On the psychical mechanism of hysterical phenomena: a lecture 2 страница

THE NEURO-PSYCHOSES OF DEFENCE (1894)

THE NEURO-PSYCHOSES OF DEFENCE(AN ATTEMPT AT A PSYCHOLOGICAL THEORY OF ACQUIRED HYSTERIA, OF MANY

PHOBIAS, AND OBSESSIONS AND OF CERTAIN HALLUCINATORY PSYCHOSES)

After making a detailed study of a number of nervous patients suffering from phobias and obsessions, I was led to attempt an explanation of those symptoms; and this enabled me afterwards to arrive successfully at the origin of pathological ideas of this sort in new and different cases. My explanation therefore seems to me to deserve publication and further examination. Simultaneously with this ‘psychological theory of phobias and obsessions’ my observation of patients resulted in a contribution to the theory of hysteria, or rather to a change in it, which appears to take into account an important characteristic that is common both to hysteria and to the neuroses I have just mentioned. Furthermore, I had occasion to gain insight into what is undoubtedly a form of mental disease, and I found at the same time that the point of view which I had tentatively adopted established an intelligible connection between these psychoses and the two neuroses under discussion. At the end of this paper I shall bring forward a working hypothesis which I have made use of in all three instances.

I

Let me begin with the change which seems to me to be called for in the theory of the hysterical neurosis.

Since the fine work done by Pierre Janet, Josef Breuer and others, it may be taken as generally recognized that the syndrome of hysteria, so far as it is as yet intelligible, justifies the assumption of there being a splitting of consciousness, accompanied by the formation of separate psychical groups. Opinions are less settled, however, about the origin of this splitting of consciousness and about the part played by this characteristic in the structure of the hysterical neurosis.

According to the theory of Janet (1892-4 and 1893), the splitting of consciousness is a primary feature of the mental change in hysteria. It is based on an innate weakness of the capacity for psychical synthesis, on the narrowness of the ‘field of consciousness (champ de la conscience)' which, in the form of a psychical stigma, is evidence of the degeneracy of hysterical individuals.

In contradistinction to Janet’s view, which seems to me to admit of a great variety of objections, there is the view put forward by Breuer in our joint communication (Breuer and Freud, 1893). According to him, ‘the basis and sine qua non of hysteria’ is the occurrence of peculiar dream-like states of consciousness with a restricted capacity for association, for which he proposes the name ‘hypnoid states’. In that case, the splitting of consciousness is secondary and acquired; it comes about because the ideas which emerge in hypnoid states are cut off from associative communication with the rest of the content of consciousness.

I am now in a position to bring forward evidence of two other extreme forms of hysteria in which it is impossible to regard the splitting of consciousness as primary in Janet’s sense. In the first of these forms I was repeatedly able to show that the splitting in the content of consciousness is the result of an act of will on the part of the patient; that is to say, it is initiated by an effort of will whose motive can be specified. By this I do not, of course, mean that the patient intends to bring about a splitting of his consciousness. His intention is a different one; but, instead of attaining its aim, it produces a splitting of consciousness.

In the third form of hysteria, which we have demonstrated by means of a psychical analysis of intelligent patients, the splitting of consciousness plays an insignificant part, or perhaps none at all. They are those cases in which what has happened is only that the reaction to traumatic stimuli has failed to occur, and which can also, accordingly, be resolved and cured by ‘abreaction’.¹ These are the pure ‘retention hysterias’.

As regards the connection with phobias and obsessions, I am only concerned with the second form of hysteria. For reasons which will soon be evident, I shall call this form ‘defence hysteria’, using the name to distinguish it from hypnoid hysteria and retention hysteria. I may also provisionally present my cases of defence hysteria as ‘acquired’ hysteria, since in them there was no question either of a grave hereditary taint or of an individual degenerative atrophy.

For these patients whom I analysed had enjoyed good mental health up to the moment at which an occurrence of incompatibility took place in their ideational life - that is to say, until their ego was faced with an experience, an idea or a feeling which aroused such a distressing affect that the subject decided to forget about it because he had no confidence in his power to resolve the contradiction between that incompatible idea and his ego by means of thought-activity.

In females incompatible ideas of this sort arise chiefly on the soil of sexual experience and sensation; and the patients can recollect as precisely as could be desired their efforts at defence, their intention of ‘pushing the thing away’, of not thinking of it, of suppressing it. I will give some examples, which I could easily multiply, from my own observation: the case of a girl, who blamed herself because, while she was nursing her sick father, she had thought about a young man who had made a slight erotic impression on her; the case of a governess who had fallen in love with her employer and had resolved to drive this inclination out of her mind because it seemed to her incompatible with her pride; and so on.²

¹ Cf. our joint communication, ibid., 2, 8-9.

