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Psychoanalysis was completely successful. Upon the completion of treatment the patient's weight had gone down to one hundred forty-three pounds and she had fully regained her vitality. Pro­fessionally she was again fully competent and, above all, she had grown up to be a mature woman. In spite of carrying a full load of work, she now found time for friendships with a number of worth­while people of both sexes.

Maria's analysis lasted a little more than four years. Toward the end of treatment she had an impressive dream which announced

A Patient with Functional and Structural "Psychosomatic" Disturbances 161

her imminent recovery. In the dream, she finds herself in an analytic session. A man enters, a professor with a very intelligent face. The analyst introduces the patient to him. The professor and the dreamer soon leave together without paying any more attention to the analyst. Together they visit a festive party. In the house where the party is taking place they \valk out onto a balcony and admire the darkness of the night. They know that they are united in their thoughts and hearts. There is no sexual urge. They know they will marry and be together physically, too. But they can wait until that time. In the meantime the festivities inside the house have ended, but the dreamer and her friend cannot tear themselves away from the beauty of the starry night. Now the sky begins to take up the festive theme. The stars arrange themselves to form a huge Christ­mas tree. A powerful organ of the spheres plays a melody of peace on earth. The dreamer falls into a deep sleep from which she awakens late the next morning in a mood of great happiness.

Two years after she had the dream it became reality, insofar as she actually did marry a very gifted and unusually knowledgeable professor whom she had not even known at the time of dreaming. She loved him with all her being. Emotionally, spiritually, and physically her relationship to him reflected her—now fully de­veloped—ability to love.

During the eleven years since her marriage, this woman has not been sick again. She has given birth twice and she has dealt in a superior fashion with two unusually heavy blows of fate. Above all, she has been capable since her recovery of carrying out the love-possibilities of her Dasein fully and normally in the relationship to her husband. As in the case of every healthy, mature woman who loves her husband with body and soul, her happiness pervades her total being. Things, other people, and with these her own self, dis­close themselves to her in a manner characterized by brightness, beauty, richness, abundance, and limitless connectedness. Her existence can now be carried out in open understanding of the world around her, particularly in an active care of her family. Due to the changes wrought by the normal fulfillment of her Dasein, she now has not only the love fantasies we expect in a mature woman, but also feelings of love for her husband as well as the instinctive, sensuous desire to fuse with him physically. She experiences the act of love physically as any normal woman does; the sensorimotoric and vegetative spheres of her body respond adequately.

162 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

"Meaningful" Hysterical Symbolization and "Meaning­less" -Organ-Neurotic Functional Disturbances in

the Light of Daseinsanalysis

We shall now discuss Maria's history with the intention of gaining new insight into the essence of, and differences between, hysterical and organ-neurotic symptoms. Maria grew up in a home char­acterized by an atmosphere of narrow prudishness. The rest of her social milieu was no less hostile toward instinctual urges. Con­sequently, all sensuous, erotic possibilities of relating had to remain dormant. At nineteen years, she attended a dance by herself for the first time. The comparative wildness of the atmosphere and, above all, the attempted rape which followed, suddenly brought into the open sensuous modes of behavior which she was unable to recognize as her own because she was still encased in childish modes of relating. But the note of instinctual relating had been struck and demanded to be heard. Because the realm of the sensual possibilities was not admitted, these could not appear as features of a love relationship. As a result, sensuous modes of relating were detoured and occurred in the pantomimic gestures of arc-de-cercle, in the spasms of the pelvic muscles, the brightness of the eyes, and the involuntary sweetish smile. All of these hysterical symptoms were a manner of relating whose meaning the patient refused to acknowledge and to freely, willingly, take over as her own. We call the voluntary motor symptoms and the autonomous eye phe­nomenon "hysterical" because both of them are clearly ways of relating to the external world, even though the ecstatic rhythm of a love relationship is carried out solely in the veiled language of gestures. Because these were real gestures and, as such, compara­tively easy to understand, Maria's mother had blushed when she first told of her daughter's rhythmic convulsions of the pelvis and her "amorous" eyes.

The therapy of the first physician, instead of effecting a cure, led to the transformation of classical hysterical symptoms into an exces­sive vaginal discharge which could not be stopped by medication. During this period of the patient's life the interpersonal love re­lationship occurred only in the medium of the "autonomous" cervi­cal glands. The hypnotic treatment constituted a covering up. It succeeded so well that from that point on the melody of the patient's life—attuned to the abundance of love—had only one

A Patient with Functional and Structural "Psychosomatic" Disturbances 163

medium at its disposal, the self-enclosed circulatory system. A heart which threatened to burst from its fullness in organ-neurotic fashion gave evidence of the fullness of her love.

