the other forms of neurosis; we have said already that the symptom is
supported by the Ego because one side of it offers a satisfaction to the
repressing Ego-tendency. More than this, a solution of the conflict by a
symptom-formation is the most convenient one, most in accordance with
the pleasure-principle; for it undoubtedly spares the Ego a severe and
painful piece of internal labour. There are indeed cases in which the
physician himself must admit that the solution of a conflict by a
neurosis is the one most harmless and most tolerable socially. Do not be
astonished to hear then that the physician himself occasionally takes
sides with the illness which he is attacking. It is not for him to
confine himself in all situations in life to the part of fanatic about
health; he knows that there is _other_ misery in the world besides
neurotic misery—real unavoidable suffering—that necessity may even
demand of a man that he sacrifice his health to it, and he learns that
such suffering in one individual may often avert incalculable hardship
for many others. Therefore, although it may be said of every neurotic
that he has taken ‘_flight into illness_,’ it must be admitted that in
many cases this flight is fully justified, and the physician who has
perceived this state of things will silently and considerately retire.
But let us continue our discussion without regard to these exceptional
cases. In the ordinary way it is apparent that by flight into neurosis
the Ego gains a certain internal ‘_advantage through illness_,’ as we
call it; under certain conditions a tangible external advantage, more or
less valuable in reality, may be combined with this. To take the
commonest case of this kind: a woman who is brutally treated and
mercilessly exploited by her husband fairly regularly takes refuge in a
neurosis, if her disposition admits of it. This will happen if she is
too cowardly or too conventional to console herself secretly with
another man, if she is not strong enough to defy all external reasons
against it and separate from her husband, if she has no prospect of
being able to maintain herself or of finding a better husband, and last
of all, if she is still strongly attached sexually to this brutal man.
Her illness becomes her weapon in the struggle against him, one that she
can use for her protection, or misuse for purposes of revenge. She can
complain of her illness, though she probably dare not complain of her
marriage; her doctor is her ally; the husband who is otherwise so
ruthless is required to spare her, to spend money on her, to grant her
absence from home and thus some freedom from marital oppression.
Whenever this external or ‘accidental’ advantage through illness is at
all pronounced, and no substitute for it can be found in reality, you
need not look forward very hopefully to influencing the neurosis by your
therapy.
You will now say that what I have just told you about the ‘advantage
through illness’ is all in favour of the view I have rejected, namely,
that the Ego itself desires the neurosis and creates it. But just a
moment! Perhaps it means merely this: that the Ego is pleased to accept
the neurosis which it is in any case unable to prevent, and that if
there is anything at all to be made out of it it makes the best of it.
This is only one side of the matter. In so far as there is advantage in
it the Ego is quite happy to be on good terms with a neurosis, but there
are also disadvantages to be considered. As a rule it is soon apparent
that by accepting a neurosis the Ego has made a bad bargain. It has paid
too heavily for the solution of the conflict; the sufferings entailed by
the symptoms are perhaps as bad as those of the conflict they replace,
and they may quite probably be very much worse. The Ego wishes to be rid
of the pain of the symptoms, but not to give up its advantage through
illness; and that is just what it cannot succeed in doing. It appears
therefore that the Ego was not quite so actively concerned in the matter
throughout as it had thought, and we will keep this well in mind.
