My VIews on the part played by sexuality in the aetiology of the neuroses 1 страница

(1906)

My theory of the aetiological importance of the sexual factor in the neuroses can best be appreciated, in my opinion, by following the history of its development. For I have no desire whatever to deny that it has gone through a process of evolution and been modified in the course of it. My professional colleagues may find a guarantee in this admission that the theory is nothing other than the product of continuous and ever deeper-going experience. What is born of speculation, on the contrary, may easily spring into existence complete and there after remain unchangeable.

Originally my theory related only to the clinical pictures comprised under the term ‘neurasthenia’, among which I was particularly struck by two, which occasionally appear as pure types and which I described as ‘neurasthenia proper’ and ‘anxiety neurosis’. It had, to be sure, always been a matter of common knowledge that sexual factors may play a part in the causation of these forms of illness; but those factors were not regarded as invariably operative, nor was there any idea of giving them precedence over other aetiological influences. I was surprised to begin with at the frequency of gross disturbances in the vita sexualis of nervous patients; the more I set about looking for such disturbances - bearing in mind the fact that everyone hides the truth in matters of sex - and the more skilful I became at pursuing my enquiries in the face of a preliminary denial, the more regularly was I able to discover pathogenic factors in sexual life, till little seemed to stand in the way of my assuming their universal occurrence. It was necessary, however, to presuppose from the start that sexual irregularities occurred with similar frequency in our ordinary society under the pressure of social conditions; and a doubt might remain as to the degree of deviation from normal sexual functioning which should be regarded as pathogenic. I was therefore obliged to attach less importance to the invariable evidence of sexual noxae than to a second discovery which seemed to me less ambiguous. It emerged that the form taken by the illness - neurasthenia or anxiety neurosis - bore a constant relation to the nature of the sexual noxa involved. In typical cases of neurasthenia a history of regular masturbation or persistent emissions was found; in anxiety neurosis factors appeared such as coitus interruptus, ‘unconsummated excitation’, and other conditions - in all of which there seemed to be the common element of an insufficient discharge of the libido that had been produced. It was only after this discovery, which was easy to make and could be confirmed as often as one liked, that I had the courage to claim a preferential position for sexual influences in the aetiology of the neuroses. Furthermore, in the mixed forms of neurasthenia and anxiety neurosis which are so common it was possible to trace a combination of the aetiologies which I had assumed for the two pure forms. Moreover, this twofold form assumed by the neurosis seemed to tally with the polar (i.e. the masculine and feminine) character of sexuality.

At the time at which I was attributing to sexuality this important part in the production of the simple neuroses,¹ I was still faithful to a purely psychological theory in regard to the psychoneuroses - a theory in which the sexual factor was regarded as no more significant than any other emotional source of feeling. On the basis of some observations made by Josef Breuer on a hysterical patient more than ten years earlier, I collaborated with him in a study of the mechanism of the generation of hysterical symptoms, using the method of awakening the patient’s memories in a state of hypnosis; and we reached conclusions which enabled us to bridge the gap between Charcot’s traumatic hysteria and common non-traumatic hysteria (Breuer and Freud, 1895). We were led to the assumption that hysterical symptoms are the permanent results of psychical traumas, the sum of affect attaching to which has, for particular reasons, been prevented from being worked over consciously and has therefore found an abnormal path into somatic innervation. The terms ‘strangulated affect’, ‘conversion’ and ‘abreaction’ cover the distinctive features of this hypothesis.

But in view of the close connections between the psychoneuroses and the simple neuroses, which go so far, indeed, that a differential diagnosis is not always easy for inexperienced observers, it could not be long before the knowledge arrived at in the one field was extended to the other. Moreover, apart from this consideration, a deeper investigation of the psychical mechanism of hysterical symptoms led to the same result. For if the psychical traumas from which the hysterical symptoms were derived were pursued further and further by means of the ‘cathartic’ procedure initiated by Breuer and me, experiences were eventually reached which belonged to the patient’s childhood and related to his sexual life. And this was so, even in cases in which the onset of the illness had been brought about by some commonplace emotion of a non-sexual kind. Unless these sexual traumas of childhood were taken into account it was impossible either to elucidate the symptoms (to understand the way in which they were determined) or to prevent their recurrence. In this way the unique significance of sexual experiences in the aetiology of the psychoneuroses seemed to be established beyond a doubt; and this fact remains to this day one of the corner-stones of my theory.

