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At the beginning of analysis the faintest attempt to start the patient to wonder about her fife situation was answered immedi­ately with an immense increase in her desire to eat. Similarly, even the slightest demand of an interpersonal nature was sufficient to make her gain four pounds. Her dreams, too, were unequivocal during this phase of her analysis. The following dream is typical. The patient, with her analyst, was walking up and down the main street of her native village. The analyst tried to persuade her to go back to school as a second grade student. Eventually she agreed. Together with the analyst she started walking in the direction of

^B Cf. M. Boss, Einfilhrung in die psychosomatische Medizin, Bern, 1954, pp. 171 ff.

172 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

the school house. To get there she had to pass a crossing near the parental home. Arriving at the crossing the patient tore herself away and ran home to her mother. Mother was just starting to give the bottle to an infant. On a table next to her was a huge cake with rich sugar frosting. The dreamer awoke, unable to decide whether she herself might not have been the infant. Commentary is hardly necessary.

After half a year of the most patient and careful analytical work the first signs of a positive relationship of the patient to the analyst became noticeable. Until then she had more or less vegetated with­out any relations to the world around her, except to food. Now she began to feel secure and sheltered in the analytical situation and to perceive the analyst as a protective and supportive father figure. As soon as her existence thus began to unfold in an interpersonal relation, her fat began to melt like butter in the sun, even though the structure of the relationship at this point was akin to that of an infant's love for her parent. Even the slightest disturbance of the "transference" relationship, however, immediately resulted in an in­creased desire to eat and a weight gain.

When, after three years of analysis, the patient had matured to the equivalent of puberty, her relationship to the analyst took on traits resembling those of a teen-age crash. It is significant that, before she could admit these feelings and fantasies to herself and verbalize them to the analyst—and thus genuinely appropriate to herself these virginal possibilities of carrying out a love relationship —intense heart symptoms occurred again. The patient felt that she had been thrown back to earlier years. What actually occurred, however, was the unwinding of, the neurotic spool of thread, a necessary part of every correctly conducted analysis. Analytical experience shows that patients grow beyond this stage of maturity in the unperturbable good-will of the analytic situation. So did our patient. Eventually she reached the maturity appropriate to her chronological age and no longer needed the analyst, because she now had taken over her existence as her own responsibility.

The question remains: how can this woman's insatiable desire to eat and the resulting adiposity be understood on the basis of her life history and the history of her cure? The answer seems in­escapable. All of the patient's possibilities for living had congregated increasingly in the one world-relation of incorporation of food, until practically her whole existence was absorbed in a compulsive desire

A Patient with Functional and Structural "Psychosomatic" Disturbances 173

to eat. Even before she started to crave food, her hungering for love had been carried out in an arrested manner through the heart symptoms. Now the relationship of hungering for love was carried out on an even lower level. The hunger for love inflated the world-relation of incorporation of edibles, the "ordinary" hunger relation, to an insatiable greed. It is by no means accidental that when the blocking of her existence was at its most extreme, it was carried out at the level of cellular metabolism. At that time two events had closed off, more than ever, the interpersonal avenues for carrying out Dasein. She had increasingly been made to feel that her physi­cians were beginning to lose interest in her and that her stereotyped complaints about cardiac symptoms were getting on their nerves more and more. The other significant event had been the death of Maria's mother, which had occurred a few weeks before she started visibly to put on weight. Moreover, soon after her mother's death, her father became completely absorbed in a love relationship with one of his fellow teachers. The patient experienced her situation as one of hopeless abandonment. M. Bleuler and his co-workers have found very similar, desolate life situations to precede Cushing-type syndromes in an unusually high number of cases.⁶ It goes without saying that in this type of research one must not look for an "absolute" or an "objective" degree of human suffering. The one valid criterion is the specific meaning a given life situation has for a concrete, suffering human being.

The patient now began to carry out her existence in the main by way of acquiring physical fat. Consequently the spiritual sphere of her Dasein became steadily emptier. Intellectual apathy and a grow­ing lack of interest in everything that could- not be eaten became increasingly noticeable. Here is the reason why, contrary to the physician's predictions, her cardiac symptoms disappeared spon­taneously without leaving any trace while she was at the same time getting heavier. We can also understand now why dietary regimens were bound to fail and why the patient panicked at the very idea of enforced fasting. If eating is the only life relation left to a patient

⁶ See, for example, M. Bleuler, Endokrinologische Psychiatrie, Stuttgart, 1954, p. 144; G. Schwobel, "Die Psychopathologie des Cushing Syndroms," in Schweiz. Arch, f. Neur. u. Psych., Vol. 74, Nos. 1, 2, 1955, pp. 369 #.; R. Furger, "Psychiatrische Untersuchungen beim Cushing Syndrom," unpublished dissertation, University of Zurich, 1961. Also, W. H. Trethowan and S. Cobb, "Neuropsychiatric Aspects of Cushing's Syndrome," in Arch. Neurobg. Psychiatr., Vol. 67, 1952, p. 283; E. Kehrer, Endokrinologie fur den Frauenarzt, Stuttgart, 1937.

