Further remarks on the neuro-psychoses of defence 2 страница

¹ (Footnote added 1924:) More correctly, no doubt, dementia paranoides. Frau P., thirty-two years of age, has been married for three years and is the mother of a child of two. Her parents were not neurotic; but her brother and sister are to my knowledge, like her, neurotic. It is doubtful whether she may not, at one time in her middle twenties, have become temporarily depressed and confused in her judgement. In recent years she was healthy and capable, until, six months after the birth of her child, she showed the first signs if her present illness. She became uncommunicative and distrustful, showed aversion to meeting her husband’s brothers and sisters and complained that the neighbours in the small town in which she lived were behaving differently towards her from how they did before and were rude and inconsiderate to her. By degrees these complaints increased in intensity, although not in definiteness. She thought people had something against her, though she had no idea what; but there was no doubt that everyone - relatives and friends - had ceased to respect her and were doing all they could to slight her. She had racked her brains, she said, to find the reason for this, but had no idea. A little time later she complained that she was being watched and that people were reading her thoughts and knew everything that was going on in her house. One afternoon she suddenly had the idea that she was being watched while she was undressing in the evening. From that time on she took the most precautionary measures when she undressed; she got into bed in the dark and did not begin to take off her things till she was under the bedclothes. Since she avoided all contact with other people, ate poorly and was very depressed, she was sent in the summer of 1895 to a hydropathic establishment. There, fresh symptoms appeared and those she already had increased in strength. Already in the spring of that year, when she was alone one day with her housemaid, she had suddenly had a sensation in her lower abdomen, and had thought to herself that the girl had at that moment had an improper idea. This sensation grew more frequent during the summer and became almost continual. She felt her genitals ‘as one feels a heavy hand’. Then she began to see images which horrified her - hallucinations of naked women, especially of the lower part of a woman’s abdomen with pubic hairs, and occasionally of male genitals as well. The image of the abdomen with hair and the physical sensation in her own abdomen usually occurred together. The images became very tormenting, for they happened regularly when she was in the company of a woman, and it made her think that she was seeing the woman in an indecent state of nakedness, but that simultaneously the woman was having the same picture of her (!). At the same time as these visual hallucinations - which vanished again for several months after their first appearance in the hydropathic establishment - she began to be pestered by voices which she did not recognize and which she could not account for. When she was in the street, they said: ‘That’s Frau P.- There she goes! Where’s she going to?’ Every one of her movements and actions was commented on; and at times she heard threats and reproaches. All these symptoms became worse when she was in company or in the street. For that reason she refused to go out; she said that eating disgusted her; and her state of health rapidly deteriorated.

I gathered all this from her when she came to Vienna for treatment with me in the winter of 1895. I have set it out at length because I want to convey the impression that what we are dealing with here really is a quite frequent form of chronic paranoia - a conclusion with which the details of her symptoms and behaviour which I have still to describe will be found to tally. At that time she concealed from me the delusions which served to interpret her hallucinations, or else the delusions had in fact not yet occurred to her. Her intelligence was undiminished; the only unusual thing I learnt was that she had repeatedly made appointments with her brother, who lived in the neighbourhood, in order to confide something important to him, but had never told him anything. She never spoke about her hallucinations, and towards the end she no longer said much either about the slights and persecutions of which she was subjected.

What I have to report about this patient concerns the aetiology of the case and the mechanism of the hallucinations. I discovered the aetiology when I applied Breuer’s method, exactly as in a case of hysteria - in the first instance for the investigation and removal of the hallucinations. In doing so, I started out from the assumption that in this case of paranoia, just as in the two other defence neuroses with which I was familiar, there must be unconscious thoughts and repressed memories which could be brought into consciousness in the same way as they were in those neuroses, by overcoming a certain resistance. The patient at once confirmed my expectation, for she behaved in analysis exactly like, for instance, a hysterical patient; with her attention on the pressure of my hand,¹ she produced thoughts which she could not remember having had, which at first she did not understand and which were contrary to her expectations. The presence of significant unconscious ideas was thus demonstrated in a case of paranoia as well, and I was able to hope that I might trace the compulsion of paranoia, too, to repression. The only peculiarity was that the thoughts which arose from the unconscious were for the most part heard inwardly or hallucinated by the patient, in the same way as her voices.

