Further remarks on the neuro-psychoses of defence 1 страница

(1896)

In a short paper published in 1894, I grouped together hysteria, obsessions and certain cases of acute hallucinatory confusion under the name of ‘neuro-psychoses of defence’, because those affections turned out to have one aspect in common. This was that their symptoms arose through the psychical mechanism of (unconscious) defence - that is, in an attempt to repress an incompatible idea which had come into distressing opposition to the patient’s ego. In some passages in a book which has since appeared by Dr. J. Breuer and myself (Studies on Hysteria) I have been able to elucidate, and to illustrate from clinical observations, the sense in which this psychical process of ‘defence’ or ‘repression’ is to be understood. There, too, some information is to be found about the laborious but completely reliable method of psycho-analysis used by me in making those investigations - investigations which also constitute a therapeutic procedure.

My observations during my last two years of work have strengthened me in the inclination to look on defence as the nuclear point in the psychical mechanism of the neuroses in question; and they have also enabled me to give this psychological theory a clinical foundation. To my own surprise, I have come upon a few simple, though narrowly circumscribed, solutions of the problems of neurosis, and in the following pages I shall give a preliminary and brief account of them. In this kind of communication it is not possible to bring forward the evidence needful to support my assertions, but I hope to be able to fulfil this obligation later in a detailed presentation.

I THE ‘SPECIFIC’ AETIOLOGY OF HYSTERIA

In earlier publications, Breuer and I have already expressed the opinion that the symptoms of hysteria can only be understood if traced back to experiences which have a ‘traumatic’ effect, and that these psychical traumas refer to the patient’s sexual life. What I have to add here, as a uniform outcome of the analyses carried out by me on thirteen cases of hysteria, concerns on the one hand the nature of those sexual traumas, and, on the other, the period of life in which they occur. In order to cause hysteria, it is not enough that there should occur at some period of the subject’s life an event which touches his sexual existence and becomes pathogenic through the release and suppression of a distressing affect. On the contrary, these sexual traumas must have occurred in early childhood (before puberty), and their content must consist of an actual irritation of the genitals (of processes resembling copulation).

I have found this specific determinant of hysteria - sexual passivity during the pre-sexual period - in every case of hysteria (including two male cases) which I have analysed. How greatly the claims of hereditary disposition are diminished by the establishment in this way of accidental aetiological factors as a determinant needs no more than a mention. Furthermore, a path is laid open to an understanding of why hysteria is far and away more frequent in members of the female sex; for even in childhood they are more liable to provoke sexual attacks.

The most immediate objections to this conclusion will probably be that sexual assaults on small children happen too often for them to have any aetiological importance, or that these sorts of experiences are bound to be without effect precisely because they happen to a person who is sexually undeveloped; and further, that one must beware of forcing on patients supposed reminiscences of this kind by questioning them, or of believing in the romances which they themselves invent. In reply to the latter objections we may ask that no one should form too certain judgements in this obscure field until he has made use of the only method which can throw light on it - of psycho-analysis for the purpose of making conscious what has so far been unconscious.¹ What is essential in the first objections can be disposed of by pointing out that it is not the experiences themselves which act traumatically their revival as a memory after the subject has entered on sexual maturity.

My thirteen cases were without exception of a severe kind; in all of them the illness was of many years’ duration, and a few came to me after lengthy and unsuccessful institutional treatment. The childhood traumas which analysis uncovered in these severe cases had all to be classed as grave sexual injuries; some of them were positively revolting. Foremost among those guilty of abuses like these, with their momentous consequences, are nursemaids, governesses and domestic servants, to whose care children are only too thoughtlessly entrusted; teachers, moreover, figure with regrettable frequency. In seven out of these thirteen cases, however, it turned out that blameless children were the assailants; these were mostly brothers who for years on end had carried on sexual relations with sisters a little younger than themselves. No doubt the course of events was in every instance similar to what it was possible to trace with certainty in a few individual cases: the boy, that is to say, had been abused by someone of the female sex, so that his libido was prematurely aroused, and then, a few years later, he had committed an act of sexual aggression against his sister, in which he repeated precisely the same procedures to which he himself had been subjected.

¹ I myself am inclined to think that the stories of being assaulted which hysterics so frequently invent may be obsessional fictions which arise from the memory-trace of a childhood trauma.

Active masturbation must be excluded from my list of the sexual noxae in early childhood which are pathogenic for hysteria. Although it is found so very often side by side with hysteria, this is due to the circumstance that masturbation itself is a much more frequent consequence of abuse or seduction than is supposed.