If we regard her hysterical and organ-neurotic symptoms in the perspective of her full development, we begin to understand that all of these symptoms form a characteristic series. Essentially just one world-relation comes to pass in all of them—that attuned to the abundance of love. At one end of the series we see hysterical con­vulsions and mimicry, very impressive to the spectator though their meaning is veiled. At the other end we find the organ-neurotic symptom of a pathological heart rate, confined to the inside of the body, invisible to others, and devoid of any gesture-like quality. The center of the continuum would be occupied by the symptom of fluor albus. Although the potential for an overflowing love relation­ship shows itself in this case through the autonomous vegetative system, hidden from the external world by her clothes, the symptom does not wholly lack the character of gesture, and thus of com­munication.

The Daseinsanalytic approach has permitted us to develop criteria for the adequate distinction between hysterical and organ-neurotic symptoms. Furthermore, the sharper differentiation between the two groups of pathological symptoms has made it possible to per­ceive their essential characteristics more clearly. This has put us into a position from where we can seriously study symbolization, a concept which traditionally plays a central role in the theory of neuroses in general and which has been decisive in differentiating between the two above-mentioned groups of symptoms in psy­chosomatic medicine up to now. As we have pointed out (see pp. 137 ff.), it has been generally accepted that one can properly talk of symbolization only within the group of hysterical symptoms. The convulsions of our patient would unquestionably have been regarded as "hysteric symbolizations" of certain repressed sexual fantasies, that is, the spasms of the pelvic muscles would have been considered to be merely symbolic expressions of those psychic things and contents which were really meant.

To suppose that a phenomenon stands in reality for another which it expresses or symbolizes is an arbitrary intellectual as­sumption not justified by experience. If we look at the phenomena themselves, we see that our patient's world-relationship of loving came into its being as immediately in the early hysterical gestures

164 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of N euros».

of arc-de-cercle and the spasms of the pelvic muscles as in the late sexual fantasies and actual sexual intercourse with a belove: partner into which she entered freely. The difference between tl earlier and later forms of carrying out the relationship of love wa only that in its earlier appearances the relationship was kept bacV as yet, from its full and open unfolding into responsible and full;. willed interhuman actions.

All psychic phenomena can be understood similarly. Thought^; ideas, fantasies on the one hand, and all hysterical physical symp­toms on the other, must be regarded as two equally autonomous forms in which Dasein itself occurs, each form being carried out in different realms of existence. This is the reason why it amounts to coercion to posit an expressive relationship between the two realms, and to even greater coercion to derive one from the other "psychologically." We would like to state here the funda­mental difference between the two terms "expressing" and "carrying out." We have previously pointed out (see pp. 136 ft.) that the concept of "expression" presupposes something "behind" appear­ance and assumes that this something "manifests" itself in what is expressed. But when Daseinsanalysts say that human existence carries itself out in a specific phenomenon, they refer always (and only) to the original and immediate occurrence of Dasein itself as this phenomenon.

The patient's existence, attuned to the overflow of love, carried itself out with the same directness in the hysterical symptoms as in the palpitations and interior chest pain which followed later. The difference was that the latter, organ-neurotic modes of carrying out the possibility of loving claimed a different realm of Dasein. Both organ-neurotic disturbances and hysterical physical symptoms are excessive corporalizations of an existential relation; each is direct and authentic. The essential content of organ-neurotic symptoms can therefore not be less than that of hysterical ones. In both instances we deal with a possibility of existing which is carried out in a way deviating from the norm. To regard hysterical symptoms as comparatively "meaningful" symbolic expressions of certain psychic factors seems as inadequate as to condemn organ-neurotic illness to the role of "meaningless" physiological mechanism or that of a mere vegetative, concomitant symptom without content. Both points of view miss the true essence of these disturbances.