If, as physicians, you have much to do with neurotics, you will soon
cease to expect that those who complain most bitterly of their illness
will be most ready to accept your help and make least difficulty—quite
the contrary. You will at all events easily understand that everything
which contributes to the advantage through illness reinforces the
resistance arising from the repressions, and increases the therapeutic
difficulties. And there is yet another kind of advantage through
illness, one which supervenes later than that born with the symptom, so
to speak. When such a mental organization as the disease has persisted
for a considerable time it seems finally to acquire the character of an
independent entity; it displays something like a self-preservative
instinct; it forms a kind of pact, a _modus vivendi_, with the other
forces in mental life, even with those fundamentally hostile to it, and
opportunities can hardly fail to arise in which it once more manifests
itself as useful and expedient, thus acquiring a _secondary function_
which again strengthens its position. Instead of taking an example from
pathology let us consider a striking illustration in everyday life. A
capable working-man earning his living is crippled by an accident in the
course of his employment; he can work no more, but he gets a small
periodical dole in compensation and learns how to exploit his mutilation
as a beggar. His new life, although so inferior, nevertheless is
supported by the very thing which destroyed his old life; if you were to
remove his disability you would deprive him for a time of his means of
subsistence, for the question would arise whether he would still be
capable of resuming his former work. When a secondary exploitation of
the illness such as this is formed in a neurosis we can range it
alongside the first and call it a ‘_secondary_ advantage through
illness.’
I should like to advise you in a general way not to underestimate the
practical importance of the advantage through illness, and yet not to be
too much impressed by its theoretical significance. Apart from the
exceptions previously recognized, this factor always reminds one of the
illustrations of “Intelligence in Animals” by Oberländer in _Fliegende
Blätter_. An Arab is riding a camel along a narrow path cut in the side
of a steep mountain. At a turn in the path he suddenly finds himself
confronted by a lion ready to spring at him. There is no escape; on one
side the abyss, on the other the precipice; retreat and flight are
impossible; he gives himself up for lost. Not so the camel. He takes one
leap with his rider into the abyss—and the lion is left a spectator. The
remedies provided by neurosis avail the patient no better as a rule;
perhaps because the solution of the conflict by a symptom-formation is
after all an automatic process which may show itself inadequate to meet
the demands of life, and involves man in a renunciation of his best and
highest powers. The more honourable choice, if there be a choice, is to
go down in fair fight with destiny.
I still owe you a further explanation of my motive in not taking
ordinary nervousness as my starting-point. Perhaps you think I avoided
doing so because it would have been more difficult to bring in evidence
of the sexual origin of the neuroses in that way; but in this you would
be mistaken. In the transference neuroses the symptoms have to be
submitted to interpretation before we arrive at this; but in the
ordinary forms of what are called the ACTUAL NEUROSES the ætiological
significance of the sexual life is a crudely obvious fact which courts
notice. I became aware of it more than twenty years ago, as one day I
began to wonder why, when we examine nervous patients, we so invariably
exclude from consideration all matters concerning their sexual life.
Investigations on this point led to the sacrifice of my popularity with
my patients, but in a very short time my efforts had brought me to this
conclusion: that no neurosis—actual neurosis, I meant—is present where
sexual life is normal. It is true that this statement ignores the
individual differences in people rather too much, and it also suffers
from the indefinite connotation inseparable from the word “normal”; but
as a broad outline it has retained its value to this day. At that time I
got so far as to be able to establish particular connections between
certain forms of nervousness and certain injurious sexual conditions; I
do not doubt that I could repeat these observations to-day if I still
had similar material for investigation. I noticed often enough that a
man who contented himself with some kind of incomplete sexual
satisfaction, e.g. with manual masturbation, would suffer from a
definite type of actual neurosis, and that this neurosis would promptly
give way to another form if he adopted some other equally unsatisfactory
form of sexual life. I was then in a position to infer the change in his
mode of sexual life from the alteration in the patient’s condition; and
I learnt to abide stubbornly by my conclusions until I had overcome the
prevarications of my patients and had compelled them to give me
confirmation. It is true that they then thought it advisable to seek
other physicians who would not take so much interest in their sexual
life.
It did not escape me at that time either that sexuality was not always
indicated as the cause of a neurosis; one person certainly would fall
ill because of some injurious sexual condition, but another because he
had lost his fortune or recently sustained a severe organic illness. The
explanation of these variations was revealed later, when insight was
obtained into the interrelationships suspected between the Ego and the
Libido; and the further this subject was explored the more satisfactory
became our insight into it. A person only falls ill of a neurosis when
the Ego loses its capacity to deal in some way or other with the Libido.