It is not at all rare for both of the two children to fall ill later on of a defence neurosis - the brother with obsessions and the sister with hysteria. This naturally gives the appearance of a familial neurotic disposition. Occasionally, however, this pseudo-heredity is resolved in a surprising fashion. In one of my cases a brother, a sister, and a somewhat older male cousin were all of them ill. From the analysis which I carried out on the brother, I learnt that he was suffering from self-reproaches for being the cause of his sister’s illness. He himself had been seduced by his cousin, and the latter, it was known in the family, had been the victim of his nursemaid.

I cannot say for certain what the upper age-limit is below which sexual injury plays a part in the aetiology of hysteria; but I doubt whether sexual passivity can bring on repression later than between the eighth and tenth years, unless it is enabled to do so by previous experiences. The lower limit extends as far back as memory itself - that is, therefore, to the tender age of one and a half or two years! (I have had two cases of this.) In a number of my cases the sexual trauma (or series of traumas) occurred in the third and fourth years of life. I should not lend credence to these extraordinary findings myself if their complete reliability were not proved by the development of the subsequent neurosis. In every case a number of pathological symptoms, habits and phobias are only to be accounted for by going back to these experiences in childhood, and the logical structure of the neurotic manifestations makes it impossible to reject these faithfully preserved memories which emerge from childhood life. True, it would be useless to try to elicit these childhood traumas from a hysteric by questioning him outside psycho-analysis; their traces are never present in conscious memory, only in the symptoms of the illness.

All the experiences and excitations which, in the period of life after puberty, prepare the way for, or precipitate, the outbreak of hysteria, demonstrably have their effect only because they arouse the memory-trace of these traumas in childhood, which do not thereupon become conscious but lead to a release of affect and to repression. This role of the later traumas tallies well with the fact that they are not subject to the strict conditions which govern the traumas in childhood but that they can vary in their intensity and nature, from actual sexual violation to mere sexual overtures or the witnessing of sexual acts in other people, or receiving information about sexual processes.¹

In my first paper on the neuroses of defence there was no explanation of how the efforts of the subject, who had hitherto been healthy, to forget a traumatic experience of this sort could have the result of actually effecting the intended repression and thus opening the door to the defence neurosis. It could not lie in the nature of the experiences, since other people remained healthy in spite of being exposed to the same precipitating causes. Hysteria, therefore, could not be fully explained from the effect of the trauma: it had to be acknowledged that the susceptibility to a hysterical reaction had already existed before the trauma.

The place of this indefinite hysterical disposition can now be taken, wholly or in part, by the posthumous operation of a sexual trauma in childhood. ’Repression’ of the memory of a distressing sexual experience which occurs in maturer years is only possible for those in whom that experience can activate the memory-trace of a trauma in childhood.

¹ In a paper on the anxiety neurosis, I remarked that ‘anxiety neurosis can be produced in girls who are approaching maturity by their first encounter with the problem of sex.... Such an anxiety neurosis is combined with hysteria in an almost typical fashion.’ I know now that the occasion on which this ‘virginal anxiety’ breaks out in young girls does not actually represent their first encounter with sexuality, but that an experience of sexual passivity had previously occurred in their childhood, the memory of which is aroused by this ‘first encounter’.

² A psychological theory of repression ought also to throw light on the question of why it is only ideas with a sexual content that can be repressed. Such an explanation might start out from the following indications. It is known that having ideas with a sexual content produces excitatory processes in the genitals which are similar to those produced by sexual experience itself. We may assume that this somatic excitation becomes transposed into the psychical sphere. As a rule the effect in question is much stronger in the case of the experience than in the case of the memory. But if the sexual experience occurs during the period of sexual immaturity and the memory of it is aroused during or after maturity, then the memory will have a far stronger excitatory effect than the experience did at the time it happened; and this is because in the meantime puberty has immensely increased the capacity of the sexual apparatus for reaction. An inverted relation of this sort between real experience and memory seems to contain the psychological precondition for the occurrence of a repression. Sexual life affords - through the retardation of pubertal maturity as compared with the psychical functions - the only possibility that occurs for this inversion of relative effectiveness. The traumas of childhood operate in a deferred fashion as though they were fresh experiences; but they do so unconsciously. I must postpone entering into any more far-reaching psychological discussion till another occasion. Let me add, however, that the period of ‘sexual maturity’ which is in question here does not coincide with puberty but falls earlier (from the eighth to the tenth year).

