neuroses with a description of nervous behavior, the nature of neurotic
suffering, and the way in which the nervous meet the conditions of their
illness and adapt themselves to these. Such subject matter is certainly
interesting and well worth knowing. It is moreover not very hard to
handle, yet it is not wise to begin with its consideration. There is
danger of not discovering the unconscious, of overlooking the great
significance of the libido, of judging all conditions as they appear to
the ego of the nervous person. It is obvious that this ego is neither a
reliable nor an impartial authority. For this very ego is the force that
denies and suppresses the unconscious; when the unconscious is
concerned, how then could we expect justice to be done? The rejected
claims of sexuality stand first in the line of these suppressions; it is
natural that from the standpoint of the ego we can never learn their
extent and significance. As soon as we attain to the point of view of
suppression, we are sufficiently warned not to make one of the
contending factions, above all not to make the victor judge of the
struggle. We are prepared to find that the testimony of the ego may lead
us astray. If one is to believe the evidence of the ego, it would appear
to have been active all along, all its symptoms would have been actively
willed and formed. Yet we know that it has passively allowed a great
deal to occur, a fact which it subsequently seeks to conceal and to
palliate. To be sure, it does not always attempt this; in the case of
the symptoms of compulsion neurosis it must admit that it is being
opposed by something alien, which it can resist only with difficulty.
Whoever does not heed these warnings not to mistake the prevarications
of the ego for truth, has clear sailing; he avoids all the resistances
which oppose the psychoanalytic emphasis upon the unconscious, on
sexuality, and on the passiveness of the ego. He will assert with Alfred
Adler that the "nervous character" is the cause instead of the result of
the neurosis, but he will not be able to explain a single detail of
symptom formation or to interpret a single dream.
You will ask: Is it not possible to do justice to the part the ego plays
in nervousness and in symptom formation without crudely neglecting the
factors revealed by psychoanalysis? I answer you: Surely it must be
possible and at some time or other it will take place; but the methods
by which we organize the work of psychoanalysis do not favor our
beginning with just this task. We can foresee the time when this task
will claim the attention of psychoanalysis. There are forms of neuroses,
the so-called narcistic neuroses, in which the ego is far more deeply
involved than in anything we have studied heretofore. The analytic
investigation of these conditions will enable us to judge reliably and
impartially the part that the ego plays in neurotic illness.
One of the relations which the ego bears to its neurosis is so obvious
that it must be considered at the very outset. In no case does it seem
to be absent, and it is most clearly recognizable in the traumatic
neuroses, conditions which we do not as yet clearly understand. You must
know that in the causation and mechanisms of all possible forms of
neurosis, the same factors are active again and again; it is only the
emphasis that is shifted from one to the other of these factors in
symptom formation. The members of a company of actors each have certain
parts to play--hero, villain, confidant, etc.--yet each will select a
different drama for his benefit. Thus the phantasies which undergo
conversion into symptoms are especially easy to detect in hysteria;
compulsion neuroses are essentially dominated by the reactionary
formations, or counter-seizures of the ego; what we designate as
_secondary elaboration_ in dreams dominates paranoia in the form of
delusions, etc.
In traumatic neuroses, particularly if they are caused by the horrors of
war, we are especially impressed by a selfish ego-impulse which seeks
protection and personal advantage. This in itself is not a sufficient
cause for illness, but it can favor its beginning and also feed its
needs once it has been established. This motive serves to protect the
ego from the dangers whose imminence precipitated the disease, and does
not permit convalescence until the recurrence of these dangers seems
impossible, or until compensation has been obtained for the danger that
has been undergone.
But the ego betrays similar interest in the origin and maintenance of
all other neuroses. We have already said that the ego suffers the
symptom to exist, because one of its phases gratifies the egoistic
tendency toward suppression. Besides, the ending of the conflict by
means of symptom development is the path of least resistance, and a
most convenient solution for the principle of pleasure. Through symptom
formation the ego is undoubtedly spared a severe and unpleasant inner
task. There are cases where even the physician must admit that the
resolution of the conflict into neurosis is the most harmless outcome
and one most easily tolerated by society. Do not be surprised, then, to
learn that occasionally even the physician takes the part of the illness
he is battling against. He does not have to restrict himself to the role
of the fanatic warrior for health in all situations of life. He knows
that the world contains not only neurotic misery, but also real,
incurable suffering. He knows that necessity may even require a human
being to sacrifice his health, and he learns that by this sacrifice on
the part of one individual untold wretchedness may be spared for many
others. So if we say that the neurotic escapes the conflict _by taking
refuge in illness_, we must admit that in some cases this escape is
justifiable, and the physician who has diagnosed the state of affairs
will retire silently and tactfully.
But let us not consider these special cases in our further discussion.
