-on qu’en reportant le malade par un artifice mental, au moment même ou le symptome a apparu pour la premiere fois, on rend ce malade plus docile a une suggestion curative.” In the interesting book of Janet, L’Automatism Psychologique, Paris, 1889, we find the description of a cure brought about in a hysterical girl by a process similar to our method.
Footnote 12:
We are unable to distinguish in this preliminary contribution what there is new in this content and what can be found in such other authors as Moebius and Strümpel who present similar views on hysteria. The greatest similarity to our theoretical and therapeutical accomplishments we accidentally found in some published observations of Benedict which we shall discuss hereafter.
Footnote 13:
The German abreagiren has no exact English equivalent. It will therefore be rendered throughout the text by “ab-react,” the literal meaning is to react away from or to react off. It has different shades of meaning, from defense reaction to emotional catharsis, which can be discerned from the context.
Footnote 14:
As an example of the technique mentioned above, that is, of investigating in a non-somnambulic state or where consciousness is not broadened, I will relate a case which I analyzed recently. I treated a woman of thirty-eight who suffered from an anxiety neurosis (agoraphobia, fear of death, etc.). Like many patients of that type she had a disinclination to admit that she acquired this disease in her married state and was quite desirous of referring it back to early youth. She informed me that at the age of seventeen when she was in the street of her small city she had the first attack of vertigo, anxiety, and faintness, and that these attacks recurred at times up to a few years ago when they were replaced by her present disease. I thought that the first attacks of vertigo, in which the anxiety was only blurred, were hysterical and decided to analyze the same. All she knows is that she had the first attack when she went out to make purchases in the main street of her city.—“What purchases did you wish to make?”—“Various things, I believe it was for a ball to which I was invited.”—“When was the ball to take place?”—“I believe two days later.”—“Something must have happened a few days before this which excited you, and which made an impression on you.”—“But I don’t know, it is now twenty-one years.”—“That does not matter, you will recall it. I will exert some pressure on your head and when I stop it you will either think of or see something which I want you to tell me.” I went through this procedure, but she remained quiet.—“Well, has nothing come into your mind?”—“I thought of something, but that can have no connection with it.”—“Just say it.”—“I thought of a young girl who is dead, but she died when I was eighteen, that is, a year later.”—“Let us adhere to this. What was the matter with your friend?”—“Her death affected me very much, because I was very friendly with her. A few weeks before another young girl died, which attracted a great deal of attention in our city, but then I was only seventeen years old.”—“You see, I told you that the thought obtained under the pressure of the hands can be relied upon. Well now, can you recall the thought that you had when you became dizzy in the street?”—“There was no thought, it was vertigo.”—“That is quite impossible, such conditions are never without accompanying ideas. I will press your head again and you will think of it. Well, what came to your mind?”—“I thought, ‘now I am the third.’”—“What do you mean?”—“When I became dizzy I must have thought, now I will die like the other two.”—“That was then the idea, during the attack you thought of your friend, her death must have made a great impression on you.”—“Yes, indeed, I recall now that I felt dreadful when I heard of her death, to think that I should go to a ball while she lay dead, but I anticipated so much pleasure at the ball and was so occupied with the invitation that I did not wish to think of this sad event.” (Notice here the intentional repression from consciousness which caused the reminiscences of her friend to become pathogenic.)
The attack was now in a measure explained, but I still needed the occasional moment which just then provoked this recollection, and accidentally I formed a happy supposition about it.—“Can you recall through which street you passed at that time?”—“Surely, the main street with its old houses, I can see it now.”—“And where did your friend live?”—“In the same street. I had just passed her house and was two houses farther when I was seized with the attack.”—“Then it was the house which you passed that recalled your dead friend, and the contrast which you then did not wish to think about that again took possession of you.”
Still I was not satisfied, perhaps there was something else which provoked or strengthened the hysterical disposition in a hitherto normal girl. My suppositions were directed to the menstrual indisposition as an appropriate moment, and I asked, “Do you know when during that month you had your menses?”—She became indignant: “Do you expect me to know that? I only know that I had them then very rarely and irregularly. When I was seventeen I only had them once.”—“Well let us enumerate the days, months, etc., so as to find when it occurred.”—She with certainty decided on a month and wavered between two days preceding a date which accompanied a fixed holiday.—Does that in any way correspond with the time of the ball?—She answered quietly: “The ball was on this holiday. And now I recall that I was impressed by the fact that the only menses which I had had during the year occurred just when I had to go to the ball. It was the first invitation to a ball that I had received.”