¹ Cf. my Studies on Hysteria.

Concerning the origin of the visual hallucinations, or at least of the vivid images, I learned the following. The image of the lower part of a woman’s abdomen almost always coincided with the physical sensation in her own abdomen; but the latter was much more constant and often occurred without the image. The first images of a woman’s abdomen had appeared in the hydropathic establishment a few hours after she had in fact seen a number of naked women at the baths; so they turned out to be simple reproductions of a real impression. It was therefore to be presumed that these impressions had been repeated only because great interest was attached to them. She told me that she had felt ashamed for these women; she herself had been ashamed to be seen naked for as long as she could remember. Since I was obliged to regard the shame as something obsessional, I concluded, in accordance with the mechanism of defence, that an experience must have been repressed here about which she had not felt ashamed. So I requested her to let the memories emerge which belonged to the theme of feeling ashamed. She promptly reproduced a series of scenes going back from her seventeenth to her eighth year, in which she had felt ashamed of being naked in her bath in front of her mother, her sister and the doctor; but the series ended in a scene at the age of six, in which she was undressing in the nursery before going to bed, without feeling any shame in front of her brother who was there. On my questioning her, it transpired that scenes like this had occurred often and that the brother and sister had for years been in the habit of showing themselves to one another naked before going to bed. I now understood the meaning of her sudden idea that she was being watched as she was going to bed. It was an unaltered piece of the old memory which involved self-reproach, and she was now making up for the shame which she had omitted to feel as a child.

My conjecture that we had to do with an affair between children, as is so often found in the aetiology of hysteria, was strengthened by the further progress of the analysis, which at the same time yielded solutions of individual details that frequently recurred in the clinical picture of the paranoia. The patient’s depression began at the time of a quarrel between her husband and her brother, as a result of which the latter no longer came to the house. She had always been very fond of this brother and she missed him very much at that time. Besides this she spoke of a certain moment in her illness at which for the first time ‘everything became clear to her’ - that is, at which she became convinced of the truth of her suspicion that she was despised by everyone and deliberately slighted. This certainty came to her during a visit from her sister-in law who, in the course of conversation, let fall the words: ‘If anything of that sort happens to me, I treat it in a light vein.’ At first Frau P. took this remark unsuspectingly; but later, after the visitor had left, it seemed to her that the words had contained a reproach, as if she was in the habit of taking serious things lightly; and from that moment on she was certain that she was the victim of general slander. When I questioned her as to what made her feel justified in applying the words to herself, she answered that it was the tone of voice in which her sister-in-law had spoken that had (although, it is true, only subsequently) convinced her of it. This is a detail which is characteristic of paranoia. I now obliged her to remember what her sister-in-law had been saying before the remark she complained of, and it emerged that the sister-in-law had related how in her parents’ home there had been all sorts of difficulties with her brothers, and had added the wise comment: ‘In every family all sorts of things happen that one would like to draw a veil over. But if anything of the kind happens to me, I take it lightly.’ Frau P. now had to admit that her depression was attached to the statements made by her sister-in-law before her last remark. Since she had repressed both the statements which might have awakened a memory of her relations with her brother, and had only retained the insignificant last one, it was with it that she was obliged to connect her feeling that her sister-in-law was making a reproach against her; and since its content offered no basis for this, she turned from the content to the tone in which the words had been spoken. This is probably a typical piece of evidence that the misinterpretations of paranoia are based on a repression.