The stronger the Ego the more easily can it accomplish this task; every
weakening of the Ego, from whatever cause, must have the same effect as
an increase in the demands of the Libido; that is, make a neurosis
possible. There are yet other and more intimate relations between the
Ego and the Libido, which I shall not go into now as we have not yet
come to them in the course of our discussions. The most essential and
most instructive point for us is that the fund of energy supporting the
symptoms of a neurosis, in every case and regardless of the
circumstances inducing their outbreak, is provided by the Libido, which
is thus put to an abnormal use.
Now I must point out to you the decisive difference between the symptoms
of the _actual neuroses_ and those of the _psychoneuroses_, with the
first group of which (the transference neuroses) we have hitherto been
so much occupied. In both the actual neuroses and the psychoneuroses the
symptoms proceed from the Libido; that is, they are abnormal ways of
using it, substitutes for satisfaction of it. But the symptoms of an
actual neurosis—headache, sensation of pain, an irritable condition of
some organ, the weakening or inhibition of some function—have no
‘meaning,’ no signification in the mind. Not merely are they manifested
principally in the body, as also happens, for instance with hysterical
symptoms, but they are in themselves purely and simply physical
processes; they arise without any of the complicated mental mechanisms
we have been learning about. They really are, therefore, what
psychoneurotic symptoms were for so long held to be. But then, how can
they be expressions of the Libido which we have come to know as a force
at work in the mind? Now, really, the answer to that is very simple. Let
me resurrect one of the very first objections ever made against
psycho-analysis. It was said that the theories were an attempt to
account for neurotic symptoms by psychology alone and that the outlook
was consequently hopeless, since no illness could ever be accounted for
by psychological theories. These critics were pleased to forget that the
sexual function is not a purely mental thing, any more than it is merely
a physical thing. It affects bodily life as well as mental life. Having
learnt that the symptoms of the psychoneuroses express the mental
consequences of some disturbance in this function, we shall not be
surprised to find that the actual neuroses represent the direct somatic
consequences of sexual disturbances.
Clinical medicine gives us a useful hint (recognized by many different
investigators) towards comprehension of the actual neuroses. In the
details of their symptomatology, and also in the peculiarity by which
all the bodily systems and functions are affected together, they exhibit
an unmistakable similarity with pathological conditions resulting from
the chronic effect or the sudden removal of foreign toxins—i.e. with
states of intoxication or of abstinence. The two groups of affections
are brought still closer together by comparison with conditions like
Basedow’s disease[49] that have also been found to result from
poisoning, not, however, from poisons derived externally, but from such
as arise in the internal metabolism. In my opinion these analogies
necessitate our regarding the neuroses as the effects of disturbances in
the sexual metabolism, due either to more of these sexual toxins being
produced than the person can dispose of, or else to internal and even
mental conditions which interfere with the proper disposal of these
substances. Assumptions of this kind about the nature of sexual desire
have found acceptance in the mind of the people since the beginning of
time; love is called an “intoxication,” it can be induced by
“potions”—in these ideas the agency at work is to some extent projected
on to the outer world. We find occasion at this point to remember the
erotogenic zones, and to reflect upon the proposition that sexual
excitation may arise in the most various organs. Beyond this the subject
of ‘sexual metabolism’ or the ‘chemistry of sexuality’ is an empty
chapter: we know nothing about it, and cannot even determine whether to
assume two kinds of sexual substances, to be called ‘male’ and ‘female,’
or to content ourselves with _one_ sexual toxin as the agent of all the
stimuli effected by the Libido. The edifice of psycho-analytic doctrine
which we have erected is in reality but a superstructure, which will
have to be set on its organic foundation at some time or other; but this
foundation is still unknown to us.
