Psychologist, Massachusetts General Hospital; Examiner in Psychotherapy,
Psychopathic Hospital, Boston, Massachusetts; Assistant in Neurology,
Graduate School of Medicine, Harvard University.
WHEN a new method of working in any field of endeavor is devised, or a new
point of view is discovered, it is natural to turn to other similar fields
to see if the method will work there. This is what is done when one
approaches the study of Epilepsy from the point of view of psychoanalysis.
It is not my purpose to undertake an exhaustive psychoanalytic study of
Epilepsy. Neither is it my purpose to enter into a discussion of the
problems of differential diagnosis. It has already been shown, in borderland
cases, that one cannot tell the difference between epilepsy and hysteria,
without a prolonged psychoanalysis, and even then one cannot be certain.
This suggests that the whole thing is more or less a matter of definition.
Into such questions I cannot enter. My aim is much more modest. The
immediate purpose of my paper is to study some of the problems of therapy,
from the psychoanalytic point of view, of that small class of patients on
the borderline between hysteria and epilepsy, or patients with epileptiform
attacks.
The first publication of studies of this general nature was made by Dr.
James J. Putnam and Dr. George A. Waterman in the Boston Medical and
Surgical Journal for May, 1905, under the title "Certain Aspects of the
differential Diagnosis between Epilepsy and Hysteria." In this paper the
authors say, "No one, so far as we are aware, has as yet studied with
sufficient thoroughness the subconscious memories of epileptics, and for all
we now can say, closer resemblances may be found between these and the
subconscious states of the hysterics than we now imagine." p. 513.
In this paper, however, therapy is only hinted at.
A contribution to our insight as to the epileptic state of mind is made by
Jung, under the title, "Analyse der Assoziationen eines Epileptikers," in
his, "Diagnostische Assoziationsstudien. Beitrage zur experimentellen
Psychopathologie." p. 175 (1906).
He found an extraordinary number of emotionally toned, egocentric relations.
There were some signs to suggest that the emotional tone in the epileptic
was unusually lasting.
The first thing published on epilepsy avowedly from the psychoanalytic
view-point was by Maeder: "Sexualitat und Epilepsy." Jahrbuch BI HI, 1909.
Maeder goes into the subject rather exhaustively, after characteristic
German fashion, but his conclusions are comparatively simple. He says, "The
sexuality of the epileptic is characterized by the prominence of auto- and
allo-erotism. It retains much of the infantile form, but has undergone,
nevertheless, a certain development, which I designate as 'sexual
polyvalence.' For some unknown reason the libido seems to have an abnormal
intensity." p. 154.
This is an important contribution to our knowledge of the psychic state of
epileptics but it is notable that not a word is said as to therapy.
Sadger published the same year, "Ein Fall von Pseudoepilepsia hysterica
psychoanalytisch erklart." (Wiener klein. Rundschau, p. 212, 1909.) But
neither does he have anything to say about therapy.
Dr. Wilhelm Stekel, however, treats the problem from the therapeutic point
of view in, "Die psychische Behandlung der Epilepsie." (Zentralblatt fur
psychoanalyse p. 220 No. 5-6, Vol. 1).
The essential kernel of Stekel's view is that the epileptic is a repressed
criminal. The convulsion is a substitute for the criminal act. He
announces categorically that pseudoepilepsy is curable by psychoanalytic
procedures. Of three cases which he completely analysed, two were cured. His
final conclusion is fourfold: (1) Epilepsy, more often than we have
hitherto thought, is of psychogenic origin. (2) In all cases there is a
strong tendency to criminality which is unbearable to consciousness. (3)
The attack is a substitute for an offense, hence, eventually a sexual
offense. (4) Pseudo-epilepsy is curable by psychoanalysis.
Spratling calls attention "to the value of an occasional convulsion in
certain cases. In some patients the fit acts as a safety valve that
unquestionably permits escape from insanity. . . In many cases the
convulsion seems t o come as the termination of an obscure (auto-toxic)
cycle which varies in duration in different individuals and bears some
relationship to the ascending period of the folie circulaire of the French.