My patient’s singular conduct, too, in making appointments with her brother, and then having nothing to tell him, was solved in a surprising fashion. Her explanation was that she had thought that if she could only look at him he would be bound to understand her sufferings, since he knew the cause of them. Now, as this brother was in fact the only person who could know about the aetiology of her illness, it was clear that she had been acting in accordance with a motive which, although she herself did not understand it consciously, could be seen to be perfectly justified as soon as it was supplied with a meaning derived from the unconscious.

I then succeeded in getting her to reproduce the various scenes in which her sexual relationship with her brother (which had certainly lasted at least from her sixth to her tenth year) had culminated. During this work of reproduction, the physical sensation in her abdomen ‘joined in the conversation’ as it were, as is regularly observed to happen in the analysis of hysterical mnemic residues. The image of the lower part of a woman’s naked abdomen (but now reduced to childish proportions and without hair on it) appeared with the sensation or stayed away, according as the scene in question had occurred in full light or in the dark. Her disgust at eating, too, found an explanation in a repulsive detail of these proceedings. After we had gone through this series of scenes, the hallucinatory sensations and images had disappeared, and (up to the present, at any rate) they have not returned.¹

¹ Later on, when an exacerbation of her illness undid the successful results of the treatment - which were in any case meagre - the patient no longer saw the offensive images of other people’s genitals but had the idea that other people saw her genitals whenever they were behind her.

(Added 1922) The fragmentary account of this analysis in the text above was written while the patient was still undergoing treatment. Very shortly after, her condition became so much more serious that the treatment had to be broken off. She was transferred to an institution and there went through a period of severe hallucinations which had all the signs of dementia praecox. Contrary to expectation, however, she recovered and returned home, had another child which was quite healthy, and was able for a long period (12 to 15 years) to carry out all her duties in a satisfactory manner. The only sign of her earlier psychosis was said to be that she avoided the company of all relatives, whether of her own family or of her husband’s. At the end of this period, affected by very adverse changes in her circumstances, she again became ill. Her husband had become unable to work and the relatives she had avoided were obliged to support the family. She was again sent to an institution, and died there soon after, of a pneumonia which rapidly supervened.

I had found, therefore, that these hallucinations were nothing else than parts of the content of repressed childhood experiences, symptoms of the return of the repressed.

I now turned to the analysis of the voices. First and foremost what had to be explained was why such an indifferent content as ‘Here comes Frau P.’, ‘She’s looking for a house now’, and so on, could have been so distressing to her; next, how it was that precisely these innocent phrases had managed to be marked out by hallucinatory reinforcement. From the first it was clear that the ‘voices’ could not be memories that were being produced in a hallucinatory way, like the images and sensations, but were rather thoughts that were being ‘said aloud’.

The first time she heard the voices was in the following circumstances. She had been reading Otto Ludwig’s fine story, Die Heiterethei, with eager interest, and she noticed that while she was reading, thoughts were emerging which claimed her attention. Immediately afterwards, she went for a walk along a country road, and, as she was passing a small peasant’s house, the voices suddenly said to her ‘That’s what the Heiterethei’s cottage looked like! There’s the spring and there are the bushes! How happy she was in spite of all her poverty!’ The voices then repeated to her whole paragraphs from what she had just been reading. But it remained unintelligible why the Heiterethei’s cottage and bushes and spring, and precisely the most trivial and irrelevant passages of the story, should be forced on her attention with pathological strength. However, the solution of the puzzle was not difficult. Her analysis showed that while she was reading, she had had other thoughts as well and that she had been excited by quite different passages in the book. Against this material - analogies between the couple in the story and herself and her husband, memories of intimacies in her married life, and of family secrets - against all this a repressing resistance had arisen because it was connected, by easily demonstrable trains of thought, with her aversion to sexuality and thus ultimately went back to the awakening of her old childhood experience. In consequence of this censorship exercised by the repression, the innocuous and idyllic passages, which were connected with the proscribed ones by contrast and also by propinquity, acquired the additional strength in their relation to consciousness which made it possible for them to be spoken aloud. The first of the repressed ideas, for instance, related to the slander to which the heroine, who lived alone, was exposed from her neighbours. My patient easily discovered the analogy with her own self. She, too, lived in a small place, met no one, and thought she was despised by her neighbours. This distrust of her neighbours had a real foundation. She had been obliged at first to be content with a small apartment, and the bedroom wall against which the young couple’s double bed stood adjoined a room belonging to their neighbours. With the beginning of her marriage - obviously through an unconscious awakening of her childhood affair, in which she and her brother had played at husband and wife - she had developed a great aversion to sexuality. She was constantly worried in case her neighbours might hear words and noises through the party wall, and this shame turned into suspiciousness towards the neighbours.

