THE DEFENSE NEURO-PSYCHOSES.
A TENTATIVE PSYCHOLOGICAL THEORY OF ACQUIRED HYSTERIA, MANY PHOBIAS AND
OBSESSIONS, AND CERTAIN HALLUCINATORY PSYCHOSES.
After an exhaustive study of many nervous patients afflicted with
phobias and obsessions a tentative explanation of these symptoms urged
itself upon me. This helped me afterwards happily to divine the origin
of such morbid ideas in new and other cases, and I therefore believe it
worthy of reporting and further examination. Simultaneously with this
“psychological theory of phobias and obsessions,” the examination of
these patients resulted in a contribution to the theory of hysteria, or
rather in an alteration of the same, which seems to imply an important
and common character to hysteria as well as the mentioned neuroses.
Furthermore, I had the opportunity to look into the psychological
mechanism of a form of indubitable psychic disease and found that my
attempted observation shows an intelligible connection between these
psychoses and the two neuroses mentioned. At the conclusion of this
theme I will describe the supporting hypothesis which I have used in all
three cases.
I.
I am beginning with that alteration which seems to be necessary for the
theory of the hysterical neuroses.
That the symptom-complex of hysteria as far as it can be understood,
justifies the assumption of a splitting of consciousness with the
formation of separate psychic groups, has attained general recognition
since P. Janet, J. Breuer, and others have given out their interesting
work. Less understood are the opinions concerning the origin of this
splitting of consciousness and concerning the rôle played by this
character in the structure of the hysterical neuroses.
According to Janet’s[36] theory, the splitting of consciousness is a
primary feature of the hysterical alteration. It is due to a congenital
weakness of the capacity for psychic synthesis, and to a narrowing of
the “field of consciousness” (champ du conscience) which as a psychic
stigma proves the degeneration of hysterical individuals.
In contradistinction to Janet’s views, which in my opinion admit the
most manifold objections, are those advocated by J. Breuer in our joint
communication. According to Breuer, the “basis and determination” of
hysteria is the occurrence of peculiar dream-like conscious states with
a narrowed association capacity, for which he proposes the name “hypnoid
states.” The splitting of consciousness is secondary and acquired, and
originates because the ideas emerging in the hypnoid states are isolated
from associative communication with the rest of consciousness.
I can now demonstrate two other extreme forms of hysteria in which it is
impossible to show that the splitting of consciousness is primary in the
sense of Janet. In the first of these forms I could repeatedly show that
the splitting of the content of consciousness was an arbitrary act of
the patient, that is, it was initiated through an exertion of the will
which motive can be stated. I naturally do not maintain that the patient
intended to produce a splitting of his consciousness; the patient’s
intention was different, but instead of attaining its aim it provoked a
splitting of consciousness.
In the third form of hysteria, as we have demonstrated by
psychic-analysis of intelligent patients, the splitting of consciousness
plays only an insignificant and perhaps really no rôle. This includes
those cases in which there had been no reaction to the traumatic
stimulus and which were then adjusted and cured by ab-reaction. They are
the pure retention hysterias.
In connection with the phobias and obsessions I have only to deal here
with the second form of hysteria which for reasons to be presently
explained I will designate as defense hysteria and thus distinguish it
from the hypnoid and retention hysterias. Preliminarily I am able to
call my cases of defense hysteria “acquired” hysterias for they show
neither marked hereditary taints nor any degenerative disfigurements.
In those patients whom I have analyzed there existed psychic health
until the moment in which a case of incompatibility occurred in their
ideation, that is, until there appeared an experience, idea, or feeling
which evoked such a painful affect that the person decided to forget it
because he did not trust his own ability to remove the resistance
between the unbearable ideas and his ego.
Such incompatible ideas originate in the feminine sex on the basis of
sexual experiences and feelings. With all desired precision the patients
recall their efforts of defense, their intention “to push it away,” not
to think of it, to repress it. As appropriate examples I can easily cite
the following cases from my own experience: A young lady reproached
herself because, while nursing her sick father, she thought of a young
man who made a slight erotic impression on her; a governess fell in love
with her employer and decided to crowd it out of her mind because it was
incompatible with her pride, etc.