Obsessions similarly presuppose a sexual experience in childhood (though one of a different nature from that found in hysteria). The aetiology of the two neuro-psychoses of defence is related as follows to the aetiology of the two simple neuroses, neurasthenia and anxiety neurosis. Both the latter disorders are direct effects of the sexual noxae themselves, as I have shown in my paper on anxiety neurosis (1895b); both the defence neuroses are indirect consequences of sexual noxae which have occurred before the advent of sexual maturity - are consequences, that is, of the psychical memory-traces of those noxae. The current causes which produce neurasthenia and anxiety neurosis often at the same time play the part of exciting causes of the neuroses of defence; on the other hand, the specific causes of a defence-neurosis - the traumas of childhood - can at the same time lay the foundations for a later development of neurasthenia. Finally, it not infrequently happens, too, that neurasthenia or anxiety neurosis is maintained, not by current sexual noxae, but, instead, solely by the persisting effect of a memory of childhood traumas.¹IITHE NATURE AND MECHANISM OF OBSESSIONAL NEUROSIS

Sexual experiences of early childhood have the same significance in the aetiology of obsessional neurosis as they have in that of hysteria. Here, however, it is no longer a question of sexual passivity, but of acts of aggression carried out with pleasure and of pleasurable participation in sexual acts - that is to say, of sexual activity. This difference in the aetiological circumstances is bound up with the fact that obsessional neurosis shows a visible preference for the male sex.

¹ (Footnote added 1924:) This section is dominated by an error which I have since repeatedly acknowledged and corrected. At that time I was not yet able to distinguish between my patients’ phantasies about their childhood years and their real recollections. As a result, I attributed to the aetiological factor of seduction a significance and universality which it does not possess. When this error had been overcome, it became possible to obtain an insight into the spontaneous manifestations of the sexuality of children which I described in my Three Essays on the Theory of Sexuality (1905d). Nevertheless, we need not reject everything written in the text above. Seduction retains a certain aetiological importance, and even to-day I think some of these psychological comments are to the point.

In all my cases of obsessional neurosis, moreover, I have found a substratum of hysterical symptoms which could be traced back to a scene of sexual passivity that preceded the pleasurable action. I suspect that this coincidence is no fortuitous one, and that precocious sexual aggressivity always implies a previous experience of being seduced. However, I can as yet give no definitive account of the aetiology of obsessional neurosis; I only have an impression that the decision as to whether hysteria or obsessional neurosis will arise on the basis of traumas in childhood depends on chronological circumstances in the development of the libido.

The nature of obsessional neurosis can be expressed in a simple formula. Obsessional ideas are invariably transformed self-reproaches which have re-emerged from repression and which always relate to some sexual act that was performed with pleasure in childhood. In order to elucidate this statement it is necessary to describe the typical course taken by an obsessional neurosis.

In a first period - the period of childhood immorality - the events occur which contain the germ of the later neurosis. First of all, in earliest childhood, we have the experiences of sexual seduction that will later on make repression possible; and then come the acts of sexual aggression against the other sex, which will later appear in the form of acts involving self-reproach.

This period is brought to a close by the advent of sexual ‘maturation’, often itself unduly early. A self-reproach now be comes attached to the memory of these pleasurable actions; and the connection with the initial experience of passivity makes it possible - often only after conscious and remembered efforts - to repress them and to replace them by a primary symptom of defence. Conscientiousness, shame and self-distrust are symptoms of this kind, with which the third period begins - the period of apparent health, but actually, of successful defence.

The next period, that of the illness, is characterized by return of the repressed memories - that is, therefore, by the failure of the defence. It is not certain whether the awakening of those memories occurs more often accidentally and spontaneously or as a result of current sexual disturbances, as a kind of by-product of them. The re-activated memories, however, and the self reproaches formed from them never re-emerge into consciousness unchanged: what become conscious as obsessional ideas and affects, and take the place of the pathogenic memories so far as conscious life is concerned, are structures in the nature of a compromise between the repressed ideas and the repressing ones.

In order to describe clearly and with probable accuracy the processes of repression, the return of the repressed and the formation of pathological compromise-ideas, one would have to make up one’s mind to quite definite assumptions about the substratum of psychical events and of consciousness. So long as one seeks to avoid this, one must be content with the following remarks which are intended more or less figuratively. There are two forms of obsessional neurosis, according to whether what forces an entrance into consciousness is solely the mnemic content of the act involving self-reproach, or whether the self-reproachful affect connected with the act does so as well.