Thus the voices owed their origin to the repression of thoughts which, in the last analysis, were in fact self-reproaches about experiences that were analogous to her childhood trauma. The voices were accordingly symptoms of the return of the repressed. But they were at the same time consequences of a compromise between the resistance of the ego and the power of the returning repressed - a compromise which in this instance had brought about a distortion that went beyond recognition. In other instances in which I had occasion to analyse Frau P.’s voices, the distortion was less great. Nevertheless, the words she heard always had a quality of diplomatic indefiniteness: the insulting allusion was generally deeply hidden; the connection between the separate sentences was disguised by a strange mode of expression, unusual forms of speech and so on - characteristics which are common to the auditory hallucinations of paranoics in general and in which I see the traces of distortion through compromise. For instance, the remark, ’there goes Frau P.; she’s looking for a house in the street’, meant a threat that she would never recover; for I had promised her that after her treatment she would be able to go back to the small town in which her husband worked.(She had provisionally taken rooms in Vienna for a few months.)

In isolated instances Frau P. also received more definite threats - for example, in regard to her husband’s relatives; yet there was still a contrast between the reserved manner in which they were expressed and the torment which the voices caused her. In view of what is known of paranoia apart from this, I am inclined to suppose that there is a gradual impairment of the resistances which weaken the self-reproaches; so that finally the defence fails altogether and the original self-reproach, the actual term of abuse, from which the subject was trying to spare himself, returns in its unaltered form. I do not know, however, whether this course of events is a constant one, or whether the censorship of the words involving the self-reproach may be absent from the beginning or may persist to the end.

It only remains for me now to employ what has been learned from this case of paranoia for making a comparison between paranoia and obsessional neurosis. In each of them, repression has been shown to be the nucleus of the psychical mechanism, and in each what has been repressed is a sexual experience in childhood. In this case of paranoia, too, every obsession sprang from repression; the symptoms of paranoia allow of a classification similar to the one which has proved justified for obsessional neurosis. Part of the symptoms, once again, arise from primary defence - namely, all the delusional ideas which are characterized by distrust and suspicion and which are concerned with ideas of being persecuted by others. In obsessional neurosis the initial self-reproach has been repressed by the formation of the primary symptom of defence: self-distrust. With this, the self-reproach is acknowledged as justified; and, to weigh against this, the conscientiousness which the subject has acquired during his healthy interval now protects him from giving credence to the self-reproaches which return in the form of obsessional ideas. In paranoia, the self-reproach is repressed in a manner which may be described as projection. It is repressed by erecting the defensive symptom of distrust of other people. In this way the subject withdraws his acknowledgement of the self-reproach; and, as if to make up for this, he is deprived of a protection against the self-reproaches which return in his delusional ideas.

