Further remarks on the neuro-psychoses of defence 6 страница

XXIX

‘The neuro-psychoses of defence: an attempt at a psychological theory of acquired hysteria, of many phobias and obsessions and of certain hallucinatory psychoses.’

The first of a series of short papers which now follow and which are directed to the task of preparing a general exposition of the neuroses on a new basis which is now in hand.

The splitting of consciousness in hysteria is not a primary characteristic of this neurosis, based on degenerative weakness, as Janet insists. It is the consequence of a peculiar psychical process known as ‘defence’ which is shown by some short reports of analyses to be present not only in hysteria but in numerous other neuroses and psychoses. Defence comes into operation when an instance of incompatibility arises in ideational life between a particular idea and the ‘ego’. The process of may be figuratively represented as though the quota of excitation were torn away from the idea that is to be repressed and put to some other use.. This can occur in a variety of ways: in hysteria the liberated sum of excitation is transformed into somatic innervation (conversion hysteria); in obsessional neurosis it remains in the psychical field and attaches itself to other ideas which are not incompatible in themselves and which are thus substitutes for the repressed idea. The source of the incompatible ideas which are subjected to defence is solely and exclusively sexual life. An analysis of a case of hallucinatory psychosis shows that this psychosis too represents a method of achieving defence.

XXX

‘Obsessions and phobias: their psychical mechanism and aetiology.’

Obsessions and phobias are to be distinguished from neurasthenia as independent neurotic affections. In both it is a question of the linkage between an idea and an affective state. In phobias the latter is always the same, namely anxiety; in true obsessions it can be of various kinds (self-reproach, sense of guilt, doubt, etc.). The affective state emerges as the essential element of the obsession, since it remains unaltered in the individual case, whereas the idea attached to it is changed. Psychical analysis shows that the affect of the obsession is justified in every instance, but that the idea attached to it represents a substitute for an idea derived from sexual life which is more appropriate to the affect and which has succumbed to repression. This state of affairs is illustrated by numerous short analyses of cases of folie du doute, washing mania, arithmomania, etc., in which the reinstatement of the repressed idea was successful and accompanied by useful therapeutic effects. The phobias in the strict sense are reserved for the paper on anxiety neurosis (No. XXXII).

XXXI

Studies on Hysteria.

(In collaboration with Dr. J. Breuer.)

This volume contains the carrying-through of the subject raised in the ‘Preliminary Communication’ (No. XXIV) dealing with the psychical mechanism of hysterical phenomena. Although it proceeds from the joint work of the two authors, it is divided into separate sections, of which four detailed case histories together with discussions and an attempt at a ‘Psychotherapy of Hysteria’ represent my share. The aetiological part played by the sexual factor is stressed with greater emphasis in this book than in the ‘Preliminary Communication’, and the concept of ‘conversion’ is used to throw light on the formation of hysterical symptoms. The essay on psychotherapy seeks to give some insight into the technique of the psycho-analytic procedure, which is alone able to lead to the investigation of the unconscious content of the mind, and the employment of which may also be expected to lead to important psychological discoveries.XXXII

‘On the grounds for detaching a particular syndrome from neurasthenia under the description "anxiety neurosis".’

The concurrence of a constant grouping of symptoms with a particular aetiological determinant makes it possible to pick out from the composite province of ‘neurasthenia’ a syndrome which deserves the name of ‘anxiety neurosis’, because all of its constituents arise from the symptoms of anxiety. These are either to be regarded as immediate manifestations of anxiety or as rudiments and equivalents of them (E. Hecker), and they are often in complete opposition to the symptoms which constitute neurasthenia proper. The aetiology of the two neuroses also points to an opposition of this kind. Whereas true neurasthenia arises from spontaneous emissions or is acquired through masturbation, the factors belonging to the aetiology of anxiety neurosis are such as correspond to a holding back of sexual excitation - such as abstinence when libido is present, unconsummated excitation and, above all, coitus interruptus. In actual life the neuroses here distinguished usually appear in combination, though pure cases can also be demonstrated. When a mixed neurosis of this kind is subjected to analysis, it is possible to indicate a mixture of several specific aetiologies.

An attempt to arrive at a theory of anxiety neurosis leads to a formula to the effect that its mechanism lies in the deflection of somatic sexual excitation from the psychical field and a consequent abnormal employment of that excitation. Neurotic anxiety is transformed sexual libido.

XXXIII

‘A reply to criticisms of my paper on anxiety neurosis.’