² These examples are taken from a volume by Breuer and myself which is still in preparation and which deals in detail with the psychical mechanism of hysteria.

I cannot, of course, maintain that an effort of will to thrust things of this kind out of one’s thoughts a pathological act; nor do I know whether and in what way intentional forgetting succeeds in those people who, under the same psychical influences, remain healthy. I only know that this kind of ‘forgetting’ did not succeed with the patients I analysed, but led to various pathological reactions which produced either hysteria or an obsession or a hallucinatory psychosis. The ability to bring about one of these states - which are all of them bound up with a splitting of consciousness -by means of an effort of will of this sort, is to be regarded as the manifestation of a pathological disposition, although such a disposition is not necessarily identical with individual or hereditary ‘degeneracy’.

As regards the path which leads from the patient’s effort of will to the onset of the neurotic symptom, I have formed an opinion which may be expressed, in current psychological abstractions, somewhat as follows. The task which the ego, in its defensive attitude, sets itself of treating the incompatible idea as ‘non arivée’ simply cannot be fulfilled by it. Both the memory-trace and the affect which is attached to the idea are there once and for all and cannot be eradicated. But it amounts to an approximate fulfilment of the task if the ego succeeds in turning this powerful idea into a weak one, in robbing it of the affect - the sum of excitation - with which it is loaded. The weak idea will then have virtually no demands to make on the work of association. But the sum of excitation which has been detached from it must be put to another use.

Up to this point the processes in hysteria, and in phobias and obsessions are the same; from now on their paths diverge. In hysteria, the incompatible idea is rendered innocuous by its sum of excitation being transformed into something somatic. For this I should like to propose the name of conversion.

The conversion may be either total or partial. It proceeds along the line of the motor or sensory innervation which is related - whether intimately or more loosely - to the traumatic experience. By this means the ego succeeds in freeing itself from the contradiction; but instead, it has burdened itself with a mnemic symbol which finds a lodgement in consciousness, like a sort of parasite, either in the form of an unresolvable motor innervation or as a constantly recurring hallucinatory sensation, and which persists until a conversion in the opposite direction takes place. Consequently the memory-trace of the repressed idea has, after all, not been dissolved; from now on, it forms the nucleus of a second psychical group.

I will only add a few more words to this view of the psycho-physical processes in hysteria. When once such a nucleus for a hysterical splitting-off has been formed at a ‘traumatic moment’, it will be increased at other moments (which might be called ‘auxiliary moments’) whenever the arrival of a fresh impression of the same sort succeeds in breaking through the barrier erected by the will, in furnishing the weakened idea with fresh affect and in re-establishing for a time the associative link between the two psychical groups, until a further conversion sets up a defence. The distribution of excitation thus brought about in hysteria usually turns out to be an unstable one. The excitation which is forced into a wrong channel (ie which has been channelled into a somatic innervation) now and then finds its way back to the idea from which it has been detached, and it then compels the subject either to work over the idea associatively or to get rid of it in hysterical attacks - as we see in the familiar contrast between attacks and chronic symptoms. The operation of Breuer’s cathartic method lies in leading back the excitation in this way from the somatic to the psychical sphere deliberately, and in then forcibly bringing about a settlement of the contradiction by means of thought-activity and a discharge of the excitation by talking.

If the splitting of consciousness which occurs in acquired hysteria is based upon an act of will, then we have a surprisingly simple explanation of the remarkable fact that hypnosis regularly widens the restricted consciousness of a hysteric and allows access to the psychical group that has been split off. Indeed, we know it as a peculiarity of all states resembling sleep that they suspend the distribution of excitation on which the ‘will’ of the conscious personality is based.

Thus we see that the characteristic factor in hysteria is not the splitting of consciousness but the capacity for conversion, and we may adduce as an important part of the disposition to hysteria - a disposition which in other respects is still unknown - a psycho-physical aptitude for transposing very large sums of excitation into the somatic innervation.

This aptitude does not, in itself, exclude psychical health; and it only leads to hysteria in the event of there being a psychical incompatibility or an accumulation of excitation. In taking this view, Breuer and I are coming closer to Oppenheim’s¹ and Strümpell’s² well-known definitions of hysteria, and are diverging from Janet, who assigns too great an importance to the splitting of consciousness in his characterization of hysteria.³ The presentation given here may claim to have made intelligible the connection between conversion and the hysterical splitting of consciousness.