Other symptoms of my case of paranoia are to be described as symptoms of the return of the repressed, and they, too, like those of obsessional neurosis, bear the traces of the compromise which alone allows them to enter consciousness. Such are, for instance, my patient’s delusional idea of being watched while she was undressing, her visual hallucinations, her hallucinations of sensation and her hearing of voices. In the delusional idea which I have just mentioned there is a mnemic content which is almost unaltered and has only been made indefinite through omission. The return of the repressed in visual images approaches the character of hysteria rather than of obsessional neurosis; but hysteria is in the habit of repeating its mnemic symbols without modification, whereas mnemic hallucinations in paranoia undergo a distortion similar to that in obsessional neurosis: an analogous modern image takes the place of the repressed one. (E. g., the abdomen of an adult woman appears instead of a child’s, and an abdomen on which the hairs are especially distinct, because they were absent in the original impression.) A thing which is quite peculiar to paranoia and on which no further light can be shed by this comparison, is that the repressed self-reproaches return in the form of thoughts spoken aloud. In the course of this process, they are obliged to submit to twofold distortion: they are subjected to a censorship, which leads to their being replaced by other, associated, thoughts or to their being concealed by an indefinite mode of expression, and they are referred to recent experiences which are no more than analogous to the old ones.

The third group of symptoms that are found in obsessional neurosis, the symptoms of secondary defence, cannot be present as such in paranoia, because no defence can avail against the returning symptoms to which, as we know, belief is attached. In place of this, we find in paranoia another source for the formation of symptoms. The delusional ideas which have arrived in consciousness by means of a compromise (the symptoms of the return) make demands on the thought-activity of the ego until they can be accepted without contradiction. Since they are not themselves open to influence, the ego must adapt itself to them; and thus what corresponds here to the symptoms of secondary defence in obsessional neurosis is a combinatory delusional formation - interpretative delusions which end in an alteration of the ego. In this respect, the case under discussion was not complete; at that time my patient did not as yet exhibit any signs of the attempts at interpretation which appeared later. But I have no doubt that if we apply psycho-analysis to this stage of paranoia as well, we shall be able to arrive at a further important result. It should then turn out that the so-called weakness of memory of paranoics is also a tendentious one - that is to say, that it is based on repression and serves the ends of repression. A subsequent repression and replacement takes place of memories which are not in the least pathogenic, but which are in contradiction to the alteration of the ego which the symptoms of the return of the repressed so insistently demand.

THE AETIOLOGY OF HYSTERIA (1896)

GENTLEMEN, - When we set out to form an opinion about the causation of a pathological state such as hysteria, we begin by adopting the method of anamnestic investigation: we question the patient or those about him in order to find out to what harmful influences they themselves attribute his having fallen ill and developed these neurotic symptoms. What we discover in this way is, of course, falsified by all the factors which commonly hide the knowledge of his own state from a patient - by his lack of scientific understanding of aetiological influences, by the fallacy of post hoc, propter hoc, by his reluctance to think about or mention certain noxae and traumas. Thus in making an anamnestic investigation of this sort, we keep to the principle of not adopting the patients’ belief without a thorough critical examination, of not allowing them to lay down our scientific opinion for us on the aetiology of the neurosis. Although we do, on the one hand, acknowledge the truth of certain constantly repeated assertions, such as that the hysterical state is a long-persisting after-effect of an emotion experienced in the past, we have, on the other hand, introduced into the aetiology of hysteria a factor which the patient himself never brings forward and whose validity he only reluctantly admits - namely, the hereditary disposition derived from his progenitors. As you know, in the view of the influential school of Charcot heredity alone deserves to be recognized as the true cause of hysteria, while all other noxae of the most various nature and intensity only play the part of incidental causes, of ‘agents provocateurs’.

You will readily admit that it would be a good thing to have a second method of arriving at the aetiology of hysteria, one in which we should feel less dependent on the assertions of the patients themselves. A dermatologist, for instance, is able to recognize a sore as luetic from the character of its margins, or the crust on it and of its shape, without being misled by the protestations of his patient, who denies any source of infection for it; and a forensic physician can arrive at the cause of an injury, even if he has to do without any information from the injured person. In hysteria, too, there exists a similar possibility of penetrating from the symptoms to a knowledge of their causes. But in order to explain the relationship between the method which we have to employ for this purpose and the older method of anamnestic enquiry, I should like to bring before you an analogy taken from an advance that has in fact been made in another field of work.