A reply to objections made by Löwenfeld to the content of No. XXXII. The problem of the aetiology of the pathology of the neuroses is dealt with here, to justify the division into three categories of the aetiological factors that appear: (a) preconditions, (b) specific causes and (c) concurrent or auxiliary causes. What are called preconditions are the factors which, though they are indispensable for producing the effect, cannot by themselves produce it but need in addition the specific causes. The specific causes are distinguished from the preconditions by the fact that they figure in only a few aetiological formulas, while the preconditions play the same part in numerous affections. Auxiliary causes are such as neither need invariably be present nor are able by themselves to produce the effect in question. - In the case of neuroses it is possible that the precondition may be heredity; the specific cause lies in sexual factors; everything else that is brought up apart from these as forming the aetiology of the neuroses (overwork, emotion, physical illness) is an auxiliary cause and can never entirely take the place of the specific factor, though it can no doubt serve as a substitute for it in the matter of quantity. The form of a neurosis depends on the nature of the specific sexual cause; whether there shall be a neurotic illness at all is determined by factors operating quantitatively; heredity works like a multiplier inserted in an electric circuit.XXXIV

‘On Bernhardt’s disturbance of sensibility in the thigh.’

A self-observation of this harmless affection, which is probably traceable to local neuritis; and a report of some other cases, including bilateral ones.

XXXV

‘Further remarks on the neuro-psychoses of defence.’

(1) The specific aetiology of hysteria. A continuation of psycho-analytic work with hysterical subjects has had the uniform result of showing that the suspected traumatic events (as mnemic symbols of which hysterical symptoms persist) occur in the patients’ earliest childhood and are to be described as sexual abuses in the narrowest sense.

(2) The nature and mechanism of obsessional neurosis. 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. The course taken by this return of the repressed is traced, as are the results of a primary and secondary work of defence.

(3) Analysis of a case of chronic paranoia. This analysis, which is reported in detail, indicates that the aetiology of paranoia is to be found in the same sexual experiences of early childhood in which the aetiology of hysteria and of obsessional neurosis has already been discovered. The symptoms of this case of paranoia are traced in detail to the activities of defence.

XXXVI

‘The aetiology of hysteria.’

More detailed reports of the infantile sexual experiences which have been shown to constitute the aetiology of the psychoneuroses. In their content these experiences must be described as ‘perversions’, and those responsible are as a rule to be looked for among the patient’s nearest relatives. A discussion of the difficulties which have to be surmounted in uncovering these repressed memories and of the objections that may be raised against the results thus arrived at. Hysterical symptoms are shown to be derivatives of memories operating unconsciously; they appear only in collaboration with such memories. The presence of infantile sexual experiences is an indispensable condition if the efforts of defence (which occur in normal people as well) are to result in producing pathogenic effects - that is to say, neuroses.

XXXVII

‘Heredity and the aetiology of the neuroses.’

The findings hitherto arrived at by psycho-analysis on the aetiology of the neuroses are here employed to criticize the current theories of the omnipotence of heredity in neuropathology. The part played by heredity has been overestimated in several directions. Firstly, by including among the inheritable neuropathic illnesses conditions such as headaches, neuralgias, etc., which are very probably attributable as a rule to organic affections of the cranial cavities (the nose). Secondly, by regarding every discoverable nervous ailment among relatives as evidence of hereditary taint and by thus from the first leaving no room for acquired neuropathic illnesses which can possess no similar evidential weight. Thirdly, the aetiological role of syphilis has been misunderstood and the nervous ailments deriving from it have been put down to the account of heredity. But in addition, a general objection is permissible against a form of heredity which is described as ‘dissimilar inheritance’ (or inheritance with a change in the form of the illness), and to which a far more important part is allotted than to ‘similar’ inheritance. But when the fact of hereditary taint in a family is demonstrated in its members being affected alternatively by every sort of nervous complaint - chorea, epilepsy, hysteria, apoplexy, etc. - without any more precise determinants, then either we need a knowledge of the laws according to which these complaints replace one another or else room is left for the individual aetiologies which determine precisely the choice of the neuropathic state which in fact results from them. If such particular aetiologies exist, they are the specific causes, so much sought after, of the various different clinical forms, and heredity is pushed back into the role of a requirement or precondition.

XXXVIII

Infantile Cerebral Palsies.