As a science psycho-analysis is characterized by the methods with which
it works, not by the subject-matter with which it deals. These methods
can be applied without violating their essential nature to the history
of civilization, to the science of religion, and to mythology as well as
to the study of the neuroses. Psycho-Analysis aims at and achieves
nothing more than the discovery of the unconscious in mental life. The
problems of the actual neuroses, in which the symptoms probably arise
through direct toxic injury, offer no point of attack for
psycho-analysis; it can supply little towards elucidation of them and
must leave this task to biological and medical research. Now perhaps you
understand better why I chose this arrangement of my material. If I had
intended an _Introduction to the Study of the Neuroses_ it would
undoubtedly have been correct to begin with the simple forms of (actual)
neuroses and proceed from them to the more complicated psychical
disorders resulting from disturbances of the Libido. I should have had
to collect from various quarters what we know or think we know about the
former, and about the latter psycho-analysis would have been introduced
as the most important technical means of obtaining insight into these
conditions. An _Introduction to Psycho-Analysis_ was what I had
undertaken and announced, however; I thought it more important to give
you an idea of psycho-analysis than to teach you something about the
neuroses; and therefore the actual neuroses which yield nothing towards
the study of psycho-analysis could not suitably be put in the
foreground. I think too that my choice was the wiser for you, since the
radical axioms and far-reaching connections of psycho-analysis make it
worthy of every educated person’s interest; the theory of the neuroses,
however, is a chapter of medicine like any other.
However, you are justified in expecting that we should take some
interest in the actual neuroses; their close clinical connection with
the psychoneuroses even necessitates this. I will tell you then that we
distinguish three pure forms of actual neurosis: _neurasthenia_,
_anxiety-neurosis_ and _hypochondria_. Even this classification has been
disputed; the terms are certainly all in use, but their connotation is
vague and unsettled. There are some medical men who are opposed to all
discrimination in the confusing world of neurotic manifestations, who
object to any distinguishing of clinical entities or types of disease,
and do not even recognize the difference between actual neuroses and
psychoneuroses; in my opinion they go too far, and the direction they
have chosen does not lead to progress. The three kinds of neurosis named
above are occasionally found in a pure form; more frequently, it is
true, they are combined with one another and with a psychoneurotic
affection. This fact need not make us abandon the distinctions between
them. Think of the difference between the science of minerals and that
of ores in mineralogy: the minerals are classified individually, in part
no doubt because they are frequently found as crystals, sharply
differentiated from their surroundings; the ores consist of mixtures of
minerals which have indeed coalesced, not accidentally, but according to
the conditions at their formation. In the theory of the neuroses we
still understand too little of the process of their development to
formulate anything similar to our knowledge of ores; but we are
certainly working in the right direction in first isolating from the
mass the recognizable clinical elements, which are comparable to the
individual minerals.
A noteworthy connection between the symptoms of the actual neuroses and
the psychoneuroses adds a valuable contribution to our knowledge of
symptom-formation in the latter; the symptom of the actual neurosis is
frequently the nucleus and incipient stage of the psychoneurotic
symptom. A connection of this kind is most clearly observable between
neurasthenia and the transference neurosis known as conversion-hysteria,
between the anxiety-neurosis and anxiety-hysteria, but also between
hypochondria and forms of a neurosis which we shall deal with later on,
namely, paraphrenia (dementia præcox and paranoia). As an example, let
us take an hysterical headache or backache. Analysis shows that by means
of condensation and displacement it has become a substitutive
satisfaction for a whole series of libidinal phantasies or memories; at
one time, however, this pain was real, a direct symptom of a sexual
toxin, the bodily expression of a sexual excitation. We do not by any
means maintain that all hysterical symptoms have a nucleus of this kind,
but it remains true that this very often is so, and that all effects
(whether normal or pathological) of the libidinal excitation upon the
body are specially adapted to serve the purposes of hysterical
symptom-formation. They play the part of the grain of sand which the
oyster envelopes in mother-of-pearl. The temporary signs of sexual
excitation accompanying the sexual act serve the psychoneurosis in the
same way, as the most suitable and convenient material for
symptom-formation.