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174 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neurose

as a possibility to exist, fasting must in the genuine sense equi destruction of the world and death. This is so because man is "there and in-the-world only in and as his relating to the things c: the world. By the same token, our patient's excessive food in­take not only diminished but did so of its own accord as soon ai another possibility of existing had again opened up for her during analysis in the form of her relationship to the therapist. Here, as in other analyses, therapy for obesity became effective only when the patient was offered something better than dietary rules which she felt were designed to rob her of the content of her life—namely, parental protection in the psychoanalytic situation. We may add that the symptoms and cure of this case of obesity, seen together, banish all doubt that dammed-up human existing can retreat even further than hysterical and organ-neurotic somatic function. If certain possibilities of existing are excessively throttled, it is ap­parently possible that an inflation in the medium of the tissue structures is the result.

An Anorexic Phase of Life. All the phenomena of the patient's illness we have discussed so far—all her hysteriform and organ-neurotic functional disturbances as well as her obesity—we have been able to understand satisfactorily as due to an insufficiently free and open execution of human life relations, which prevented a genuine being-herself. We are satisfied that all hysterical symptoms must be regarded as an abnormal "inflation" of one or the other part of the bodily realm, an inflation which occurs because the carrying-out of an important world-relation has been confined to this particular sphere of a patient's existence. Only some of the organ-neurotic disturbances, however, fall into this category. Maria's anorexia teaches us that there are organ-neurotic illnesses which do not even have this much in common with hysterical symptoms.

The patient's anorexia mentalis began, as it so often does, at a time when she had already started to menstruate. The first symptom was not anorexia but the distaste she suddenly developed for her mother's obesity. As for herself, the patient's initial concern had been to delay development of her body to a more mature feminine shape. Thus she bound back her developing breasts as much as possible. During analysis she recalled this time vividly, in particular her sadness, even despair, over being unable to remain a child any longer. The big bodies of grown-ups all of a sudden appeared dis­gusting to her. She began to experience her own body as a devilish

A Patient with Functional and Structural "Psychosomatic" Disturbances 175

oppression. She horrified her mother by stating that she never wanted to marry or have children because she did not intend to populate the world further with such disgusting flesh. The bigger and heavier she became, the more sinful and dirty she felt. As soon, however, as she began to lose weight through fasting, she perceived her physical lightness as cleanliness and it made her happy. Through excessive fasting she could achieve a state of blissful suspension during which things around her seemed airy, too—winged, trans­lucent, and weightless. She thought that this must be the way the angels in heaven felt.

She also reported that she had dreamed at the time of either flying or being suspended almost every night. As a rule, however, only the beginning of these dreams had been blissfully happy; they had all ended horribly. At the beginning of the dreams she had never actually seen the earth below; almost always, she would be suspended above delicate, bluish cloud formations or above a diffuse sea of whitish vapor. Suddenly her ability to float would leave her. She would drop down through the filmy atmosphere and then would regularly face the mortal danger of being swallowed up by an immensely large, stinking morass of grayish-black color. Some­times she had been able to muster all her strength and swing herself up again above the clouds. More frequently, however, she had awakened, horrified by the threat of drowning.

What is at stake for this person in her anorexia she tells us as clearly by her waking behavior as in her dreams. Her existence has collected itself totally in defiance of all life relations of an earthy, sensuous, and erotic kind. She does not want to have anything to do with the fleshliness of her own body or those of other people. This is because everything earthy and material discloses itself to her Dasein only in its suffocating and decomposing aspects. The ex­cessive care of the patient's mother, her father's lack of attention to her and his lack of recognition of her femininity—all of this, com­bined with the extreme hostility of her social milieu toward the domain of the sensual, put the biggest possible obstacles in the way of her ability to mature normally. There is little left for her but to re­main suspended in midair, as her dreams show her to be. The more her developing body presses her to enter into the earthy, sensuous life relations concomitant with sexual maturing, the more desperately she tries to hold on to her ethereal dreams. But—in contrast to all hysterical and some organ-neurotic symptoms—our patient's attitude

176 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

of radical defense against the fleshy, sensual, material sphere of her world was not at all kept back from being carried out within the open realm of reflected upon, willed, interpersonal actions. On the contrary, we notice that she openly and knowingly fights her mother, the possessor of such opulent corporeality; we also see her take forceful steps to stop the development of her own breasts. All this is in striking contrast to her later hysterical and organ-neurotic symptomatology, occasioned by the arrest of certain possibilities of living in the domain of her body.