In average cases the ego, by having recourse to neurosis, obtains a
certain inner _advantage from the disease_. Under certain conditions of
life, there may also be derived a tangible external advantage, more or
less valuable in reality. Let me direct your attention to the most
frequent occurrences of this sort. Women who are brutally treated and
mercilessly exploited by their husbands almost always adopt the evasion
of the neurosis, provided that their predisposition permits this. This
usually follows when the woman is too cowardly or too virtuous to seek
secret solace in the arms of another, or when she dare not separate from
her husband in the face of all opposition, when she has no prospect of
maintaining herself or of finding a better husband and especially when
her sexual emotions still bind her to this brutal man. Her illness
becomes a weapon in her struggle with him, one that she can use for
self-protection and misuse for purposes of vengeance. She probably dare
not complain of her marriage, but she can complain of her illness. The
doctor becomes her assistant. She forces her inconsiderate husband to
spare her, to attend to her wishes, to permit her absence from the house
and thus free her from the oppressions of her married life. Wherever
such external or accidental gain through illness is considerable and
can find no substitute in fact, you can prophesy that the possibility of
influencing neurosis through therapy is very slight.
You will tell me that what I have said about the advantage gained from
the disease speaks entirely for the hypothesis I have rejected, namely,
that the ego itself wills and creates the neurosis. Just a moment! It
probably does not mean more than that the ego passively suffers the
neurosis to exist, which it is unable to prevent anyway. It makes the
most of the neurosis, if anything can be made of it at all. This is only
one side of the question, the advantageous side. The ego is willing to
endure the advantages of the neurosis, but there are not only
advantages. As a rule it soon appears that the ego has made a poor deal
in accepting the neurosis. It has paid too high a price for the
mitigation of the conflict; and the sensations of suffering which the
symptoms bring with them are perhaps every bit as bad as the agonies of
conflict, usually they cause even greater discomfort. The ego wants to
rid itself of the pain of the symptoms without relinquishing the gain of
illness, and that is impossible. Thus the ego is discovered as by no
means so active as it had thought itself to be, and this we want to keep
in mind.
If you were to come into contact with neurotics as a physician, you
would soon cease to expect that those who complain most woefully of
their illness are the ones who will oppose its therapy with the least
resistance or who will welcome any help. On the contrary, you would
readily understand that everything contributing to the advantage derived
from the disease will strengthen the resistance to the suppression and
heighten the difficulty of the therapy. We must also add another and
later advantage to the gain of illness which is born with the symptom.
If a psychic organization, such as this illness, has persisted for a
long time, it finally behaves as an independent unit, it expresses
something like self-preservation, attains a kind of _modus vivendi_
between itself and other parts of psychic life, even those that are
fundamentally hostile to it. And occasions will probably arise where it
can prove again to be both useful and valuable, by which it will attain
a _secondary function_, which gives strength to its existence. Instead
of an illustration from pathology take a striking example from everyday
life. An efficient workman who earns his living is crippled for his
occupation by some disaster; his work is over for him. After a while,
however, he receives a small accident insurance, and learns to exploit
his injury by begging. His new existence, though most undesirable, is
based upon the very thing that robbed him of his former maintenance. If
you could cure his defect, he would be without a means of subsistence,
he would have no livelihood. The question would arise: Is he capable of
resuming his former work? That which corresponds to such secondary
exploitation of illness in neurosis we may add to the primary benefit
derived therefrom and may term it a _secondary_ advantage of disease.
In general I should like to warn you not to underestimate the practical
significance of the advantage from illness and yet not to be too much
impressed by it theoretically. Aside from the previously recognized
exceptions, I am always reminded of Oberlaender's pictures on "the
intelligence of animals" which appeared in the _Fliegende Blaetter_. An
Arab is riding a camel on a narrow path cut through a steep mountain
side. At a turn of the trail he is suddenly confronted by a lion who
makes ready to spring. He sees no way out, on one side the precipice, on
the other the abyss; retreat and flight--both are impossible; he gives
himself up as lost. Not so the camel. He leaps into the abyss with his
rider--and the lion is left in the lurch. The help of neurosis is as a
rule no kinder to the rider. It may be due to the fact that the
settlement of the conflict through symptom development is nevertheless
an automatic process, not able to meet the demands of life, and for
whose sake man renounces the use of his best and loftiest powers. If it
were possible to choose, it were indeed best to perish in an honorable
struggle with destiny.