It seems that the specific cause of the fit in these cases is something that
permeates the entire organism; something that comes and goes; that grows
rapidly in intensity, exerting a pernicious influence on the patient by
making him act out of harmony with his normal state, until the limit is
reached and the mind loses its direction and control. The power of
inhibition being finally destroyed, the nervous storm breaks with great
force and violence." p. 361.
Although Spratling had in mind a toxic agent, one cannot but be struck with
how completely his terms describe an emotional outburst.
In a paper read in Boston last winter, Dr. L. Pierce Clark advanced the view
that the epilpetic seizure was the symbolical expression of the desire of
the patient to return to the mutterleib. The convulsive moments were such
reflect and random acts as one sees in infants or infers in the embryo.
Regard for social sanctions is lost. This, of course, suggests the first
step in criminality. Clark found that favorable cases were amenable to
psychic treatment and said that some cases had been very much helped by
psychoanalysis. I am not certain whether he claims to have cured any
particular case of pseudo-epilepsy or epileptiform attacks, by
psychoanalysis. In presenting some of my own cases let me begin with one
that certainly was not a complete success, but nevertheless was much helped
by psychoanalysis.
This case is that of a young girl, aged 14, without known inherited
tendency. Her first attacks had occurred about a year previous in the form
of fainting spells. These were afterwards followed by convulsions. In
convulsions the patient thrashed about, kicking her legs and clawing at her
chest. These convulsive movements stopped after a while and were followed
by a deep sleep, after which the patient awoke without any memory of what
had happened.
It was found that during the convulsion the patient imagined she was being
pursued by a black-faced figure with claw-like hands, of a peculiar shape
like her father's.
Further investigation showed that her father got drunk and did chase her,
sometimes kicking her out of the house. She would undress her father
sometimes and put him to bed. Once when taking off his shoes he kicked her,
as she was bending over him, in the lower part of the abdomen. This was just
before the convulsions developed. The fainting spells occurred soon after
she had first seen her father naked. The image of his nakedness so
distressed her by continually coming before her mind that she made the most
desperate efforts to repress it, finally partially succeeding. Speaking of
her father she said, "Every time I think of him I feel like taking a fit.
Oh! It makes me feel terrible."
Her father had kicked her in the chest, too, which perhaps partially
accounts for the clawing.
In the light of this knowledge the convulsive movements become a little more
comprehensible. They are futile attempts to run away. They are the partial
movements of flight.
The cries that sometimes initiated and accompanied the convulsions at first,
afterwards became sufficiently articulate to be understood as calls "Mama,
Mama, Mama."
It was found that when her father would chase her about the house, in
drunken fury, she would call for her mother in frantic fear. Here,
apparently, is a meaning of the call preceding the convulsions.
Under a very short psychoanalytic treatment the patient showed marked
improvement. Her attacks became much less violent and much farther apart.
She became able to control them to a great extent. Finally she became so
well that one might say she had practically recovered.
Apparently there is no hint here of a repressed criminal complex. But a
little deeper analysis suggests it, however. The first attack, which was in
the form of a faint, occurred under the following circumstances. The patient
was at the funeral of the father of her best girl friend. As she looked at
the dead body of her friend's father the thought flashed through her mind,
"He was so good, and now he is dead, while my father who is so bad, still
lives. I wish he were dead." Shortly after she fainted.
There were a number of reasons, seemingly adequate, for incomplete success
in this case. In the first place, the patient had been in this country only
a few years and spoke very broken English. She is a Russian Jew. Obviously
this was a very great barrier to understanding. In the next place it was
almost impossible to change conditions of home, although Social Service
worked wonders in this case. The father continued to get drunk, and one of
the last of her now infrequent attacks occurred on his return from jail. The
patient was dreadfully afraid lest her father find out that the knowledge of
his delinquency had been discovered through her.
Not the least of the reasons militating against complete success was the
short time possible for psychoanalytic treatment. The patient was seen only
three weeks. As the time needed for a psychoanalysis is variable depending
on the particular patient, it is clear that this would be too short a time
to enable a young girl, only recently here from Russia, to understand, or to
overcome resistances. That the treatment was as nearly successful as it was
is perhaps encouraging to the hope that suitable cases under favorable
conditions might be cured.
