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.