This is a summary of the two works on the same theme published in 1891 and 1893, together with the additions and alterations which have since become necessary. These affect the chapter on poliomyelitis acuta, which has meantime been recognized as a non-systematic disease, on encephalitis as an initial process of spastic hemiplegia, and on the interpretation of cases of paraplegic spasticity, the cerebral nature of which affection may recently have been placed in doubt. A special discussion is concerned with the attempts to split up the content of the cerebral diplegias into several clearly divided clinical entities, or at least to separate what is known as ‘Little’s disease’ as a clinical individual from among the medley of forms of similar affections. The difficulties which meet such attempts are pointed out, and it is maintained as the only justifiable view that ‘infantile cerebral palsy’ shall be retained at present as a collective clinical concept for a whole number of similar affections with an exogenous aetiology. The rapid increase in observations of familial and hereditary nervous disorders of children, which resemble infantile cerebral palsies clinically at many points, has made it a pressing matter to collect these new forms and to attempt to draw a fundamental distinction between them and infantile cerebral palsies.

APPENDIXA. Works written under my influence.

E. Rosenthal, Contribution à létude des diplégies cérérebrales de l’enfance. Thèse de Lyon. (Médaille d’argent.) (1892.)

L. Rosenberg, Casuistische Beiträge zur Kenntnis der cerebralen Kinderlähmungen und der Epilepsie. (No. IV, New Series, of Beiträge zur Kinderheilkunde, edited by

Kassowitz.) (1893.)

B. Translations from the French.

J.-M Charcot, Neue Vorlesungen über die Krankheiten des Nervensystems, insbesondere über Hysterie. (Toeplitz & Deuticke, Vienna.)

H Bernheim, Die Suggestion und ihre Heilwirkung. (Fr. Deuticke, Vienna.) (Second Edition, 1896.)

H Bernheim, Neue Studien über Hypnotismus, Suggestion und Psychotherapie. (Fr. Deuticke, Vienna.)

J.-M Charcot, Poliklinische Vortrage. Vol. I. (Leçons du Mardi.)

With notes by the translator. (Fr. Deuticke, Vienna.)

SEXUALITY IN THE AETIOLOGY OF THE NEUROSES (1898)

Exhaustive researches during the last few years have led me to recognize that the most immediate and, for practical purposes, the most significant causes of every case of neurotic illness are to be found in factors arising from sexual life. This theory is not entirely new. A certain amount of importance has been allowed to sexual factors in the aetiology of the neuroses from time immemorial and by every writer on the subject. In certain marginal regions of medicine a cure for ‘sexual complaints’ and for ‘nervous weakness’ has always been promised in the same breath. When once the validity of the theory ceases to be denied, therefore, it will not be hard to dispute its originality.

In a few short papers which have appeared during the last years in the Neurologisches Zentralblatt, the Revue Neurolgique and the Wiener klinische Rundschau, I have tried to give an indication of the material and the points of view which offer scientific support for the theory of the ‘sexual aetiology of the neuroses’. A full presentation is, however, still wanting, mainly because, in endeavouring to throw light on what is recognized as the actual state of affairs, we come upon ever fresh problems for the solution of which the necessary preliminary work has not been done. It does not seem to me at all premature, however, to attempt to direct the attention of medical practitioners to what I believe to be the facts so that they may convince themselves of the truth of my assertions and at the same time of the benefits they may derive in their practice from a knowledge of them.

I am aware that efforts will be made, by the use of arguments with an ethical colouring, to prevent the physician from pursuing the matter further. Anyone who wants to make certain whether or not his patients’ neuroses are really connected with their sexual life cannot avoid asking them about their sexual life and insisting upon receiving a true account of it. But in this, it is asserted, lies the danger both for the individual and society. A doctor, I hear it being said, has no right to intrude upon his patients’ sexual secrets and grossly injure their modesty (especially with women patients) by an interrogation of this sort. His clumsy hand can only ruin family happiness, offend the innocence of young people and encroach upon the authority of parents; and where adults are concerned he will come to share uncomfortable knowledge and destroy his own relations to his patients. It is therefore his ethical duty, the conclusion is, to keep away from the whole business of sex.

To this one may well reply that it is the expression of a prudery which is unworthy of a physician and which inadequately conceals its weakness behind bad arguments. If factors arising out of sexual life must really be acknowledged to be causes of illness, then, for that very reason, investigation and discussion of them automatically falls within the sphere of a physician’s duty. The injury to modesty of which he is guilty in this is no different and no worse, one would imagine, than when he insists on examining a woman’s genital organs in order to cure a local affection - a demand on which he is pledged to insist by his medical training itself. Even now one often hears elderly women who have spent their youth in the provinces tell of how at one time they were reduced to a state of exhaustion by excessive genital haemorrhages, because they could not make up their minds to allow a doctor to see their nakedness. The educative influence which has been exercised on the public by the medical world has, in the course of one generation, so altered things that an objection of this sort is an extremely rare occurrence among the young women of to-day. If it were to occur, it would be condemned as unreasonable prudery, as modesty in the wrong place. Are we living in Turkey, a husband would ask, where all that a sick woman may show to the physician is her arm through a hole in the wall?