The next case is one where the diagnosis lay between hysteria and epilepsy.
The symptoms were as follows: The patient had attacks in which she became
unconscious, gasped, and spittle ran from her mouth. She also bit her
tongue. She becomes stiff, eyes stark, and is left tired and weak. These
attacks were first noticed about five years ago. Since then she has had
about five similar attacks, the last three coming within five months. The
last two were within a day of each other and frightened her so she came to
the hospital. At the age of eight or nine she said that she had flashes of
speechlessness, and a thought which she cannot define, as of a horse or a
man. She never became unconscious or bit her tongue. After her first
catamenial these flashes of speechlessness and thought came only at this
time. At the age of two the patient said that she had fallen down stairs
and hit her head. She said she was unconscious twenty-four hours.
As a result of a psychoanalysis the following facts were learned. The
patient was a very sensitive child, exceedingly responsive to her
environment. She was also stubborn and self-willed, at times. She was
reserved and capable of great repression. When she was about three or four
she remembers seeing in the Bible a picture of the Devil on a white horse.
This used to make her shudder, but it also had a sort of irresistible
fascination. Later, when she was seven or eight, it would come into her
mind in school even and make her feel so badly she would lay her head on her
arms. But she never told anybody what it was that troubled her and she
would put it out of her mind. She thoroughly believed her mother when she
told her that the Devil would come and get her if she did wrong.
At about the age of ten or eleven she began going with a girl much older
than herself. She used to visit this girl and spend the night with her, and
in turn have her at her own home. In this way they spent the night together
quite frequently. Soon the girl wanted to masturbate her and although she
repelled her advances at first she finally allowed it because she was told
she would be regarded as queer if she didn't as other girls did it and liked
it. She, however, never did get any pleasure out of the practice, and
remained perfectly passive. She thought if her friend enjoyed it and it
didn't hurt her she should let her have her pleasure. She never told of
this.
The patient now began having what she called staring spells. These never
lasted more than a second or so and they were never observed. She carefully
concealed them. Just before the patient began to menstruate which was when
she was about fourteen, she noticed that the day after she had been with the
girl who masturbated her she had a terrific headache. Then she remembered
that for a long time it had been so though she had never connected the
headaches before with the masturbation. She stopped the practice immediately
and never allowed it to be resumed.
After menstruation began the staring spells became grouped and came only
during her periods. But they were more numerous. She would have a number in
one day. They were not yet sufficiently observable to be noticed. At about
this time she had a terrible fright. She was kneeling at her mother's side
listening to a story when she thought she saw a woman's face looking at her
over her mother's shoulder. She was speechless with terror. This was not
noticed and she did not tell. Around this time too she had another fright.
She was studying one evening at the dining-room table when she saw a face
looking in at the window. She screamed, and kept on screaming, but finally
was able to tell that she had seen someone looking in at the window. Her
father took her out and showed that it couldn't be so because there were no
tracks in the snow which was on the ground. She wouldn't or couldn't stop
crying, however, and kept it up all night, she said. Just before
menstruation she did some sleep-walking. She got up one night and went to
her mother and said she had something to tell her. Her mother tried to get
her to say what it was but could not, and saw that her daughter was asleep.
She kept saying, "you know what it is." The mother did not dare to waken her
and finally got her quietly back into bed. The next morning she remembered
nothing of what had happened.
When the patient was about sixteen she married. Her husband did not want
any children and practiced coitus interruptus, but she became pregnant
nevertheless and had an abortion performed. Although c.i. continued to be
practiced she became pregnant again and this time she had a daughter. Four
more years of c. i. followed. During all this time the patient had the
staring spells, but they were never noticed and she never told, not even her
mother. Then, like a thunder bolt out of a clear sky, came a tragedy.
She was pregnant again, and visiting her mother, expecting her husband for
over Sunday, when she received a letter saying he had left her and had gone
off with another woman. When she read the letter she lost consciousness.