Our patient's illness raises still other questions of crucial impor-

A Patient with Functional and Structural "Psychosomatic" Disturbances 165

tance for psychosomatic medicine. The speedy transformation of classic hysterical symptomatology into equally classic organ-neurotic symptoms mercilessly confronts us, above all, with the difficult prob­lem of so-called choice of neurosis, a problem which Freud tried to answer but before which he had to capitulate after many at­tempts at solution had failed. In the end he saw no way out but to identify the problem with the vague notion of "sexual constitution," thereby dumping it into the lap of biological research.²

The Problem of "Choice of Neurosis"

Two very different kinds of influence were responsible for the change of the patient's symptoms from hysterical to organ-neurotic ones. The first influence consisted in her physician's careful hints regarding a possible connection between her attacks and the sexual experience she had undergone. The second influence was the change in her parents' behavior; they had, it will be remembered, followed the physician's instructions to stop paying any attention to her symptoms to a point which amounted almost to Maria's complete isolation. Apparently as a result of the first of these measures, the hysterical disguise no longer sufficed to hide the sensual and erotic aspect of loving from the patient. At that time of her life she had not yet unfolded to become a real self; she was still caught in the mentality of her surroundings. In her world, instinctual and sensu­ous modes of behaving were considered sinful and were not ad­mitted. Because the physician's hints emphasized the sensuous and erotic content of her hysterical symptoms—at a time when she was not yet ready to take over such modes of relating—stronger de­fenses and disguises became necessary. When possibilities of re­lating cannot be carried out appropriately, they are blocked. Often, when the initial blockage proves not to be strong enough, it is displaced from the periphery to the inside of the body, a change which implies greater concealment. This is what happened in Maria's case. Pelvic spasms and fades hysterica gave place to fuor albus and, finally, assisted by hypnotherapy, to an organ-neurotic

² See, for example, S. Freud, "My Views on the Part Played by Sexuality in the Aetiology of the Neuroses," in SE, Vol. VII, pp. 269 ff.; "Notes upon a Case of Obsessional Neurosis," in SE, Vol. X, pp. 153 #.; "Formulations on the Two Principles of Merffal Functioning," in SE, Vol. XII, pp. 213 #.; "The Disposition to Obsessional Neurosis: A Contribution to the Problem of Choice of Neurosis," in SE, Vol. ХП, pp. 311 f ■

166 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

cardiac disturbance. Furthermore, because every hysterical symp­tom is a distinctly interpersonal phenomenon, it needs to be shared with a partner or partners. If partners are missing, it cannot occur as an hysterical symptom. Therefore, when the patient's parents ceased paying attention to her on the advice of the physician, they withdrew thereby the possibility for carrying out her love relation­ship in an hysterical manner.

The transition from hysterical to organ-neurotic symptomatology in this case immediately brings to mind an analogous phenomenon —the peculiar changes generally observed in neurotic symp­tomatology during the past decades. It is, for instance, generally known that the First World War produced whole battahons of "shakers," men who became unfit for combat because of the hysterical tremor of their extremities. The armies of World War II, however, produced hardly any soldiers with hysterical symptoms; but organ-neurotic stomach and intestinal disorders increased enormously. Is it possible that we see here, on a large scale, the same phenomenon (and for the same reasons) which we encoun­tered in our patient? Did the development and popularization of psychoanalysis result in a general psychological enlightenment which spread far and deep into the knowledge of all social strata? Also, is it not true that contemporary forms of social living bring with them a considerable amount of isolation of the individual, so that the individual is forced back upon himself when it comes to those realms of living which matter most? At the very least, this patient's case teaches us that the problem of choice of neurosis can never be understood on the basis of the isolated individual alone. Sociological factors and even factors which are not capable of psy­chological interpretation must also be considered. To phrase it more succinctly: the problem of choice of neurosis can be understood only on the basis of Dasein in its totality;³ and Dasein, apart from always being my Dasein, is always also being-with, i.e., Dasein exists funda­mentally with others and is related to the things of a world it has in common with the others.

The question of "choice of neurosis" is, of course, by no means settled by these deliberations. We hardly need point out, for example, that "choice," in the sense of a free decision for something, cannot play any part within this frame of reference. For all neurotic

—«----

³ See also H. Biirger-Prinz, "Ш>ег die mannliche Sexualitat," in Zschr. f. Sexual-forschung, Vol. I, No. 2, 1950, p. 5.

A Patient with Functional and Structural "Psychosomatic" Disturbances 167

phenomena are in themselves indications that a person has lost, to an important extent, his freedom to decide, that he is "being somaticized" when he should carry himself out in freely and responsibly accepted interpersonal relationships. But we do under­stand this much about the hysterical and organ-neurotic symptoms of our patient: both kinds of symptoms carry out the same world-relationship, but conceal this world-relationship to different degrees. ^We saw that Maria's hysterical symptoms appeared when a pos­sibility of living was restricted to a sphere of existence which, though it did not permit appropriate carrying out, still permitted a language addressed to fellow human beings, the admittedly inadequate and veiled language of gestures. We also saw that her organ-neurotic phenomena were characterized by the fact that these same modes of existing (or possibilities of living) congealed in the taciturn medium of her innermost bodily realm.