I am unable to maintain that the exertion of the will, in crowding such
thoughts out of one’s mind, is a pathological act, nor am I able to
state whether and how, the intentional forgetting succeeds in those
persons who remain well under the same psychic influences. I only know
that in the patients whom I analyzed such “forgetting” was unsuccessful
and led to either a hysteria, obsession, or a hallucinatory psychosis.
The ability to produce, by the exertion of the will one of these states
all of which are connected with the splitting of consciousness, is to be
considered as the expression of a pathological disposition, but it need
not necessarily be identified with personal or hereditary
“degeneration.”
Over the road leading from the patient’s exertion of the will to the
origin of a neurotic symptom I formed a conception which in the current
psychological abstractions may be thus expressed: The task assumed by
the defensive ego to treat the incompatible idea as “non arrivée” can
not be directly accomplished. The memory trace as well as the affect
adhering to the idea are here and can not be exterminated. The task can
however, be brought to an approximate solution if it is possible to
change the strong idea into a weak one and to take away the affect or
sum of excitement which adheres to it. The weak idea will then exert
almost no claims on the association work; but the separated sum of
excitement must be utilized in another direction.
Thus far the processes are the same in hysteria, in phobias and
obsessions, but from now on their ways part. The unbearable idea in
hysteria is rendered harmless because the sum of excitement is
transformed into physical manifestations, a process for which I would
like to propose the term conversion.
The conversion may be total or partial, and follows that motor or
sensory innervation which is either ultimately or more loosely connected
with the traumatic experience. In this way the ego succeeds in freeing
itself from opposition but instead it becomes burdened with a memory
symbol which remains in consciousness as an unadjusted motor
innervation, or as a constantly recurring hallucinatory sensation
similar to a parasite. It thus remains fixed until a conversion takes
place in the opposite direction. The memory symbol of the repressed idea
does not perish, but from now on forms the nucleus for a second psychic
group.
I will follow up this view of the psycho-physical processes in hysteria
with a few more words. If such a nucleus for an hysterical splitting is
once formed in a “traumatic moment” it then increases in other moments
which might be designated as “auxiliary traumatic” as soon as a newly
formed similar impression succeeds in breaking through the barrier
formed by the will and in adding new affects to the weakened idea, and
in forcing for a while the associative union of both psychic groups
until a new conversion produces defense. The condition thus attained in
hysteria in regard to the distribution of the excitement, proves to be
unstable in most cases. As shown by the familiar contrast of the attacks
and the persistent symptoms, the excitement which was pushed on a false
path (in the bodily innervation) now and then returns to the idea from
which it was discharged and forces the person to associative elaboration
or to adjustment in hysterical attacks. The effect of Breuer’s cathartic
method consists in the fact that it consciously reconducts the
excitement from the physical into the psychic spheres and then forces an
adjustment of the contradiction through intellectual work, and a
discharge of the excitement through speech.
If the splitting of consciousness in acquired hysteria is due to an act
of volition we can explain with surprising simplicity the remarkable
fact that hypnosis regularly broadens the narrowed consciousness of
hysteria, and causes the split off psychic groups to become accessible.
For we know that it is peculiar to all sleep-like states to remove that
distribution of excitement which depends on the “will” of the conscious
personality.
We accordingly recognize that the characteristic moment of hysteria is
not the splitting of consciousness but the ability of conversion, and as
an important part of the hitherto unknown disposition of hysteria we can
mention the psycho-physical adaptation for the transference of a great
sum of excitement into bodily innervation.
The adaptation does not in itself exclude psychic health, and leads to
hysteria only in event of a psychic incompatibility or accumulation of
excitement. With this turn, we—Breuer and I—come near to the familiar
definitions of hysteria of Oppenheim[37] and Strümpel,[38] and deviate
from Janet,[39] who assigns to the splitting of consciousness too great
a rôle in the characteristics of hysteria. The description here given
can lay claim to the fact that it explains the connection between the
conversion and the hysterical splitting of consciousness.
II
In a predisposed person if there is no adaptation for conversion, and
still for the purpose of defense a separation of the unbearable idea
from its affect is undertaken, the affect must then remain in the
psychic sphere. The weakened idea remains apart from all association in
consciousness, but its freed affect attaches itself to other not in
themselves unbearable ideas, which on account of this “false” connection
become obsessions. This is in brief the psychological theory of the
obsessions and phobias concerning which I have spoken above.