The first form includes the typical obsessional ideas, in which the content engages the patient’s attention and, as an affect, he merely feels an indefinite unpleasure, whereas the only affect which would be suitable to the obsessional idea would be one of self-reproach. The content of the obsessional idea is distorted in two ways in relation to the obsessional act of childhood. First, something contemporary is put in the place of something past; and secondly, something sexual is replaced by something analogous to it that is not sexual. These two alterations are the effect of the inclination to repress, still in force, which we will ascribe to the ‘ego’. The influence of the re-activated pathogenic memory is shown by the fact that the content of the obsessional idea is still in part identical with what has been repressed or follows from it by a logical train of thought. If, with the help of the psycho-analytic method, we reconstruct the origin of an individual obsessional idea, we find that from a single current impression two different trains of thought have been set going. The one which has passed by way of the repressed memory proves to be as correctly logical in its structure as the other, although it is incapable of being conscious and insusceptible to correction. If the products of the two psychical operations do not tally, what takes place is not some sort of logical adjustment of the contradiction between them; instead, alongside of the normal intellectual outcome, there comes into consciousness, as a compromise between the resistance and the pathological intellectual product, an obsessional idea which appears absurd. If the two trains of thought lead to the same conclusion, they reinforce each other, so that an intellectual product that has been arrived at normally now behaves, psychologically, like an obsessional idea. Wherever a neurotic obsession emerges in the psychological sphere, it comes from repression. Obsessional ideas have, as it were, a compulsive psychical currency, not on account of their intrinsic value, but on account of the source from which they derive or which has added a contribution to their value.

A second form of obsessional neurosis comes about if what has forced its way to representation in conscious psychical life is not the repressed mnemic content but the likewise repressed self-reproach. The affect of self-reproach can, by means of some mental addition, be transformed into any other unpleasurable affect. When this has happened there is no longer anything to prevent the substituted affect from becoming conscious. Thus self-reproach (for having carried out the sexual act in childhood) can easily turn into shame (in case some one else should find out about it), into hypochondriacal anxiety (fear of the physical injuries resulting from the act involving the self-reproach), into social anxiety (fear of being punished by society for the misdeed), into religious anxiety, into delusions of being noticed (fear of betraying the act to other people), or into fear of temptation (a justified mistrust of one’s own moral powers of resistance), and so on. In addition, the mnemic content of the act involving self-reproach may be represented in consciousness as well, or it may remain completely in the background - which makes diagnosis much more difficult. Many cases which, on a superficial examination, seem to be common (neurasthenic) hypochondria, belong to this group of obsessional affects; what is known as ‘periodic neurasthenia’ or ‘periodic melancholia’ seems in particular to resolve itself with unexpected frequency into obsessional affects and obsessional ideas - a discovery which is not a matter of indifference therapeutically.

Besides these compromise symptoms, which signify the return of the repressed and consequently a collapse of the defence that had been originally achieved, the obsessional neurosis constructs a set of further symptoms, whose origin is quite different. For the ego seeks to fend off the derivatives of the initially repressed memory, and in this defensive struggle it creates symptoms which might be classed together as ‘

secondary defence’. These are all of them ‘protective measures’, which have already done good service in the fight against obsessional ideas and obsessional affects. If these aids in the defensive struggle genuinely succeed in once more repressing the symptoms of the return which have forced themselves on the ego, then the obsession is transferred to the protective measures themselves and creates a third form of ‘obsessional neurosis’- obsessional actions. These actions are never primary; they never contain anything but a defence - never an aggression. A psychical analysis of them shows that, in spite of their peculiarity, they can always be fully explained by being traced back to the obsessional memories which they are fighting against.¹

¹ To take a single example only. An eleven-year-old boy had in an obsessional way instituted the following ceremonial before going to bed. He did not go to sleep until he had told his mother in the minutest detail all the experiences he had had during the day; there must be no bits of paper or other rubbish on the carpet in his bedroom in the evening; his bed had to be pushed right up against the wall, three chairs had to be placed in front of it, and the pillows had to lie in a particular way. In order to go to sleep he was obliged first to kick both his legs out a certain number of times and then lie on his side. This was explained in the following manner. Years before, a servant-girl who put the nice looking boy to bed had taken the opportunity of lying down on him and abusing him sexually. When, later on, this memory was aroused in him by a recent experience, it manifested itself in his consciousness in a compulsion to perform the ceremonial I have described above. The meaning of the ceremonial was easy to guess and was established point by point by psycho-analysis. The chairs were placed in front of the bed and the bed pushed against the wall in order that nobody else should be able to get at the bed; the pillows were arranged in a particular way so that they should be differently arranged from how they were on that evening; the movements with his legs were to kick away the person who was lying on him; sleeping on his side was because in the scene he had been lying on his back; his circumstantial confession to his mother was because, in obedience to a prohibition by his seductress, he had been silent to his mother about this and other sexual experiences; and, finally, the reason for his keeping his bedroom floor clean was that neglect to do so had been the chief reproach that he had so far had to hear from his mother.