It is not true that interrogation of his patients and knowledge about their sexual concerns give the physician a dangerous degree of power over them. It was possible in earlier times for the same objection to be made against the uses of anaesthetics, which deprive the patient of his consciousness and of the exercise of his will and leave it to the doctor to decide whether and when he shall regain them. And yet to-day anaesthetics have become indispensable to us because they are able, better than anything else, to assist the doctor in his medical work; and among his many other serious obligations, he has taken over the responsibility for their use.

A doctor can always do harm if he is unskilful or unscrupulous, and this is no more and no less true where it is a question of investigating his patients’ sexual life than it is in other things. Naturally, if someone, after an honest self-examination, feels that he does not possess the tact, seriousness and discretion which are necessary for questioning neurotic patients, and if he is aware that revelations of a sexual character would provoke lascivious thrills in him rather than scientific interest, then he will be right to avoid the topic of the aetiology of the neuroses. All we ask, in addition, is that he should also refrain from treating nervous patients.

Nor is it true that patients put insuperable obstacles in the way of an investigation into their sexual life. After some slight hesitation, adults usually adjust themselves to the situation by saying: ‘After all, I’m at the doctor’s; I can say anything to him.’ A great many women who find it difficult enough to go through life concealing their sexual feelings, are relieved to find that with the doctor no other consideration outweighs that of their recovery, and they are grateful to him that for once they are allowed to behave quite humanly about sexual things. A dim knowledge of the overwhelming importance of sexual factors in the production of neuroses (a knowledge which I am trying to capture afresh for science) seems never to have been lost in the consciousness of laymen. How often do we witness scenes like this: A married couple, one of whom is suffering from a neurosis, comes to us for consultation. After we have made a great many introductory remarks and apologies to the effect that no conventional barriers should exist between them and the doctor who wants to be of use in such cases, and so on, we tell them that we suspect that the cause of the illness lies in the unnatural and detrimental form of sexual intercourse which they must have chosen since the wife’s last confinement. We tell them that doctors do not as a rule concern themselves with such matters, but that that is reprehensible of them, even though the patients do not want to be told about things like that, etc. Thereupon one of the couple nudges the other and says: ‘You see! I told you all along it would make me ill.’ And the other answers: ‘Well, I know, I thought so too; but what is one to do?’

In certain other circumstances, such as when one is dealing with young girls, who, after all, are systematically brought up to conceal their sexual life, one will have to be content with a very small measure of sincere response on the part of the patient. But an important consideration comes into play here namely that a doctor who is experienced in these things does not meet his patients unprepared and as a rule does not have to ask them for information but only for a confirmation of his surmises. Anyone who will follow my indications as to how to elucidate the morphology of the neuroses and translate it into aetiological terms, will need the addition of very few further admissions from his patients; in the very description of their symptoms, which they are only too ready to give, they have usually acquainted him at the same time with the sexual factors that are hidden behind.

It would be a great advantage if sick people had a better knowledge of the certainty with which a doctor is now in a position to interpret their neurotic complaints and to infer from them their operative sexual aetiology. It would undoubtedly spur such people on to abandon their secretiveness from the moment they have made up their minds to seek help for their sufferings. Moreover, it is in the interest of all of us that a higher degree of honesty about sexual things should become a duty among men and women than has hitherto been expected of them. This cannot be anything but a gain for sexual morality. In matters of sexuality we are at present, every one of us, ill or well, nothing but hypocrites. It will be all to our good if, as a result of such general honesty, a certain amount of toleration in sexual concerns should be attained.

Doctors usually take very little interest in a good many of the questions which are discussed among neuropathologists in connection with the neuroses: whether, for instance, one is justified in making a strict differentiation between hysteria and neurasthenia, whether one may distinguish hystero-neurasthenia alongside of them, whether obsessions should be classed with neurasthenia or recognized as a separate neurosis, and so on. And, indeed, such distinctions may well be a matter of indifference to a practitioner, so long as no further consequences follow from the decisions arrived at - no deeper insight and no pointers for therapeutic treatment - and so long as the patient will in every instance be sent off to a hydropathic establishment, and be told that there is nothing the matter with him. But it will be a different thing if our point of view about the causative relations between sexuality and the neuroses is adopted. Fresh interest is then aroused in the symptomatology of the different neurotic cases, and it becomes of practical importance that one should be able correctly to break down the complicated picture into its components and correctly to name them. For the morphology of the neuroses can with little difficulty be translated into aetiology and a knowledge of the latter leads on quite naturally to new indications for methods of cure.