Then followed a terrible time. In hate of her husband and on account of
fear lest she be unable to care for her baby she had another abortion
performed. This time she nearly died through not having proper medical
attendance afterwards, but she finally recovered and lived a life of
feverish activity and hate.
During her marriage she had been entirely frigid with respect to the sexual
act. A friend told her she had been missing an essential experience of
marriage. About a year after her husband left her she met a man who
thrilled her through and through, and thought, "this is what my friend
meant." This man showed her some attention and she set out consciously to
seduce him. She soon succeeded and though he was wildly in love with her and
wanted to marry her, she steadfastly refused on the score of not loving him,
but was his mistress for two or three years. During this time her staring
spells seem to have been at a minimum, but I cannot assert that they
disappeared.
Then she met the man who became her second husband. She had refused to marry
her lover because she did not "love" him. She now dropped him completely,
and getting a divorce from her husband on the ground of desertion, married.
She was happy about a year and a half when her husband moved to a country
cross-road near a "hotel" (bar-room). Here he began drinking badly, and
consorting with prostitutes. For three years she fought her husband off, in
fear of infection. During this time she had no intercourse. At this time
began the attacks of unconsciousness. She was alone one night, while her
husband was off carousing, when she had a terrible fright on seeing a man
trying to get in at the window. This was probably hallucinatory as nothing
came of it. But from this time forth she was subject to attacks, in which
she lost consciousness, had convulsions, frothed at the mouth, and bit her
tongue badly.
At the end of about three years, however, her patience broke, and she told
her husband that if he did not stop she should leave him. This threat
brought him to his senses apparently, and he completely reformed. But her
love for him was dead. And though she now permitted marital relations to be
resumed, she remained from this time on absolutely frigid. Her husband too,
now suffered from premature ejaculation. Thus from the point of view both
of "passion" and of "love" the patient was not satisfied. Her attacks
increased in number and violence, coming now at any time, not being confined
to the menstrual period as at first, and coming days as well as nights.
In this patient we have represented the points of view both of Stekel and of
Clark. The patient showed conclusively her capacity for criminal action.
She also illustrates the craving for a return to the mother. The morning of
the day on which she had the first attack in which she bit her tongue, she
passed through the town where her mother was living and thought, "Oh, if I
could only go to my mother." But remembering she had promised her lawyer to
live a year with her husband, she went on. Of the sexual character of her
conflicts no further comment is necessary.
Here then we have the natural history of what? Hysteria? or Epilepsy? This
question I shall not attempt to answer. But what has been the therapeutic
result of psychoanalysis? This question I can answer.
In the six months during which the analysis has been in progress the patient
has had no attacks in which she has had convulsions, frothed at the mouth,
or bitten her tongue. She has had only three spells in which consciousness
was lost and these were mild. The last one was described by the daughter.
She said it was like a faint; that her mother was in it only a short time;
that she had none of the symptoms she used to have; and was all right soon
afterwards with no bad after-effects. She added that since her mother had
been coming to the hospital she had improved so much they never thought of
her now as being sick. The bad feelings have diminished so much in number
and intensity as to be almost negligible. Family relations have so improved
husband and wife are practically at one in their purposes. Social relations
have also improved to such an extent that the patient has been able to
prevent the wreck of the home of a friend, and in her church is an active
worker on a number of committees. She is now doing her best to get her
daughter started right in life. The patient regards herself as having
practically recovered.
The next case I wish to present for your consideration is that of a young
man twenty-six years old. He was brought into the accident-room of the
hospital one night last Summer suffering from convulsions. He continued to
have convulsions throughout the night, and as many as five interns were
required to hold him quiet. These convulsions seemed to have enough purpose
in them to warrant the diagnosis of hysteria, so the next morning he was
referred to me.
"Last Wednesday night," he said, "I was having dinner with a customer at the
Hotel Thorndike. I began to feel sick and went to the toilet and vomited.