¹ According to Oppenheim, hysteria is an intensified expression of motion. The ‘expression of emotion’, however, represents the amount of psychical excitation which normally undergoes conversion.

² Strümpell maintains that in hysteria the disturbance lies psycho-physical sphere - in the region where the somatic and the mental are linked together.

³ In the second section of his acute paper ‘Quelques définitions...’ Janet has himself dealt with the objection which argues that splitting of consciousness occurs in psychoses and in so-called ‘psychasthenia’ as well as in hysteria, but in my judgement he has not met it satisfactorily. It is in the main this objection which obliges him to describe hysteria as a form of degeneracy. But he has failed to produce any characteristic which sufficiently distinguishes the splitting of consciousness in hysteria from that in psychoses and similar states.

II

If someone with a disposition lacks the aptitude for conversion, but if, nevertheless, in order to fend off an incompatible idea, he sets about separating it from its affect, then that affect is obliged to remain in the psychical sphere. The idea, now weakened, is still left in consciousness, separated from all association. But its affect, which has become free, attaches itself to other ideas which are not in themselves incompatible; and, thanks to this ‘false connection’, those ideas turn into obessional ideas. This, in a few words, is the psychological theory of obsessions and phobias mentioned at the beginning of this paper.

I will now indicate which of the various elements put forward in this theory can be directly demonstrated and which have been filled in by me. What can be directly demonstrated, apart from the end-product of the process - the obsession - is in the first place the source of the affect which is now in a false connection. In all the cases I have analysed it was the subject’s sexual life that had given rise to a distressing affect of precisely the same quality as that attaching to his obsession. Theoretically, it is not impossible that this affect should sometimes arise in other fields; I can only report that so far I have not come across any other origin. Moreover, it is easy to see that it is precisely sexual life which brings with it the most copious occasions for the emergence of incompatible ideas.

Furthermore, the most unambiguous statements by the patients give proof of the effort of will, the attempt at defence, upon which the theory lays emphasis; and at least in a number of cases the patients themselves inform us that their phobia or obsession made its first appearance after the effort of will had apparently succeeded in its aim. ‘Something very disagreeable happened to me once and I tried very hard to put it away from me and not to think about it any more. I succeeded at last; but then I got this other thing, which I have not been able to get rid of since.’ It was with these words that a woman patient confirmed the chief points of the theory I have developed here.

Not everyone who suffers from obsessions is as clear as this about their origin. As a rule, when one draws a patient’s attention to the original idea of a sexual kind, the answer is: ’It can’t come from that. I didn’t think at all much about that. For a moment I was frightened, but I turned my mind away from it and I haven’t been troubled by it since.’ In this frequent objection we have evidence that the obsession represents a substitute or surrogate for the incompatible sexual idea and has taken its place in consciousness.

Between the patient’s effort of will, which succeeds in repressing the unacceptable sexual idea, and the emergence of the obsessional idea, which, though having little intensity in itself, is now supplied with an incomprehensibly strong affect, yawns the gap which the theory here developed seeks to fill. The separation of the sexual idea from its affect and the attachment of the latter to another, suitable but not incompatible idea-these are processes which occur without consciousness. Their existence can only be presumed, but can not be proved by any clinico-psychological analysis. Perhaps it would be more correct to say that these processes are not of a psychical nature at all, that they are physical processes whose psychical consequences present themselves as if what is expressed by the terms ‘separation of the idea from its affect’ and ‘false connection’ of the latter had really taken place.

Alongside of the cases which show a sequence between an incompatible sexual idea and an obsessional idea, we find a number of other cases in which obsessional ideas and sexual ideas of a distressing character are present simultaneously. To call the latter ‘sexual obsessional ideas’ will not do very well, for they lack one essential feature of obsessional ideas: they turn out to be fully justified, whereas the distressing character of ordinary obsessional ideas is a problem for both doctor and patient. So far as I have been able to see my way in cases of this kind, what is happening is that a perpetual defence is going on against sexual ideas that are continually coming up afresh - a piece of work, that is to say, which has not yet come to completion.

So long as the patients are aware of the sexual origin of their obsessions, they often keep them secret. If they do complain about them, they usually express their astonishment that they should be subject to the affect in question - that they should feel anxiety, or have certain impulses, and so on. To the experienced physician, on the contrary, the affect seems justified and comprehensible; what he finds noticeable is only that an affect of that kind should be linked with an idea which does not merit it. The affect of the obsession appears to him, in other words, as being dislodged or transposed; and if he has accepted what has been said in these pages, he will be able, in a number of cases of obsessions, to attempt to re-translate them into sexual terms.