The combination of the events can now be readily constructed and the mechanism of this hysterical attack readily viewed. To be sure the result was gained after painstaking labor. It necessitated on my side full confidence in the technique and individual directing ideas in order to reawaken such details of forgotten experiences after twenty-one years in a sceptical and awakened patient. But then everything agreed.
Footnote 15:
A better description of this peculiar state in which one knows something and at the same time does not know it, I could never obtain. It can apparently be understood only if one has found himself in such a state. I have at my disposal a very striking recollection of this kind which I can vividly see. If I make the effort to recall what passed through my mind at that time my output seems very poor. I saw at that time something which was not at all appropriate to my expectations, and what I saw did not in the least divert me from my definite purpose, whereas this perception ought to have done away with my purpose. I did not become conscious of this contradiction nor did I remark the affect of the repulsion to which it was undoubtedly due that this perception did not attain any psychic validity. I was struck with that form of blindness in seeing eyes, which one admires so much in mothers towards their daughters, in husbands towards their wives, and in rulers towards their favorites.
Footnote 16:
It will be shown that, notwithstanding, I erred.
Footnote 17:
Die Abwehr-Neuropsychosen, Neurologisches Centralblatt, 1 June, 1894.
Footnote 18:
I can neither exclude nor prove that this pain, especially of the thighs, was of a neurasthenic nature.
Footnote 19:
To my surprise I once discovered that such subsequent ab-reaction—through other impressions than nursing—may form the content of an otherwise enigmatic neurosis. It was the case of a pretty girl of nineteen, Miss Matilda H. whom I first saw with an incomplete paralysis of the legs, and months afterward I was again called because her character had changed. She was depressed and tired of living, entertaining lack of consideration for her mother, and was irritable and inapproachable. The whole picture of the patient did not seem to me to be that of an ordinary melancholia. She could easily be put into a somnambulic state, and I made use of this peculiarity to impart to her each time commands and suggestions to which she listened in her profound sleep and responded with profuse tears, but which, however, caused but little change in her condition. One day while hypnotized she became talkative and informed me that the reason for her depression was the breaking of her betrothal many months before. She stated that on closer acquaintance with her fiance the things displeasing to her and her mother became more and more evident. On the other hand, the material advantages of the engagement were too tangible to make the decision of a rupture easy, thus, both of them hesitated for a long time. She then merged into a condition of indecision in which she allowed everything to pass apathetically, and finally her mother pronounced for her the decisive “no.” Shortly after, she awoke as from a dream and began to occupy herself fervently with the thoughts about the broken betrothal, she began to weigh the pros and cons, a process which she continued for some time. At present she continues to live in that time of doubt, and entertains daily the moods and the thoughts which would have been appropriate for that day. The irritability against her mother could only be explained if we took into consideration the circumstances that existed on that decisive day. Next to this thought activity she found her present life a mere phantom just like a dream. I did not again succeed in getting the girl to talk—I continued my exhortations during deep somnambulism. I saw her each time burst into tears without however receiving any answer from her. But one day, it was near the anniversary of the engagement, the whole state of depression disappeared. This was attributed to my great hypnotic cure.
Footnote 20:
It is different in a hypnoid-hysteria. Here the content of the separate psychic groups may never have been in the ego consciousness.
Footnote 21:
I had under my observation another case in which a contracture of the masseters made it impossible for the artist to sing. The young lady in question through painful experiences in the family was forced to go on the stage. While in Rome rehearsing, in great excitement she suddenly perceived the sensation of being unable to close her opened mouth and sank fainting to the floor. The physician who was called closed her jaws forcibly, but the patient since that time was unable to open her jaws more than a finger’s breadth and had to give up her newly chosen profession. When she came under my care many years later, the motives for that excitement were apparently over for some time, for massage in a light hypnosis sufficed to open her mouth widely. The lady has since sung in public.
Footnote 22:
But perhaps spinal neurasthenic?
Footnote 23:
See Studien über Hysterie, p. 57, footnote.
Footnote 24:
l. c.
Footnote 25:
The literal translation of Auftreten is to press down by treading.