There is a similar process of special diagnostic and therapeutic
interest. In persons who are disposed to be neurotic without having yet
developed a neurosis on a grand scale, some morbid organic
condition—perhaps an inflammation, or an injury—very commonly sets the
work of symptom-formation in motion; so that the latter process swiftly
seizes upon the symptom supplied by reality, and uses it to represent
those unconscious phantasies that have only been lying in wait for some
means of expression. In such a case the physician will try first one
therapy and then the other; will either endeavour to abolish the organic
foundation on which the symptom rests, without troubling about the
clamorous neurotic elaboration of it; or will attack the neurosis which
this opportunity has brought to birth, while leaving on one side the
organic stimulus which incited it. Sometimes one and sometimes the other
procedure will be found justified by success; no general rules can be
prescribed for mixed cases of this kind.
TWENTY-FIFTH LECTURE
ANXIETY
You will certainly have judged the information that I gave you in the
last lecture about ordinary nervousness as the most fragmentary and most
inadequate of all my accounts. I know that it was; and I expect that
nothing surprised you more than that I made no mention of the ‘anxiety’
which most nervous people complain of and themselves describe as their
most terrible burden. Anxiety or dread can really develop tremendous
intensity and in consequence be the cause of the maddest precautions.
But in this matter at least I wished not to cut you short; on the
contrary, I had determined to put the problem of nervous anxiety to you
as clearly as possible and to discuss it at some length.
_Anxiety_ (or _dread_)[50] itself needs no description; everyone has
personally experienced this sensation, or to speak more correctly this
affective condition, at some time or other. But in my opinion not enough
serious consideration has been given to the question why nervous persons
in particular suffer from anxiety so much more intensely, and so much
more altogether, than others. Perhaps it has been taken for granted that
they should; indeed, the words “nervous” and “anxious” are used
interchangeably, as if they meant the same thing. This is not
justifiable, however; there are anxious people who are otherwise not in
any way nervous and there are, besides, neurotics with numerous symptoms
who exhibit no tendency to dread.
However this may be, one thing is certain, that the problem of anxiety
is a nodal point, linking up all kinds of most important questions; a
riddle, of which the solution must cast a flood of light upon our whole
mental life. I do not claim that I can give you a complete solution; but
you will certainly expect psycho-analysis to have attacked this problem
too in a different manner from that adopted by academic medicine.
Interest there centres upon the anatomical processes by which the
anxiety condition comes about. We learn that the medulla oblongata is
stimulated, and the patient is told that he is suffering from a neurosis
in the vagal nerve. The medulla oblongata is a wondrous and beauteous
object; I well remember how much time and labour I devoted to the study
of it years ago. But to-day I must say I know of nothing less important
for the psychological comprehension of anxiety than a knowledge of the
nerve-paths by which the excitations travel.
One may consider anxiety for a long time without giving a thought to
nervousness. You will understand me at once when I describe this form of
anxiety as REAL ANXIETY, in contrast to neurotic anxiety. Now _real_
anxiety or dread appears to us a very natural and rational thing; we
should call it a reaction to the perception of an external danger, of an
injury which is expected and foreseen; it is bound up with the reflex of
flight, and may be regarded as an expression of the instinct of
self-preservation. The occasions of it, i.e. the objects and situations
about which anxiety is felt, will obviously depend to a great extent
upon the state of the person’s knowledge and feeling of power regarding
the outer world. It seems to us quite natural that a savage should be
afraid of a cannon or of an eclipse of the sun, while a white man who
can handle the weapon and foretell the phenomenon remains unafraid in
the same situation. At other times it is knowledge itself which inspires
fear, because it reveals the danger sooner; thus a savage will recoil
with terror at the sight of a track in the jungle which conveys nothing
to an ignorant white man, but means that some wild beast is near at
hand; and an experienced sailor will perceive with dread a little cloud
on the horizon because it means an approaching hurricane, while to a
passenger it looks quite insignificant.