To provide this secondary connection for the liberated affect, any idea can be made use of which is either able, from its nature, to be united with an affect of the quality in question, or which has certain relations to the incompatible idea which make it seem as though it could serve as a surrogate for it. Thus, for example, liberated anxiety, whose sexual origin must not be remembered by the patient, will seize upon the common primary phobias of mankind about animals, thunderstorms, darkness and so on, or upon things which are unmistakably associated in one way or another with what is sexual-such as micturition, defaecation, or dirtying and contagion generally.

The ego gains much less advantage from choosing transposition of affect as a method of defence than from choosing the hysterical conversion of psychical excitation into somatic innervation. The affect from which the ego has suffered remains as it was before, unaltered and undiminished, the only difference being that the incompatible idea is kept down and shut out from recollection. The repressed ideas, as in the other case, form the nucleus of a second psychical group, which, I believe, is accessible even without the help of hypnosis. If phobias and obsessions are unaccompanied by the striking symptoms which characterize the formation of an independent psychical group in hysteria, this is doubtless because in their case the whole alteration has remained in the psychical sphere and the relationship between psychical excitation and somatic innervation has undergone no change.

To illustrate what has been said about obsessions, I will give a few examples which are, I imagine, of a typical kind:

(1) A girl suffered from obsessional self-reproaches. If she read something in the papers about coiners, the thought would occur to her that she, too, had made counterfeit money; if a murder had been committed by an unknown person, she would ask herself anxiously whether it was not she who had done the deed. At the same time she was perfectly conscious of the absurdity of these obsessional reproaches. For a time, this sense of guilt gained such an ascendancy over her that her powers of criticism were stifled and she accused herself to her relatives and her doctor of having really committed all these crimes. (This was an example of a psychosis through simple intensification - an ‘Überwältigungspsychose’.) Close questioning then revealed the source from which her sense of guilt arose. Stimulated by a chance voluptuous sensation, she had allowed herself to be led astray by a woman friend into masturbating, and had practised it for years, fully conscious of her wrong-doing and to the accompaniment of the most violent, but, as usual, ineffective self-reproaches. An excessive indulgence after going to a ball had produced the intensification that led to the psychosis. After a few months of treatment and the strictest surveillance, the girl recovered.

(2) Another girl suffered from the dread of being overcome by the need to urinate, and of being unable to avoid wetting herself, ever since a need of this kind had in fact once obliged her to leave a concert hall during the performance. By degrees this phobia had made her completely incapable of enjoying herself or of going into society. She only felt well if she knew that there was a W. C. near at hand which she could reach unobtrusively. There was no question of any organic complaint which might justify this mistrust in her power to control her bladder; when she was at home, in quiet conditions, or at night, the need to urinate did not arise. A detailed examination showed that the need had occurred first in the following circumstances. In the concert hall a gentleman to whom she was not indifferent had taken a seat not far from her. She began to think about him and to imagine herself sitting beside him as his wife. During this erotic reverie she had the bodily sensation which is to be compared with an erection in a man, and which in her case - I do not know if this is always so - ended with a slight need to urinate. She now became greatly frightened by the sexual sensation (to which she was normally accustomed) because she had resolved within herself to combat this particular liking, as well as any other she might feel; and next moment the affect had become transferred on to the accompanying need to urinate and compelled her after an agonizing struggle to leave the hall. In her ordinary life she was so prudish that she had an intense horror of everything to do with sex and could not contemplate the thought of ever marrying. On the other hand, she was so hyperaesthetic sexually that during every erotic reverie, in which she readily indulged, the same voluptuous sensation appeared. The erection was each time accompanied by the need to urinate, though without its making any impression on her until the scene in the concert hall. The treatment led to an almost complete control over her phobia.

(3) A young married woman who, in five years of marriage, had had only one child, complained to me of an obsessional impulse to throw herself out of the window or from the balcony, and also of a fear which seized her when she saw a sharp knife, of stabbing her child with it. She admitted that marital intercourse seldom occurred, and only subject to precautions against conception, but she did not miss it, she said, as hers was not a sensual nature. At this point I ventured to tell her that at the sight of a man she had erotic ideas and that she had therefore lost confidence in herself and regarded herself as a depraved person, capable of anything. The translation back of the obsessional idea into sexual terms was successful. In tears, she at once confessed the long-concealed poverty of her marriage; and later she told me also of distressing ideas of an unmodified sexual character such as the often-recurring sensation of something forcing itself under her skirt.