During the period of her anorexia, then, Maria openly and voluntarily carries out a defense against having to exist as a sexually mature feminine being. She collects almost all her potentialities in this one manner of relating, i.e., the defense against being feminine. The result is a strain of such severity on this manner of relating that the domain of her body, too, is drawn into the defense of all that is sensual and physical. Soon the structure of her body falls in line with this direction of her Dasein. The pituitary ceases to produce FSH hormone, in accordance with the existential world-relation of this human being. The ovaries either fall silent again or are neutralized by the production of opposing hormones, so that the patient regresses to an infantile amenorrheic phase. Her over-all physical habitus more and more begins to resemble that of an unreal ghost. A change occurs only when the platonic encounter with a similarly ethereal male enables her belatedly to mature to some extent. Now the structure of her Dasein, hitherto forcefully com­pressed into a child-like manner of existing, is given an opportunity to broaden its base. As she grows richer in regard to interpersonal relations, her physical substance grows also. Pituitary and ovaries are even permitted to get ahead of her emotional love relationship. It is hardly surprising, however, that the process of maturing, so recently begun, could not stand the brutality of an attempted rape. It is remarkable that the patient had in the meantime developed sufficiently to make a retreat to the old and radical defense of an anorexia impossible. What happened was "merely" a concealment of her love possibilities to the realm of hysterical gestures.

Our patient's anorexia has given us an opportunity to demonstrate the second manner in which neurotic somatic illnesses may arise. At the same time we would like to emphasize that the same rules concerning "specific organ choice" apply to symptoms arising in this fashion as to those symptoms whose appearance is due to the

A Patient with Functional and Structural "Psychosomatic" Disturbances 177

arresting of a life relation in the medium of the interior of the body. Even if the overextension and distortion of the somatic existential realm is due, not to the concealment of a life relation, but—as in this case of anorexia mentalis —to excessive collection and reduction of a Dasein in a given life relation which, though it is carried out know­ingly and voluntarily in interpersonal relationships, is overbur­dened by such concentration—even then only specific somatic realms will become involved in the process of illness: those which somatically are partial phenomena of that particular world-relation. Finally, we should not overlook the fact that a secondary damming-up of a forced life relation into the somatic sphere often accompanies the second category of organ-neurotic disturbances, a damming-up that we described earlier as the essential characteristic of the first category of organ-neurotic illnesses. Once an existence is concentrated in one relationship to the world, an open, unUmited carrying out of this world-relation exclusively in the realm of inter­personal actions would assume forms which neither conscience, self-esteem, or one's fellow men would permit.

"Anxiety Hysteria"

As an example of symptom formation in anxiety hysteria Freud chose a "well-analyzed animal phobia." He writes as follows:

The instinctual impulse subjected to repression here is a libidinal attitude towards the father, coupled with fear of him. After repres­sion, this impulse vanishes out of consciousness: the father does not appear in it as an object of libido. As a substitute for him we find in a corresponding place some animal which is more or less fitted to be an object of anxiety. The formation of the substitute for the ideational portion which has come about by displacement along a chain of connections which is determined in a particular way. The quantitative portion has not vanished, but has been trans­formed into anxiety. The result is fear of a wolf, instead of a demand for love from the father.¹

We have gone through this and Freud's other case histories of phobias in order to find proof for "displacement" of "ideational content" and "transformation" of its "quantitative portion" into anxiety. We found no such proof. We did, however, analyze a patient with a similar animal phobia and found the following.

At the age of nine, he had begun to be very much afraid of police dogs. Analysis revealed that through the perception of these animals he immediately became aware of the animalistic, sensuous, aggres­sive, impulsive possibilities of relating to fellow human beings—pos­sibilities which were as much part of him as they are of every human being. What frightened the boy was his immediate awareness of these aspects of his world. No mysterious transformation of libido into anxiety needs to be assumed as a basis for explanation. His fear can be understood on the basis of his life history and his human condi­tion. He existed, to a greater extent than one would expect for a boy of his age, under the absolute tutelage of his parents. Every

¹S. Freud, "Repression," in SE, Vol. XIV, p. 155. The case to which Freud refers is the one he later published under the title, "From the History of an Infantile Neurosis."