Our differentiation between the two forms of neurosis does not tell us anything about the specific somatic region through which a concealed life relation may appear. The problem of "choice of neurosis," with its question of the form of the neurosis (hysterical or organ-neurotic), first narrows down to the question of "choice of organ," and finally to the question of specificity of the "choice of organ." Many reseachers do not hesitate to call this question the "crucial problem" of modern psychosomatic medicine.⁴

The Problem of "Choice of Organ"

We now ask why our patient produced exclusively those symp­toms which we have mentioned—pelvic spasms,'hysterical smile, and amorous eyes—during her hysterical phase? Could she not just as well have developed torticollis spasmodicus, hysterical paralysis of the foot, or hysterical aphasia? Why did she not, after she began to exist organ-neurotically, develop gastric symptoms? Why did she not develop bronchial spasms with asthma attacks, or cranial vascular changes with migraine headaches? Did the dis­turbances in the patient's internal genitalia and her cardiac symp­toms arise out of necessity or could other symptoms have arisen?

The question of choice of organ is open to the same objections

⁴ See, for example, F. Alexander and Т. М. French, Studies in Psychosomatic Medicine, New York, 1948, p. 10.

168 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

which we have voiced in connection with the problem of choice of neurosis. Both terms persist only because we are accustomed to them. The state of affairs to which the term "choice of organ" is supposed to refer does not even come into view as long as the term is used. The term is misleading in two ways, for in reality neither "choice" nor "organ" are involved here at all. The concept of organ as used here presupposes that the human body is the sum of its more or less connected parts and organ-objects. This being the case, "choice" must necessarily be attributed to a more or less con­scious subject, or to a more or less unconscious subjective function, either one of them superimposed on the body and capable of "choosing" this or that part of the body. In reality, however, it is always a relation to the world—the one as which the existence of a person happens to be carried out at the time—which determines the specific corporealization at any given time. It follows that at a particular time those realms of the body will predominate which belong to the particular relation which is carried out, those realms of the body (to state it even more precisely) which this particular relation is, insofar as it shows itself somatically.

We have already identified the factor which, in cases like that of our patient, decides whether an organ-neurotic or a hysterical form of neurosis will appear. We saw that we cannot differentiate on the basis of the specific kind of relationship which is prevented from its full and free unfolding; the decisive factor is the degree to which a possibility of relating to somebody or something of the world is being kept back. This means that in some instances it can be car­ried out only in the covered-up realms of the interior of the body, and in other instances in the much larger realm of involuntary, compulsive, hysterical gestures, which almost reach the open sphere of normal, responsible, willed interpersonal relationships.

The determinants of so-called organ-choice are of a different kind. The particular somatic realm where either hysterical or organ-neurotic symptoms will appear depends on the specific kind of world-relation which is not being permitted to unfold freely. Even in healthy people, that bodily realm of their existence is in the fore­ground which constitutes a partial phenomenon of the world-relation that is being carried out at the time. The somatic phe­nomena which push themselves into the limelight in hysterical and organ-neurotic disturbances also belong exclusively to the world-

A Patient with Functional and Structural "Psychosomatic" Disturbances 169

relation as which a human being is existing at the time, though only in a dammed-up way.