I have turned observations of this kind to account in my therapeutic work by leading back the attention of patients with phobias and obsessions to the repressed sexual ideas in spite of all their protestations, and, wherever possible, by stopping up the sources from which those ideas sprang. I cannot, of course, assert that all phobias and obsessions arise in the manner I have shown here. In the first place, my experience of them includes only a limited number compared with the frequency of these neuroses; and in the second place, I myself am aware that such ‘psychasthenic’ symptoms, as Janet terms them, are not all equivalent.¹ There are, for instance, purely hysterical phobias. Nevertheless, I think that it will be possible to show the presence of the mechanism of transposition of affect in the great majority of phobias and obsessions, and I would therefore urge that these neuroses, which are found in an isolated state as often as in combination with hysteria or neurasthenia, should not be thrown into a heap along with common neurasthenia, for the basic symptoms of which there is no ground at all to assume a psychical mechanism.

¹ The group of typical phobias, of which agoraphobia is a typical model, cannot be traced back to the psychical mechanism described above; on the contrary, the mechanism of agoraphobia differs from that of obsessions proper, and of the phobias that are reducible to them, in one decisive point. There is no repressed idea from which the anxiety affect might have been separated off. The anxiety of these phobias has another origin.

III

In both the instances considered so far, defence against the incompatible idea was effected by separating it from its affect; the idea itself remained in consciousness, even though weakened and isolated. There is, however, a much more energetic and successful kind of defence. Here, the ego rejects the incompatible idea together with its affect and behaves as if the idea had never occurred to the ego at all. But from the moment at which this has been successfully done the subject is in a psychosis, which can only be classified as ‘hallucinatory confusion. A single example may serve to illustrate this statement:

A girl had given her first impulsive affection to a man, and firmly believed that he returned her love. In fact, she was wrong; the young man had a different motive for visiting the house. Disappointments were not wanting. At first she defended herself against them by effecting a hysterical conversion of the experiences in question and thus preserved her belief that one day he would come and ask her hand. But at the same time she felt unhappy and ill, because the conversion was incomplete and because she was continually being met by fresh painful impressions. Finally, in a state of great tension, she awaited his arrival on a particular day, the day of a family celebration. But the day wore on and he did not appear. When all the trains by which he could arrive had come and gone, she passed into a state of hallucinatory confusion: he had arrived, she heard his voice in the garden, she hurried down in her night-dress to receive him. From that time on she lived for two months in a happy dream, whose content was that he was there, always at her side, and that everything was as it had been before (before the time of the disappointments which she had so laboriously fended off). Her hysteria and her depression of spirits were overcome. During her illness she was silent about the whole latter period of doubt and suffering; she was happy so long as she was left undisturbed, and she broke out in fury only when some rule of conduct insisted on by those around her hindered her in something which seemed to her to follow quite logically from her blissful dream. This psychosis, which had been unintelligible at the time, was explained ten years later with the help of a hypnotic analysis.

The fact to which I now wish to call attention is that the content of a hallucinatory psychosis of this sort consists precisely in the accentuation of the idea which was threatened by the precipitating cause of the onset of the illness. One is therefore justified in saying that the ego has fended off the incompatible idea through a flight into psychosis. The process by which this has been achieved once more eludes the subject’s self perception, as it eludes psychologico-clinical analysis. It must be regarded as the expression of a pathological disposition of a fairly high degree and it may be described more or less as follows. The ego breaks away from the incompatible idea; but the latter is inseparably connected with a piece of reality, so that, in so far as the ego achieves this result, it, too, has detached itself wholly or in part from reality. In my opinion this latter event is the condition under which the subject’s ideas receive the vividness of hallucinations; and thus when the defence has been successfully carried out he finds himself in a state of hallucinatory confusion.

I have only very few analyses of psychoses of this sort at my disposal. But I think we have to do here with a type of psychical illness which is very frequently employed. For no insane asylum is without what must be regarded as analogous examples - the mother who has fallen ill from the loss of her baby, and now rocks a piece of wood unceasingly in her arms, or the jilted bride who, arrayed in her wedding-dress, has for years been waiting for her bridegroom.

It is perhaps not superfluous to point out that the three methods of defence here described and, along with them, the three forms of illness to which those methods lead, may be combined in the same person. The simultaneous appearance of phobias and hysterical symptoms which is so often observed in practice is one of the factors which render it difficult to separate hysteria clearly from other neuroses and which make it necessary to set up the category of ‘mixed neuroses’. It is true that hallucinatory confusion is not often compatible with a persistence of hysteria, nor, as a rule, of obsessions. On the other hand, it is not rare for a psychosis of defence episodically to break through the course of a hysterical or mixed neurosis.

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