Imagine that an explorer arrives in a little-known region where his interest is aroused by an expanse of ruins, with remains of walls, fragments of columns, and tablets with half effaced and unreadable inscriptions. He may content himself with inspecting what lies exposed to view, with questioning the inhabitants - perhaps semi-barbaric people - who live in the vicinity, about what tradition tells them of the history and meaning of these archaeological remains, and with noting down what they tell him - and he may then proceed on his journey. But he may act differently. He may have brought picks, shovels and spades with him, and he may set the inhabitants to work with these implements. Together with them he may start upon the ruins, clear away the rubbish, and, beginning from the visible remains, uncover what is buried. If his work is crowned with success, the discoveries are self-explanatory; the ruined walls are part of the ramparts of a palace or a treasure house; the fragments of columns can be filled out into a temple; the numerous inscriptions, which, by good luck, may be bilingual, reveal an alphabet and a language, and, when they have been deciphered and translated, yield undreamed-of information about the events of the remote past, to commemorate which the monuments were built. Saxa loquuntur!

If we try, in an approximately similar way, to induce the symptoms of a hysteria to make themselves heard as witnesses to the history of the origin of the illness, we must take our start from Josef Breuer’s momentous discovery: the symptoms of hysteria (apart from the stigmata) are determined by certain experiences of the patient’s which have operated in a traumatic fashion and which are being reproduced in his psychical life in the form of mnemic symbols. What we have to do is to apply Breuer’s method - or one which is essentially the same - so as to lead the patient’s attention back from his symptom to the scene in which and through which that symptom arose; and, having thus located the scene, we remove the symptom by bringing about, during the reproduction of the traumatic scene, a subsequent correction of the psychical course of events which took place at the time.

It is no part of my intention to-day to discuss the difficult technique of this therapeutic procedure or the psychological discoveries which have been obtained by its means. I have been obliged to start from this point only because the analyses conducted on Breuer’s lines seem at the same time to open up the path to the causes of hysteria. If we subject a fairly large number of symptoms in a great number of subjects to such an analysis, we shall, of course, arrive at a knowledge of a correspondingly large number of traumatically operative scenes. It was in these experiences that the efficient causes of hysteria came into action. Hence we may hope to discover from the study of these traumatic scenes what the influences are which produce hysterical symptoms and in what way they do so.

This expectation proves true; and it cannot fail to, since Breuer’s theses, when put to the test in a considerable number of cases, have turned out to be correct. But the path from the symptoms of hysteria to its aetiology is far more laborious and leads through other connections than one would have imagined.

For let us be clear on this point. Tracing a hysterical symptom back to a traumatic scene assists our understanding only if the scene satisfies two conditions; if it possesses the relevant suitability to serve as a determinant and if it recognizably possesses the necessary traumatic force. Instead of a verbal explanation, here is an example. Let us suppose that the symptom under consideration is hysterical vomiting; in that case we shall feel that we have been able to understand its causation (except for a certain residue) if the analysis traces the symptom back to an experience which justifiably produced a high amount of disgust - for instance, the sight of a decomposing dead body. But if, instead of this, the analysis shows us that the vomiting arose from a great fright, e.g. from a railway accident, we shall feel dissatisfied and will have to ask ourselves how it is that the fright has led to the particular symptom of vomiting. This derivation lacks suitability as a determinant. We shall have another instance of an insufficient explanation if the vomiting is supposed to have arisen from, let us say, eating a fruit which had partly gone bad. Here, it is true, the vomiting is determined by disgust, but we cannot understand how, in this instance, the disgust could have become so powerful as to be perpetuated in a hysterical symptom; the experience lacks traumatic force.

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