I will now state what parts demanded in this theory can be directly
demonstrated and what parts I have supplemented. Besides the end product
of the process, the obsession, we can in the first place directly
demonstrate the source from which the affect in the false connection
originates. In all cases that I have analyzed it was the sexual life
that has furnished a painful affect of precisely the same character as
the one attached to the obsession. It is not theoretically excluded that
this affect could not occasionally originate in other spheres, but I
must say that thus far I have found no other origin. Moreover, one can
readily understand that it is precisely the sexual life which furnishes
the most manifold occasions for the appearance of unbearable ideas.
Moreover, the exertion of the will, the attempt at defence, upon which
this theory lays stress is demonstrated by the most unequivocal
utterances of the patients. At least in a number of cases the patients
themselves inform us that the phobia or obsession appeared only after
the exertion of the will manifestly gained its point. “Something very
disagreeable happened to me once and I have exerted all my power to push
it away, not to think of it. When I have finally succeeded I have gotten
the other thing instead, which I have not lost since.” With these words
a patient verified the main points of the theory here developed.
Not all who suffer from obsessions are so clear concerning the origin of
the same. As a rule when we call the patient’s attention to the original
idea of a sexual nature we receive the following answer: “It could not
have come from that. Why I have not thought much about it. For a moment
I was frightened, then I distracted myself and since then it has not
bothered me.” In this, so frequent objection, we have the proof that the
obsession represents a compensation or substitute for the unbearable
sexual idea, and that it has taken its place in consciousness.
Between the patient’s exertion of the will which succeeds in repressing
the unacceptable sexual idea and the appearance of the obsession, which
though in itself of little intensity, is here furnished with
inconceivably strong affect, there is a yawning gap which the theory
here developed will fill. The separation of the sexual idea from its
affect and the connection of the latter with another suitable but not
unbearable idea—these are processes which take place unconsciously which
we can only presume but not prove by any clinico-psychological analysis.
Perhaps it would be more correct to say that these are not really
processes of a psychic nature but physical processes of which the
psychic result so presents itself that the expressions “separation of
the idea from its affect and false connection of the latter,” seem
actual occurrences.
Besides the cases evincing in turn the sexual unbearable idea and the
obsession we find a series of others in which there are simultaneously
obsessions and painfully accentuated sexual ideas. It will not do very
well to call the latter “sexual obsessions”; they lack the essential
character of obsessions in proving themselves fully justified, whereas
the painfulness of the ordinary obsession is a problem for the doctor as
well as the patient. From the amount of insight that could be obtained
in such cases, it seems that we deal here with a continued defense
against sexual ideas which are constantly renewed, a work heretofore not
accomplished.
As long as the patients are aware of the sexual origin of their
obsessions they often conceal them. If they complain they generally
express surprise that this affect underlies the symptoms, at being
afraid, and at having certain impulses, etc. To the experienced
physician, however, the affect appears justified and intelligible; he
finds the striking part only in the connection of such an affect with an
idea unworthy of it. In other words the affect of the obsession appears
to him as one dislocated or transposed, and if he has accepted the
observations here laid down he can in a great many cases of obsessions
attempt a retranslation into the sexual.
Any idea which either through its character may be combinable with an
affect of such quality or which bears a certain relation to the
unbearable by virtue of which it seems fit as a substitute for the same,
may be used for the secondary connection of the freed affect. Thus, for
example, freed anxiety, the sexual origin of which can not be recalled,
attaches itself to the common primary phobias of man for animals,
thunderstorms, darkness, etc., or to things which are unmistakably in
some way associated with the sexual, such as urination, defecation,
pollutions and infections.
The advantage gained by the ego in the transposition of the affect for
the purpose of defense is considerably less than in the hysterical
conversion of psychic excitement into somatic innervation. The affect
under which the ego has suffered remains now as ever unchanged and
undiminished, but the unbearable idea is suppressed and excluded from
memory. The repressed ideas again form the nucleus of a second psychic
group which I believe can be accessible without having recourse to
hypnotism. That in the phobias and obsessions there appear none of the
striking symptoms which in hysteria accompany the formation of an
independent psychic group, is due to the fact that in the former case
the whole transformation remains in the psychic sphere and the somatic
innervation experiences no change.