I still owe you further explanation as to why, in my presentation of the
theory of neurosis, I did not proceed from ordinary nervousness as a
starting point. You may assume that, had I done this, the proof of the
sexual origin of neurosis would have been more difficult for me, and so
I refrained. There you are mistaken. In transference neurosis we must
work at interpretations of the symptoms to arrive at this conclusion. In
the ordinary forms of the so-called true neuroses, however, the
etiological significance of sexual life is a crude fact open to
observation. I discovered it twenty years ago when I asked myself one
day why we regularly barred out questions concerning sexual activity in
examining nervous patients. At that time I sacrificed my popularity
among my patients to my investigations, yet after a brief effort I could
state that no neurosis, no true neurosis at least, is present with a
normal sexual life. Of course, this statement passes too lightly over
the individual differences, it is unclear through the vagueness with
which it uses the term "normal," but even to-day it retains its value
for purposes of rough orientation. At that time I reached the point of
drawing comparisons between certain forms of nervousness and sexual
abnormalities, and I do not doubt that I could repeat the same
observations now, if similar material were at my disposal. I frequently
noticed that a man who contented himself with incomplete sexual
gratification, with manual ononism, for instance, would suffer from a
true neurosis, and that this neurosis would promptly give way to another
form, if another sexual regime no less harmful were substituted. From
the change in the condition of the patient I was able to guess the
change in the mode of his sexual life. At that time I learned to hold
obstinately to my conjectures until I had overcome the patient's
prevarications and had forced him to confirm my suppositions. To be
sure, then he preferred to consult other physicians who did not inquire
so insistently into his sexual life.
At that time it did not escape my notice that the origin of the disease
could not always be traced back to sexual life; sexual abnormality would
cause the illness in one person, while another would fall ill because he
had lost his fortune or had suffered an exhausting organic disease. We
gained insight into this variation by means of the interrelations
between the ego and the libido, and the more profound our insight
became, the more satisfactory were the results. A person begins to
suffer from neurosis when his ego has lost the capacity of accommodating
the libido. The stronger the ego, the easier the solution of the
problem; a weakening of the ego from any cause whatsoever has the same
effect as a superlative increase of the claims of the libido. There are
other and more intimate relations between the ego and the libido which I
shall not discuss, as we are not concerned with them here. To us it is
of enlightening significance that in every case, regardless of the way
in which the illness was caused, the symptoms of neurosis were opposed
by the libido and thus gave evidence for its abnormal use.
Now, however, I want to draw your attention to the difference between
the symptoms of the true neuroses and the psychoneuroses, the first
group of which, the transference neurosis, has occupied us considerably.
In both cases the symptoms proceed from the libido. They are accordingly
abnormal uses of it, substitutes for gratification. But the symptoms of
the true neurosis--such as pressure in the head, sensations of pain,
irritability of an organ, weakening or inhibition of a function--these
have no meaning, no psychic significance. They are manifested not only
in the body, as for instance hysteric symptoms, but are in themselves
physical processes whose creation is devoid of all the complicated
psychic mechanism with which we have become acquainted. They really
embody the character that has so long been attributed to the
psychoneurotic symptom. But how can they then correspond to uses of the
libido, which we have come to know as a psychological force? That is
quite simple. Let me recall one of the very first objections that was
made to psychoanalysis. It was stated that psychoanalysis was concerned
with a purely psychological theory of neurotic manifestations; that this
was a hopeless outlook since psychological theories could never explain
illness. The objectors chose to forget that the sexual function is
neither purely psychic nor merely somatic. It influences physical as
well as psychic life. In the symptoms of the psychoneuroses we have
recognized the expression of a disturbance in psychic processes. And so
we shall not be surprised to discover that the true neuroses are the
direct somatic consequences of sexual disturbances.
The medical clinic gives us a valuable suggestion (observed by many
research workers) for the comprehension of the true neuroses. In all the
details of their symptomatology, and as well in their characteristic
power to influence all organic systems and all functions, the true
neuroses reveal a marked similarity to the conditions of those diseases
which originate through the chronic influence of foreign poisons and as
well through their acute diminution; with conditions prevalent in
intoxication and abstinence. The two groups of conditions are brought
still closer together by the relation of intermediate conditions, which,
following M. Basedowi, we have learned to attribute to the influence of
toxic substances, but of toxins, however, which are not introduced into
the body from without, but arise in its own metabolism. These analogies,
I think, lead us directly to the consideration of these neuroses as
disturbances in sexual metabolism. It may be that more sexual toxins are
produced than the individual can dispose of, or that inner, even psychic
conditions, stand in the way of the proper elaboration of these
substances. The language of the people has always favored such
assumptions as to the nature of sexual desires. It calls love an
"intoxication"; it will have love-madness aroused through potions, and
thus sees the motive force removed, as it were, to the outer world. For
the rest, the phrase "sexual metabolism" or "chemism of sexuality" is a
chapter-head without content. We know nothing about it and cannot even
decide whether we are to assume two sexual substances, the male and the
female, or, if there is only _one_ sexual toxin, which to consider the
carrier of all the stimulating power of the libido. The structure of
psychoanalysis that we have erected is really only a superstructure
which at some future time must be placed upon its organic foundation;
but what this is we do not know as yet.