Now the important decision we have to make - and this can be done with certainty in every instance if the symptoms are carefully assessed - is whether the case bears the characteristics of neurasthenia or of a psychoneurosis (hysteria, obsessions).(Mixed cases in which signs of neurasthenia are combined with signs of a psychoneurosis are of very frequent occurrence; but we will leave consideration of them till later.) It is only in neurasthenias that questioning the patient succeeds in disclosing the aetiological factors in his sexual life. These factors are, of course, known to him and belong to the present time, or, more properly, to the period of his life since sexual maturity (though this delimitation does not cover every case). In psychoneuroses questioning of this kind has little result. It may perhaps give us a knowledge of the factors which have to be recognized as precipitating ones, and these may or may not be connected with sexual life. If they are, they show themselves to be no different in kind from the aetiological factors of neurasthenia; that is, they entirely lack any specific relation to the causation of the psychoneurosis. And yet, in every instance, the aetiology of the psychoneuroses, too, lies in the field of sexuality. By a curious circuitous path, of which I shall speak later, it is possible to arrive at a knowledge of this aetiology and to understand why the patient was unable to tell us anything about it. For the events and influences which lie at the root of every psychoneurosis, belong, not to the present day, but to an epoch of life which is long past and which is, as it were, a prehistoric one-to the time of early childhood; and that is why the patient, too, knows nothing of them. He has - though only in a particular sense - forgotten them.

Thus, in every case of neurosis there is a sexual aetiology; but in neurasthenia it is an aetiology of a present-day kind, whereas in the psychoneuroses the factors are of an infantile nature. This is the first great contrast in the aetiology of the neuroses. 1 A second one emerges when we take account of a difference in the symptomatology of neurasthenia itself. Here, on the one hand, we find cases in which certain complaints characteristic of neurasthenia (intracranial pressure, proneness to fatigue, dyspepsia, constipation, spinal irritation, etc.) are prominent; in other cases these signs play a minor part and the clinical picture is composed of other symptoms, all of which exhibit a relation to the nuclear symptom, that of anxiety (free anxiousness, unrest, expectant anxiety, complete, rudimentary or supplementary anxiety attacks, locomotor vertigo, agoraphobia, insomnia, increased sensitivity to pain, and so on). I have left the name of neurasthenia to the first type, but have distinguished the second type as ‘anxiety neurosis’; and I have given reasons for this separation in another place, where I have also taken account of the fact that as a rule both neuroses appear together. For the present purpose it is enough to emphasize that parallel to the difference in the symptoms of these two forms of illness there goes a difference in their aetiology. Neurasthenia can always be traced back to a condition of the nervous system such as is acquired by excessive masturbation or arises spontaneously from frequent emissions; anxiety neurosis regularly discloses sexual influences which have in common the factor of reservation or of incomplete satisfaction - such as coitus interruptus, abstinence together with a lively libido, so-called unconsummated excitation, and so on. In my short paper intended to introduce anxiety neurosis I put forward the formula that anxiety is always libido which has been deflected from its employment.

Where there is a case in which symptoms of neurasthenia and of anxiety neurosis are combined - where, that is, we have a mixed case - we have only to keep to our proposition, empirically arrived at, that a mingling of neuroses implies the collaboration of several aetiological factors, and we shall find our expectation confirmed in every instance. How often these aetiological factors are linked with one another organically, through the interplay of sexual processes - for instance, coitus interruptus or insufficient potency in the man, going along with masturbation - would well deserve separate discussion.

Having diagnosed a case of neurasthenic neurosis with certainty and having classified its symptoms correctly, we are in a position to translate the symptomatology into aetiology; and we may then boldly demand confirmation of our suspicions from the patient. We must not be led astray by initial denials. If we keep firmly to what we have inferred, we shall in the end conquer every resistance by emphasizing the unshakeable nature of our convictions. In this way we learn all sorts of things about the sexual life of men and women, which might well fill a useful and instructive volume; and we learn, too, to regret from every point of view that sexual science is even to-day still regarded as disreputable. Since minor deviations from a normal vita sexualis are much too common for us to attach any value to their discovery, we shall only allow a serious and long continued abnormality in the sexual life of a neurotic patient to carry weight as an explanation. Moreover, the idea that one might, by one’s insistence, cause a patient who is psychically normal to accuse himself falsely of sexual misdemeanours - such an idea may safely be disregarded as an imaginary danger.

Дата добавления: 2014-12-23