Then I went back and got my friend and started for a drug store in Park
Square to get some quinine. But before I got very far I began to shiver and
shake and I knew that it took quinine two or three hours to work so I
started back to the hotel to get a room. No rooms were to be had, so I said
'get a taxi and take me to the hospital.' I lost the use of my legs on the
steps and they had to carry me. In this attack I was more or less conscious
all through it." What were you thinking of in the taxi, I asked. "I don't
know. I felt as if I wanted to jump at something and grab something." Can
you not remember what was in your mind, I continued. "Only what I've told
you," he answered. Will you lie down and close your eyes and imagine
yourself back in the taxi, I asked. Now tell me what you see. After a
moment he said, "I see flames." What else do you see? "Nothing, only
flames. I feel as if I wanted to jump into the fire." Did you see flames
in the taxi, I asked. "Yes, that was what I wanted to jump at." At this
moment the patient gave a start. What did you see then, I asked. "There is
something in the flames, an object, I don't know what it is. It might be a
thing or a person. I feel as if I wanted to grab the object." At this
instant the patient gave a violent jump into the air and then sank back
relaxed. What did you see, I asked. "This object. It seemed to be
attracting me." Can't you tell what it is, I said. "No. But it seems almost
like a person. It seems as if I could see an arm." What else do you see?
"The arms seem beckoning me." It is a person then? Is it a man or a woman?
"I don't know. I can't make out." Look. "It is a woman. I can see now."
Is it anybody you know? "No, I can't see any face." What do you see? "Just
a woman, standing in the flames, with outstretched arms, as if imploring me
to come. I feel a yearning, as if I must jump and grab her." The patient
stiffened slightly and gave a sort of spring up from the couch and then sank
back, breathing a little heavier. What did you see, I asked. "I thought she
beckoned me to come." Can you see who it is now? "No The face is blank."
Look again and see if you can't tell who it is. What do you see? "I can't
tell. I see several faces come and go." Do you recognize them? "Yes. The
first is my little girl's; then I see a former sweetheart of mine; then I
see my wife's face."
Gradually the following story was elicited from the patient. His mother died
when he was seven and his father married again in less than a year. The
former sweetheart was his step-mother's half-sister who came to live at
their house because the schools were better. He became infatuated with this
girl and his step-mother did everything she could to encourage his feeling
as she thought it would be a good match. The vision of his sweetheart in the
flames was based on an actual occurrence. She was sitting in front of a
fireplace once when a log of burning wood fell out and he jumped to pull her
away and held her close in his arms for a moment.
Finally, however, he broke off absolutely all relations with the girl. The
reason seems quite adequate. Why didn't you marry, I asked. He answered,
"we quarrelled and I left her. I didn't like her morals. She went with
other men and had connection with them. I saw her go into the woods one
night with another fellow, and once at Salisbury Beach I saw her go into a
hotel with a man and register as his wife."
About a year after this the patient began going with another girl more in an
attempt to crowd the image of his former first love out of his mind than
because he had fallen in love again. A year later they married. From the
first his married life was not entirely happy. More or less unconsciously he
began to regret lost opportunities. He was a travelling man and soon after
marriage his route was enlarged necessitating his being away from home a
month at a time. On these trips he used to get exceedingly lonesome
especially as he steadily refused going with other travelling men and making
a night of it as they often did. One of his routes took him to Virginia and
he said that he had returned from New York on the way there just for the
sake of spending a night with his wife. Once, in New York, he was
unfaithful to his wife and on that occasion contracted gonorrhea. This,
however, was the only time he has ever had extra-marital sexual relations,
he said.
Just before his attacks began, which was about four years ago, he was told
by his wife's doctor that it would be impossible for her to have any more
children as she was suffering from heart disease. To his mind this meant
giving up coitus. Then, unconsciously, he began to dream of Anna, his first
love. He regretted more than ever not taking advantage of his former
opportunities, and unconsciously dallied with the thought of deserting his
wife. Just at this time his attacks began.
As the analysis progressed his attacks diminished and shortly disappeared.