Footnote 26:
In conditions of profounder psychic changes we apparently find a symbolic stamp (mark) of the more artificial usage of language in the form of emblematic pictures and sensations. There was a time in Mrs. Cäcilie M. during which every thought was changed into an hallucination, and which solution frequently afforded great humor. She at that time complained to me of being troubled by the hallucination that both her physicians, Breuer and I, were hanged in the garden on two nearby trees. The hallucination disappeared after the analysis revealed the following origin: The evening before Breuer refused her request for a certain drug. She then placed her hopes on me but found me just as inflexible. She was angry at both of us, and in her affect she thought, “They are worthy of each other, the one is a pendant of the other!”
Footnote 27:
E. Hecker, Centralblatt für Nervenheilkunde, Dec., 1893.
Footnote 28:
See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und Wien, 1895, p. 15.
Footnote 29:
See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und Wien, 1895, p. 106.
Footnote 30:
See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und Wien, 1895, p. 15.
Footnote 31:
As mentioned in the preface the author has long since discarded this pressure procedure.—Translator’s note.
Footnote 32:
See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und Wien, 1895, p. 85.
Footnote 33:
l. c., p. 15.
Footnote 34:
See Breuer und Freud, Studien über Hysterie. Deuticke, Wien und Leipzig, 1895, p. 28.
Footnote 35:
See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und Wien, 1895, p. 55.
Footnote 36:
État mental des hystériques, Paris, 1893 and 1894. Quelques définitions récentes de l’hystérie, Arch. de Neurol., 1893, XXXV-VI.
Footnote 37:
Oppenheim: Hysteria is an exaggerated expression of emotion. But the “expression of emotion” represents that amount of psychic excitement which normally experiences conversion.
Footnote 38:
Strümpel: The disturbance of hysteria lies in the psycho-physical, there where the physical and psychical are connected with each other.
Footnote 39:
Janet, in the second chapter of his spirited essay “Quelques definitions,” etc., has treated the objection that the splitting of consciousness belongs also to the psychoses and the so called psychaesthenia, but in my opinion he has not satisfactorily solved it. It is essentially this objection which urged him to call hysteria a form of degeneration. But through no characteristic is he able to separate sufficiently the hysterical splitting of consciousness from the psychopathic, etc.
Footnote 40:
The group of typical phobias, for which agoraphobia is a prototype, cannot be reduced to the psychic mechanisms here developed. Furthermore the mechanism of agoraphobia deviates in one decisive point from that of the real obsessions and from phobias based on such. Here there is no repressed idea from which the affect of fear has been separated. The fear of this phobia has another origin.
Footnote 41:
E. Hecker, Über larvierte und abortive Angstzustände bei Neurasthenie, Centralblatt für Nervenheilkunde, December, 1893.—Anxiety is made
## particularly prominent among the chief symptoms of neurasthenia by
Kaan, Der neurasthenische Angstaffekt bei Zwangsvorstellungen und der primordiale Grübelzwang, Wien, 1893.
Footnote 42:
Die Abwehr-Neuropsychosen, Neurol. Centralbl., 1894, Nr. 10 u. 11.
Footnote 43:
Obsession et phobies, Révue neurologique, 1895.
Footnote 44:
Moebius, Neuropathologische Beiträge, 1894, 2. Heft.
Footnote 45:
Peyer, Die nervösen Affektionen des Darmes, Wiener Klinik, Jänner, 1893.
Footnote 46:
Freud, Abwehr-Neuropsychosen.
Footnote 47:
Neurologisches Centralblatt, 1896, Nr. 10.
Footnote 48:
I myself surmise that the so frequently fabricated assaults of hysterical persons are obsessional confabulations emanating from the memory traces of infantile traumas.
Footnote 49:
In an article on the anxiety neurosis (Neurologisches Centralblatt, 1895, Nr. 2) I stated that “an anxiety neurosis which can almost typically be combined with hysteria can be evoked in maturing girls at the first encounter with the sexual problem.” I know today that the occasion in which such virginal anxiety breaks out does not really correspond to the first encounter with sexuality, but that in such persons there was in childhood a precedent experience of sexual passivity which memory was awakened at the “first encounter.”