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detail of his behavior was directed by their wishes and intentions, to the point that he lived "through" them, so to speak. The atmos­phere of his home was characterized by an extreme pietistic hostility toward the world. The father in particular leaned toward an overly ascetic way of life. Existing within this type of parental relationship to the world and completely caught in it, the boy felt that any engagement in the sensual realm of animal wildness was sinful and punishable. He could not achieve a free relationship to his own impulsive and sensual possibilities of relating, nor to the realms of being which show themselves in the light of these possi­bilities. On the contrary, he had every reason to fear that his unauthentic, unstable self might be swallowed up by the forbidden, but supremely powerful, animalistic realms. As soon, however, as the patient was able to experience, in and through the relationship to his analyst, the fact that impulsive and sensual manners of re­lating are part of being human and may thus be permitted to be part of his own self, the animal phobia disappeared completely and forever. Hypotheses such as "repression of an instinctual repre­sentative into an unconscious," "displacement of perceptual content," or "transformation of quantities of libido" had been unnecessary for both the understanding and the cure of the phobia. Direct observation, on the contrary, taught us that it was the oppressive presence of an actual realm of being emerging within the boy's world-openness that he feared—which is to say that no repression had taken place, much less a return of the repressed.

The fears of patients suffering from agoraphobia, claustrophobia, and acrophobia are, in principle, similar to those of the boy we have just described. These types of neuroses differ from animal phobias only in that the things that belong to realms of being which the patients fear or hate are prevented even more strongly from appear­ing openly in Daseins light. Agoraphobics keep things so far away, claustrophobics close themselves off to such an extent, neurotics who fear high places fly so high into the lofty spheres of their in­tellect and will power, that only the approach of a completely un­known and uncanny something from the distance, from the enclosed or out of the depths, can be feared—he no longer fears such well-defined living beings as dogs or horses. Here again, what is feared is by no means absent, hidden in some hypothetical container such as the unconscious. These phobic people are, on the contrary, so

180 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

much under the spell of the anxiety-laden relationship to what they fear that—by their very repulsion of that which they are involved in—they are the more tied to, and attracted by, what appears fearsome to them.

On the other hand—and here Daseinsanalysis agrees with Freud and not with certain of the contemporary pseudo-Daseinsanalytic theoreticians—phobic people are always afraid of a concrete, though unknown, event which suddenly may overtake them from a distance, from within the enclosed or from the depths. It is by no means a matter of their not being able to master the "symbolic spatial qualities of distance, depth, and narrowness." Such a conception presupposes the existence of a primarily given three-dimensional space, or of a world-case within which man finds himself to be present in the manner of an object, along with all other objects in the world. It further presupposes that the neurotically ill person, under certain conditions, assigns the symbolic spatial qualities of distance, depth, and narrowness to such pre-given spatial dimen­sions, and fears them because they "symbolize" the future and the enlargement of his existence.

Now the decisive discovery of analysis of Dasein is precisely that Dasein is primordially spatial in itself (see pp. 42 ff.). The primary spatial dimensions of a world-case which the above-mentioned theories postulate are not primarily given at all. Man originally exists only in and as his world-disclosing relations with what he encounters. Man's primary spatiality opens itself up in these very relationships and unfolds according to their specific character, i.e., according to the kind and degree of meaningfulness of what man encounters. The encountered touches' man "closely" or only in a "distant" way, or—if he is an agoraphobic, a claustrophobic, or an acrophobic—he fearfully keeps certain things away and concealed from himself, thereby preventing himself from unfolding into a free spatiality. Every analysis of such a patient demonstrates anew that he fears, keeps away, and flees from the same things which patients suffering from animal phobias fear—namely those things that either constitutional weakness or a faulty education made fearful for them.

The very patients whom the pseudo-Daseinsanalytic investigators cite as witnesses give the lie to the conception of "symbolic spatial qualities." For example, one of the patients whom von Gebsattel mentions says that "something terrifying is rolling towards me from

"Anxiety Hysteria" 181

the distance."² Univocally, what terrorizes her is not the concept of distance but something that wants to approach her and show itself in the light of her Dasein, but which she fears to encounter and to admit. Nor does the distance symbolize the future for this patient.³ Rather will the future unfold itself only as the very ways in which she will deal with what she fears. Her future will present itself to her—i.e., will become her actual present and then her living past— only if she will permit what she fears to approach her, and if she will enter into a free relationship to what she still dreads. If she will not—or can not—do so, her existence will come to a standstill and there will be no future for her at all.