Psychoanalysis is characterized as a science, not by reason of the
subject matter it handles but by the technique it employs. This can be
employed in dealing with the history of civilization, the science of
religion or mythology, as well as with the theory of neurosis, without
altering its character. The revealing of the unconscious in psychic life
is all it aims to accomplish. The problems of the true neuroses, whose
symptoms probably originate in direct toxic damage, yield no point of
attack to psychoanalysis. Psychoanalysis can do little for their
elucidation, and must leave the task to biological-medical research.
Perhaps you understand now why I did not choose to organize my material
differently. If I had given to you an _Introduction to the Theory of the
Neuroses_ as you wished, it would unquestionably have been correct to
proceed from the simple forms of the true neuroses to those complex
illnesses caused by a disturbance of the libido. In discussing the true
neuroses I would have had to bring together the facts we have gleaned
from various quarters and present what we think we know of them. Only
later, under the psychoneuroses, would psychoanalysis have been
discussed as the most important technical aid for insight into these
conditions. I had, however, intended and announced _A General
Introduction to Psychoanalysis_, and it seemed to me more important to
give you an idea of psychoanalysis than to present certain positive
facts about neuroses; and so I could not place the true neuroses into
the foreground, for they prove sterile for the purposes of
psychoanalysis. I believe that I have made the wiser choice for you,
since psychoanalysis deserves the interest of every educated person
because of its profound hypotheses and far-reaching connections. The
theory of neurosis, on the other hand, is a chapter of medicine like any
other.
You are, however, justified in expecting some interest on our part in
the true neuroses. Because of their intimate connection with
psychoneuroses we find this decidedly necessary. I shall tell you then
that we distinguish three pure forms of true neuroses: _neurasthenia_,
_anxiety neurosis_ and _hypochondria_. Even this classification has not
remained uncontradicted. The terms are all widely used, but their
connotation is vague and uncertain. Besides, there are in this world of
confusion physicians who object to any distinctions between
manifestations, any emphasis of clinical detail, who do not even
recognize the separation of true neuroses and psychoneuroses. I think
they have gone too far and have not chosen the road which leads to
progress. The types of neuroses we have mentioned occur occasionally in
pure form; more often they are blended with one another or with a
psychoneurotic condition. This need not discourage us to the extent of
abandoning the task of distinction. Think of the difference between the
study of minerals and that of ores in mineralogy. Minerals are described
as individuals; frequently of course they occur as crystals, separated
sharply from their surroundings. Ores consist of an aggregate of
minerals which have coalesced not accidentally, but as a result of the
conditions of their origin. We understand too little of the process of
development of neuroses, to create anything similar to the study of
ores. But we are surely working in the right direction when we isolate
the known clinical factors, comparable to the separate minerals, from
the great mass.
A noteworthy connection between the symptoms of the true neuroses and
the psychoneuroses adds a valuable contribution to our knowledge of
symptom formation in the latter. The symptom in the true neuroses is
frequently the nucleus and incipient stage of development of the
psychoneurotic symptom. Such a connection is most easily observed
between neurasthenia and the transference neuroses, which are termed
conversion hysteria, between anxiety neurosis and anxiety hysteria, but
also between hypochondria and paraphrenia (dementia praecox and
paranoia), forms of neuroses of which we shall speak subsequently. Let
us take as an illustration the hysteric headache or backache. Analysis
shows that through elaboration and displacement this pain has become the
gratification substitute for a whole series of libidinous phantasies or
reminiscences. But once upon a time this pain was real, a direct sexual
toxic symptom, the physical expression of libidinous excitation. We do
not wish to assert, by any means, that all hysteric symptoms can be
traced to such a nucleus, but it is true that this is frequently the
case, and that all influences upon the body through libidinous
excitation, whether normal or pathological, are especially significant
for the symptom development in hysteria. They play the part of the grain
of sand which the mollusc has enveloped in mother-of-pearl. In the same
way passing signs of sexual excitation, which accompany the sexual act,
are used by psychoneurosis as the most convenient and appropriate
material for symptom formation.
A similar procedure is of diagnostic and therapeutic interest
especially. Persons who are disposed to be neurotic, without suffering
from a flourishing neurosis, frequently set in motion the work of
symptom development as the result of an abnormal physical change--often
an inflammation or an injury. This development rapidly makes the symptom
given by reality the representative of the unconscious phantasies that
had been lurking for an opportunity to seize upon a means of expression.
In such a case the physician will try different ways of therapy. Either
he will try to do away with the organic basis without bothering about
its noisy neurotic elaboration, or he will struggle with the neurosis
brought out by the occasion, and ignore its organic cause. The result
will justify now one, now the other method of procedure; no general laws
can be laid down for such mixed cases.
TWENTY-FIFTH LECTURE
GENERAL THEORY OF THE NEUROSES
_Fear and Anxiety_