Gradually the image of his wife took full possession of his mind and the
image of Anna disappeared. Towards the end of the analysis as he was lying
on the couch with his eyes shut, he saw Anna in the flames and felt the
yearning but not so strongly as to lead to any impulsive movements. What do
you think all this might mean, I asked. "I don't know," he answered, "it
might mean I still cared for Anna and that if I let myself go it would break
up my home." With his full realization of the meaning of this symbolization,
it was assumed that he was cured.
Seven months later, in company with a colleague, I visited my former patient
and he told me that he had not had a moment's illness since I last saw him.
He told me that while occasionally the thought of Anna would come to his
mind, it never disturbed him, and never distracted his attention from other
things. He has prospered in his business, and I saw every evidence of a
happy home.
This case merits consideration for a number of reasons. In the first place
the attacks were cured by psychoanalysis. No one who saw the association of
the symbolical imagery and the convulsive movements could fail to see that
there was a causal connection between them. The subsidence in violence and
frequency of the convulsive movements as the conscious grasp of the meaning
of the mental symbolical imagery increased was also completely convincing of
the therapeutic value of the analysis. The question of the permanence of the
recovery is of course open, because seven months is far too short a time to
carry complete conviction.
The comparison of this case with the one immediately preceding raises a very
interesting question. Why is this patient apparently completely cured and
the other one not? Several reasons may be noted. The patient is much
younger. He had never been through anything like the same mental strains.
His trouble was of short duration. But above all as he was successful in
his business he was successful in his sublimation. Here is a sine qua non of
a successful psychoanalysis: the capacity and the opportunity for successful
sublimation. If these are present the prognosis is good.
It is interesting also to compare this case in its results with the
contentions of Clark and of Stekel. It is hard to see any signs of a
definite criminal tendency. Inasmuch as the temptation to go back to his
early love is a sign of a tendency towards regression and erotism generally
the patient shows what Clark has spoken of as a desire to return to the
mother-body. This case is not very important, however, to the views of
either Clark or Stekel as the analysis is relatively superficial, and there
is no knowing what a more thorough analysis might reveal. From the point of
view of superficiality, however, the case is important as it emphasizes
Taylor's view of the value of a modified analysis. The patient was seen only
five times.
On the basis of these, and a number of other similar cases, I should like to
suggest, from a descriptive point of view, that the epileptiform seizure is
of the nature of an orgasm. An orgasm is a sudden, explosive, discharge of
nervous energy, raised to the breaking point of nervous tension. I should
like to generalize the idea of orgasm. Ordinarily, of course, it is confined
to the sexual sphere. In the last case I reported it seems to me fairly
clear that the explosive actions, convulsive-like impulses, were closely
associated in the mind of the patient with sexual ideas. That they were
substitutes for the normal relief of sexual tension, seems to me also clear.
This idea is perhaps more convincing if I add the fact, as stated by the
patient, that his last attack started when he saw an attractive girl sitting
at a nearby table in the Thorndike Hotel, and who started him dreaming about
Anna, because she looked so much like her.
The second case I reported seems also easily brought under this conception.
Here we know more about the earliest childhood of the patient and we can
easily imagine that there was an especial predisposition for the form the
symptoms took. This, however, does not militate against the descriptive
value of the above conception. That the epileptiform attacks did not take
place until after actual sexual orgasms had been experienced, lends weight
to the conception I am presenting here. The first case is not so clear.
This is partly due to the fact that it was impossible to make anything like
a complete analysis. But it shows nothing contradictory to the conception,
and indeed has some slight value as added evidence in favor of the
conception, in as much as the original trauma consisted of a kick in the
genitals, by her father.
This conception does not contradict either Stekel's or Clark's ideas, but
rather supplements them. The essence of the criminal act lies in its
unrestrained aggressive character. From this point of view anything getting
in the way of the libido discharge has to take the consequences. This also
agrees with Clark, only his idea seems to me perhaps a little too passive to
describe fully the dynamic quality of the attack.
Here, as in Hysteria, the therapeutic effect of an analysis depends on the
possibility of sublimation. The three cases I have given in some detail may
easily be arranged in order. The last case having the best chances for
sublimation shows the best results.