Footnote 50:
A psychological theory of the repression ought also to inform us why only ideas of a sexual content can be repressed. It may be formulated as follows: It is known that ideas of a sexual content produce exciting processes in the genitals resembling the actual sexual experience. It may be assumed that this somatic excitement becomes transformed into psychic. As a rule the activity referred to is much stronger at the time of the occurrence than at the recollection of the same. But if the sexual experience takes place during the time of sexual immaturity and the recollection of the same is awakened during or after maturity, the recollection then acts disproportionately more exciting than the previous experience, for puberty has in the mean time incomparably increased the reactive capacity of the sexual apparatus. But such an inverse proportion seems to contain the psychological determination of repression. Through the retardation of the pubescent maturity in comparison with the psychic function, the sexual life offers the only existing possibility for that inversion of the relative efficacy. The infantile traumas subsequently act like fresh experiences, but they are then unconscious. Deeper psychological discussions I will have to postpone for another time. I moreover call attention to the fact that the here considered time of “sexual maturity” does not coincide with puberty, but occurs before the same (eight to ten years).
Footnote 51:
One example instead of many: An eleven-year-old boy has obsessively arranged for himself the following ceremonial before going to bed: He could not fall asleep unless he related to his mother most minutely all experiences of the day; not the smallest scrap of paper or any other rubbish was allowed in the evening on the carpet of his bedroom. The bed had to be moved close to the wall, three chairs had to stand in front of it, and the pillows had to lie in just such a position. In order to fall asleep he had to kick with both legs a number of times, and then had to lie on the side. This was explained as follows: Years before while putting this pretty boy to sleep, the servant girl made use of this opportunity to lay over him and assault him sexually. When this reminiscence was later awakened by a recent experience it made itself known to consciousness by the compulsion in the above mentioned ceremonial which sense could really be surmised and the details verified by psychoanalysis. The chairs before the bed which was close to the wall—so that no one could have access to it; the arrangement of the pillows in a definite manner—so that they should be differently arranged than they were on that evening; the motion with the legs—to kick away the person lying on him; sleeping on the side—because during that scene he lay on his back; the detailed confession to his mother—because in consequence of the prohibition of his seductress he concealed from his mother this and other sexual experiences; finally, keeping the floor of his bedroom clean—because this was the main reproach which he had to hear from his mother up to that time.
Footnote 52:
When the meagre success of this treatment was later removed by an exacerbation, she did not again see the offensive pictures of strange genitals, but she had the idea that strangers saw her genitals as soon as they were behind her.
Footnote 53:
Lecture delivered before the Vienna Medic. Doktorenkollegium, on December 12, 1904.
Footnote 54:
From Löwenfeld, “Sexualleben und Nervenleiden,” IV ed., 1906.
Footnote 55:
See Chapter VII, and Zur Aetiologie der Hysterie, Wiener, Klinische Rundschau, 1896.
Footnote 56:
An English translation in preparation.
Footnote 57:
Zeitschrift für Sexualwissenschaft, herausgegeben von Hirschfeld, I, 1908.
Footnote 58:
Compare Breuer and Freud Studien über Hysterie, 1895. P. Janet, Névroses et ideés fixes, I (Les rêveries subconscientes), 1898. Havelock Ellis, Sexual Impulse and Modesty (German by Kötscher), 1900. Freud, Traumdeutung, 1906, 2d ed., 1909. A. Pick, Über pathologische Träumerei und ihre Beziehungen zur Hysteria, Jahrbuch für Psychiatrie und Neurologie, XIV, 1896.
Footnote 59:
H. Ellis similarly expresses himself, l. c., p. 185.
Footnote 60:
Compare Freud, Traumdeutung, 2d ed., p. 302.
Footnote 61:
Compare Freud, Three Contributions to the Sexual Theory, 1895.
Footnote 62:
The same thing holds true for the relation between the “latent” thoughts of the dream and the elements of the manifest content of the dream. See the Chapter on the “Work of the Dream” in the author’s Traumdeutung.
Footnote 63:
Indeed J. Sadger, who recently discovered this sentence in question, independently by psychoanalysis, claims for it a general validity (Die Bedeutung der psychoanalytische Methode nach Freud, Centralbl. f. Nerv. u. Psych., Nr. 229.)
Footnote 64:
Three Contributions to the Sexual Theory.
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TRANSCRIBER’S NOTES
Page Changed from Changed to
10 the so called χατ’ εξοχὴν of the so called κατ’ ἐξοχὴν of traumatic hysteria or of a traumatic hysteria or of a series of series of
65 scenes like the one of being scenes like the one of being forced to hold our her hand in forced to hold out her hand in
123 be identified with personel or be identified with personal or hereditary “degeneration.” hereditary “degeneration.”
● Typos fixed; non-standard spelling and dialect retained. ● Used numbers for footnotes, placing them all at the end of the last chapter. ● Enclosed italics font in _underscores_.