Secondary defence against the obsessional ideas may be effected by a forcible diversion on to other thoughts with a content as contrary as possible. This is why obsessional brooding, if it succeeds, regularly deals with abstract and suprasensual things; because the ideas that have been repressed are always concerned with sensuality. Or else the patient tries to make himself master of each of his obsessional ideas singly by logical work and by having recourse to his conscious memories. This leads to obsessional thinking, to a compulsion to test things and to doubting mania. The advantage which perception has over memory in such tests at first causes the patient, and later compels him, to collect and store up all the objects with which he has come into contact. Secondary defence against obsessional affects leads to a still wider set of protective measures which are capable of being transformed into obsessional acts. These may be grouped according to their purpose: penitential measures (burdensome ceremonials, the observation of numbers), precautionary measures (all sorts of phobias, superstition, pedantry, increase of the primary symptom of conscientiousness); measures to do with fear of betrayal (collecting scraps of paper, seclusiveness), or to ensure numbing (dipsomania). Among these obsessional acts and obsessional impulses, phobias, since they circumscribe the patient’s existence, play the greatest part.

There are cases in which one can observe how the obsession is transferred from the idea or from the affect on to the protective measure; others in which the obsession oscillates periodically between the symptom of the return of the repressed and the symptom of the secondary defence; and yet other cases in which no obsessional idea is constructed at all, but, instead, the repressed memory is at once represented by what is apparently a primary measure of defence. Here we reach at one bound the stage which elsewhere only completes the course run by the obsessional neurosis after the defensive struggle has taken place. Severe cases of this disorder end in the ceremonial actions becoming fixated, or in a general state of doubting mania, or in a life of eccentricity conditioned by phobias.

The fact that the obsessional ideas and everything derived from them meet with no belief is no doubt because at their first repression the defensive symptom of conscientiousness has been formed and that that symptom, too, acquires an obsessional force. The subject’s certainty of having lived a moral life throughout the whole period of his successful defence makes it impossible for him to believe the self-reproach which his obsessional idea involves. Only transitorily, too, on the appearance of a new obsessional idea and occasionally in melancholic states of exhaustion of the ego, do the pathological symptoms of the return of the repressed compel belief. The ‘obsessional’ character of the psychical formations which I have described here has quite generally nothing to do with attaching belief to them. Nor is it to be confused with the factor which is described as the ‘strength’ or ‘intensity’ of an idea. Its essence is rather indissolubility by psychical activity that is capable of being conscious; and this attribute undergoes no change, whether the idea to which the obsession attaches is stronger or weaker, or less or more intensely ‘illuminated’, or ‘cathected with energy’ and so on.

The cause of this invulnerability of the obsessional idea and its derivatives is, however, nothing more than its connection with the repressed memory from early childhood. For if we can succeed in making that connection conscious - and psychotherapeutic methods already appear able to do so - the obsession, too, is resolved.

III ANALYSIS OF A CASE OF CHRONIC PARANOIA ¹

For a considerable time I have harboured a suspicion that paranoia, too - or classes of cases which fall under the heading of paranoia - is a psychosis of defence; that is to say, that, like hysteria and obsessions, it proceeds from the repression of distressing memories and that its symptoms are determined in their form by the content of what has been repressed. Paranoia must, however, have a special method or mechanism of repression which is peculiar to it, in the same way as hysteria effects repression by the method of conversion into somatic innervation, and obsessional neurosis by the method of substitution (viz. by displacement along the lines of certain categories of associations). I had observed several cases which favoured this interpretation, but had found none which proved it; until, a few months ago, I had an opportunity, through the kindness of Dr. Josef Breuer, of undertaking the psycho-analysis for therapeutic purposes of an intelligent woman of thirty-two, in whose case a diagnosis of chronic paranoia could not be questioned. I am reporting in these pages, without waiting further, some of the information I have been able to obtain from this piece of work, because I have no prospect of studying paranoia except in very isolated instances, and because I think it possible that my remarks may encourage a psychiatrist better placed than I am in this matter to give its rightful place to the factor of ‘defence’ in the discussion as to the nature and psychical mechanism of paranoia which is being carried on so actively just now. I have, of course, on the strength of the following single observation, no intention of saying more than: ‘This case is a psychosis of defence and there are most probably others in the class of "paranoia" which are equally so.’

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