In Maria's case, the main issue was the lif e-possibility of being-to-gether-in-love with a person of the opposite sex. For the full occur­rence of this manner of existing, the partial phenomena of the loving glances and the smiling mouth, as well as the muscular phenomena of the pelvic region, the vaginal secretions, and the increased heart rate, are as essential as the physical, sensual union of the partners and their loving thoughts for each other. This is the reason why these specific spheres of the body, bodily functions, and gestures—and no other—were inflated to hysteriform and organ-neurotic symptoms when the patient's ability for a loving relationship was arrested. If the patient had hated her brutal partner because of his attempt to rape her, if she had actually wanted to hit him but had not permitted herself to become fully aware of this impulse or to carry out the deed because of moral scruples, this relationship of hate would presumably have carried itself out in form of a hysterical paralysis or a hysterical spasm of the arm muscles. If the desire to hit which she had not permitted herself to carry out had been pushed away even further than into the sphere of an hysterical gesture of which she was not aware, it would pos­sibly have been carried out in the realm of organ-neurotic symp­toms by way of a general tension state and increased tonus of the skeletal muscles. We conclude that the greater the prohibition against carrying out a given manner of existing in open, knowing, interpersonal behavior—the further it has to retreat, to the realm of hysterical gestures where there is no awareness, and then perhaps even further, to the muted realm of bodily functions where organ-neurotic symptoms occur—the more a characteristic loss of dif­ferentiation inevitably accompanies this retreat. Instead of a hitting motion, directed against a specific, hated person and carried out at a specific moment with full knowledge and decision, there appears a hysterical, unwilled muscular spasm in the right arm. When the same arrested world-relation appears organ-neurotically, it is even more generalized. There is a general increase of tonus which affects all of the skeletal muscles for an indefinite period of time.

However, experience shows that it is not only basically loving people, like our patient, who develop severe organ-neurotic heart symptoms. Persons whose whole Dasein is attuned to and absorbed in hate show identical symptoms if they do not freely take over

170 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neurose*

their hating existence in the form of conscious aggressive fantasies or even by getting into brawls. On the other hand, we also know of lovers who, like frustrated haters, suffer from hysterical cramps in the arms when they do not dare to carry out their relationship to the loved one by caressing him or at least by admitting to them­selves that they want to caress him.

If, however, neurotic illness of one and the same bodily sphere can be connected with relationships of either love or hate; if, further­more, neurotically disturbed love as well as repressed hate relation­ships can come to the fore in completely different regions of the body, does this not mean that it has been shown conclusively that there is no such thing as specificity of neurotic "organ-choice"? The very manner in which this question is posed reifies and artificially dismembers that which needs to be understood. Once the human body has been pictured as a conglomeration of organs, it is almost inevitable that "specificity" must come to mean a lawful correlation between separate psychic things and specific organs. Such reification and dismemberment confuses the issue from the outset so that it no longer matters whether one imagines the psychic things to be love, hate, personality traits, character traits, unconscious instinctual con­flicts, or emotional constellations.

The way in which we use the term "specificity" is not subject to such criticism. We use "specificity" to mean that if somatic realms of a Dasein exhibit disturbances, such disturbances are always integral to an arrested world-relation; the disturbance of a bodily realm is the restricted world-relation itself—its somatic part. We should remember, however, that heart and hand (for instance) are partial somatic phenomena of both,the world-relation of love and the world-relation of hate. For this reason both heart and hand are prominently engaged whenever an existence is attuned to either love or hate. Even within the realm we consider normal, the heart beats faster and the hand performs specific acts regardless of whether two people embrace each other in love or hit each other in hate.

It would have been surprising, however, if our patient had de­veloped a colitis mucosa. Such "choice of organ" is impossible on principle (and has never been shown to occur) in an existence attuned totally to the interpersonal relation of loving submission. The somatic realm of the colon cannot be "chosen" by an existence so attuned, because this realm belongs to a totally different world-

A Patient with Functional and Structural "Psychosomatic" Disturbances 171

relation, namely that of expulsion or retention of particular beings.⁵ The multiform history of Maria's life and suffering poses still more problems. Her organ-neurotic heart troubles of long standing seemed unexplainably to disappear into thin air without treatment —a long time, moreover, before psychoanalysis enabled her to achieve a complete recovery. The patient simply discovered one day that she was no longer really aware of her heart. Or, perhaps it was not "thin air" into which the cardiac neurosis disappeared, but rather the fat of the suspected Cushing syndrome that eventually sucked all her heart symptoms into itself. Nothing could at first glance seem less likely than such a supposition. Yet, the events which occurred soon after the patient had started psychoanalysis force us seriously to consider such a possibility.

Daseinsanalytic Reflections on the Anatomical-Structural Symptoms

An Adipose Phase of Life. Undeniably, the cardiac symptoms of our patient started at a time when she weighed one hundred thirty-four pounds and disappeared five years later when she weighed one hundred ninety-four pounds. In the meantime, however, she had not only become frighteningly fat physically but also had become a totally different person mentally. She had lost all her earlier vitality and initiative and except for short periods of depression had become an indifferent, apathetic being. She called herself a "stuffed reptile," smiling indolently and phlegmatically while saying so. In the main, all her interests had become concentrated in the greed to eat appetizing dishes, particularly sweets.

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