What I have here said concerning obsessions I will explain by some
examples which are probably of a typical nature:
1. A young girl suffers from obsessive reproaches. If she reads anything
in the journal about false coiners she conceives the thought that she
too, made counterfeit money; if a murder was anywhere committed by an
unknown assassin she anxiously asked herself whether she had not
committed this crime. At the same time she is perfectly aware of the
absurdity of these obsessive reproaches. For a time the consciousness of
her guilt gained such a power over her that her judgment was suppressed,
and she accused herself before her relatives and physician of having
really committed all these crimes (Psychosis through simple
aggravation—overwhelming psychosis—Uberwältigungspsychose). A thorough
examination revealed the source of the origin of this guilty conscience.
Accidentally incited by a sensual feeling she allowed herself to be
allured by a friend to masturbate. She practiced it for years with the
full consciousness of her wrong doing, and under the most violent but
useless self reproaches.—The girl was cured after a few months’
treatment and strict watching.
2. Another girl suffered from the fear of getting sudden desires of
micturition and of being forced to wet herself. This began after such a
desire had really forced her to leave a concert hall during the
performance. This phobia had gradually caused her to become quite
incapable of any enjoyment and social relationship. She felt secure only
when she knew that there was a toilet in the neighborhood to which she
could repair unobserved. An organic suffering which might have justified
this lack of confidence of the control of the bladder was excluded. At
home among quiet surroundings and during the night there was no such
desire to micturate. Detailed examination showed that the desire to
micturate appeared for the first time under the following conditions: A
gentleman to whom she was not indifferent took a seat in the concert
hall not far from her. She began to think and to picture to herself how
she would sit near him as his wife. In this erotic revery she
experienced that physical feeling which must be compared to erection in
the man, and which in her—I do not know whether it is general—ended in a
slight desire to micturate. She now became extremely frightened over her
otherwise accustomed sexual sensation because she had determined to
overcome this as well as every desire, and in the next moment the affect
transposed itself to the accompanying desire to micturate and forced her
to leave the hall after a very painful struggle. In her life she was so
prudish that she experienced an intensive horror for all things sexual,
and could not conceive the thought of ever marrying; on the other hand
she was sexually so hyperesthetic that during every erotic revery, which
she gladly allowed herself, there appeared sensual feeling. The erection
was always accompanied by the desire to micturate, and up to the time of
the scene in the concert hall it had made no impression on her. The
treatment led to an almost complete control of the phobia.
3. A young woman who had only one child after five years of married life
complained of obsessive impulses to throw herself from the window or
balcony, and of fears lest at the sight of a sharp knife she might kill
her child. She admitted that the marriage relations were seldom
practised and then only with caution against conception; but she added
that she did not miss this as she was not of a sensual nature. I then
ventured to tell her that at the sight of a man she conceives erotic
ideas, and that she therefore lost confidence in herself and imagined
herself a depraved person fit for anything. The retranslation of the
obsession into the sexual was successful; weeping, she soon admitted her
long concealed marital misery, and then mentioned painful ideas of an
unchanged sexual character such as the often recurring sensation of
something forcing itself under her skirts.
I have made use of such experiences in the therapy of phobias and
obsessions, and despite the patient’s resistances I have redirected the
attention to the repressed sexual ideas, and wherever feasible I have
blocked the sources from which the same originated. To be sure I cannot
maintain that all phobias and obsessions originate in the manner here
revealed; first, my experience, in proportion to the abundance of these
neuroses, embraces only a limited amount, and second, I, myself, know
that these “psychasthenic” symptoms (according to Janet’s designation)
are not all of the same value.[40] Thus, for instance, there are pure
hysterical phobias. But I believe that the mechanism of the
transposition of the affect will be demonstrated in the greater part of
the phobias and obsessions, and I must assert that these neuroses, which
are found just as often isolated as combined with hysteria and
neurasthenia, are not to be thrown together with the ordinary
neurasthenia for which fundamental symptom a psychic mechanism is not
all to be assumed.
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.