²V. v. Gebsattel, Die phobische Grundhaltung," in Handbuch der Neurosenlehre und Psychotherapie, Vol. II, Munich and Berlin, 1959, p. 120.

³ As to the fundamental impossibility of the "symbolization" of anything by any­thing else within the Daseinsanalytic understanding of man and his world, see M. Boss, The Analysis of Dreams, New York, 1958, pp. 91 ff.

Obsessional Neurosis

Freud distinguished hysteria from obsessional neurosis in this way: in hysteria, forbidden psychic content, together with the affect which accompanies it, is repressed; the psychic energy belonging to it converts into somatic innervations. In obsessional neurosis, on the other hand, the defense against an unbearable idea is accomplished by the separation of the idea from its affect:

... Thus weakened, the idea remains present in consciousness, detached from all associations; but its affect, now freed from it, attaches itself to other ideas which are not in themselves unbear­able, but which through this 'false connection' grow to be obses­sions. This is shortly the psychological theory of obsessions and phobias.. -¹

In another context, Freud describes another mechanism of re­pression present in obsessional neurosis. He states that in such illness a regression of libido from the genital to the earlier, anal-sadistic organization always takes place. In these cases, he says, "we can observe the result of a regressive deterioration of the genital organ­ization: all the phantasies originally conceived on the genital level are set back on to the anal level; the penis is replaced by the faecal mass, the vagina by the rectum/'² For this reason, Freud claims, we must regard obsessive symptoms also as reaction formations against anal-erotic and sadistic impulses.

Daseinsanalysis raises the following objections to this psycho­analytic theory of obsessional neurosis. First we must repeat that the idea of isolated, separately existing, and displaceable_affects does not correspond to any observable phenomena; it is merely an intellectual abstraction. In reality, man exists alw ays and..only as} the myriads of possibili ties for rel ating to and discl osing thf» living 1

¹ S. Freud, "The Defence Neuro-Psychoses," in CP, Vol. I, p. 66.

² S. Freud, "On the Transformation of Instincts, with Special Reference to Anal
Erotism," in CP, Vol. II, p. 169. Trans, by E. Glover.

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Obsessional Neurosis 183

beings and things he encounters?Dcsein, thus being essentially and primordially of a disclosing, i.e., luminating, nature, shines forth at any given time. But—as with every kind of "light"—its rumination varies as to color and brightness. Color and degree of brightness determine beforehand what kinds of particular beings and which aspects of them will be disclosed. This means that, in the_cas e of obsessional neurotics (as with every neurotic and psychotic), the carrying-out of human existingjs constricted in a specific manner. \ Obsessional patients are ready to acknowledge as belonging to their own existence only those possibilities of relating which apper­tain to the realm of "pure," objective, and conceptual thinking. In doing so these patients maintain distance from all they encounter. They are not warding off affects, supposedly capable of isolation from thinking. They are avoiding at all costs any full engagement of their existence in world-relationships. For if they really did open themselves wholeheartedly, the result would be intimate, "emotional" closeness to all realms of being, including those against which the obsessional neurotic has been sensitized in early childhood and which he experiences as low, dirty, animalistic, decomposed, or nauseating. An important area within this sphere of the forbidden, the dangerous, the unworthy, the sinful, is that of human excrement. Obsessional neurotics can be found to have undergone a misguided type of toilet training, where they learned their unfree and defensive attitude toward the creature-realm of their existence, an attitude that eventually crippled their whole life.

To maintain distance from the earthy—and supposedly dirty (because of decomposition)—realms of human existence is anything but freedom from these realms. On the contrary, the obsessional neurotic's intensive defense against the things he regards as dis­gusting amounts to his captivity by them. The lives of such people are forever attuned to anxiety. Because of their subjection to dirt and decay, they can understand their own existence only in terms of this realm of things, a realm they detest and fear. Hence their constant fear of becoming soiled and of deteriorating. This same subjection results in the fact that obsessional neurotics are open for little else except the perception of the dirty and decaying meaning of whatever they encounter. When they see a pile of manure, for instance, their existence is closed to the experience—except possibly in a coldly intellectual, distant manner—of the life-giving aspect of manure when it is used for fertilizer. All it can mean to them is

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