¹ In my paper on anxiety neurosis (1895b).7

This theory might be expressed by saying that the cause of life-long hysterical neuroses lies in what are in themselves for the most part the trivial sexual experiences of early childhood; and, put in this way, it might no doubt sound strange. But if we take the historical development of the theory into account, and see as its essence the proposition that hysteria is the expression of a particular behaviour of the individual’s sexual function and that this behaviour is decisively determined by the first influences and experiences brought to bear in childhood, we shall be a paradox the poorer but the richer by a motive for turning our attention to something of the highest importance (though it has hitherto been grossly neglected) - the after-effects of the impressions of childhood.

I will postpone until later in this paper a more thorough going discussion of the question whether we are to regard the sexual experiences of childhood as the causes of hysteria (and obsessional neurosis), and I will now return to the form taken by the theory in some of my shorter preliminary publications during the years 1895 and 1896 (Freud, 1896b and 1896c). By laying stress on the supposed aetiological factors it was possible at that time to draw a contrast between the common neuroses as disorders with a contemporary aetiology and psychoneuroses whose aetiology was chiefly to be looked for in the sexual experiences of the remote past. The theory culminated in this thesis: if the vita sexualis is normal, there can be no neurosis.

Though even to-day I do not consider these assertions incorrect, it is not to be wondered at that, in the course of ten years of continuous effort at reaching an understanding of these phenomena, I have made a considerable step forward from the views I then held, and now believe that I am in a position, on the basis of deeper experience, to correct the insufficiencies, the displacements and the misunderstandings under which my theory then laboured. At that time my material was still scanty, and it happened by chance to include a disproportionately large number of cases in which sexual seduction by an adult or by older children played the chief part in the history of the patient’s childhood. I thus over-estimated the frequency of such events (though in other respects they were not open to doubt). Moreover, I was at that period unable to distinguish with certainty between falsifications made by hysterics in their memories of childhood and traces of real events. Since then I have learned to explain a number of phantasies of seduction as attempts at fending off memories of the subject’s own sexual activity (infantile masturbation). When this point had been clarified, the ‘traumatic’ element in the sexual experiences of childhood lost its importance and what was left was the realization that infantile sexual activity (whether spontaneous or provoked) prescribes the direction that will be taken by later sexual life after maturity. The same clarification (which corrected the most important of my early mistakes) also made it necessary to modify my view of the mechanism of hysterical symptoms. They were now no longer to be regarded as direct derivatives of the repressed memories of childhood experiences; but between the symptoms and the childish impressions there were inserted the patient’s phantasies (or imaginary memories), mostly produced during the years of puberty, which on the one side were built up out of and over the childhood memories and on the other side were transformed directly into the symptoms. It was only after the introduction of this element of hysterical phantasies that the texture of the neurosis and its relation to the patient’s life became intelligible; a surprising analogy came to light, too, between these unconscious phantasies of hysterics and the imaginary creations of paranoics which become conscious as delusions.

After I had made this correction, ‘infantile sexual traumas’ were in a sense replaced by the ‘infantilism of sexuality’. A second modification of the original theory lay not far off. Along with the supposed frequency of seduction in childhood, I ceased also to lay exaggerated stress on the accidental influencing of sexuality on to which I had sought to thrust the main responsibility for the causation of the illness, though I had not on that account denied the constitutional and hereditary factors. I had even hoped to solve the problem of choice of neurosis (the decision to which form of psychoneurosis the patient is to fall a victim) by reference to the details of the sexual experiences of childhood. I believed at that time - though with reservations - that a passive attitude in these scenes produced a predisposition to hysteria and, on the other hand, an active one a predisposition to obsessional neurosis. Later on I was obliged to abandon this view entirely, even though some facts demand that in some way or other the supposed correlation between passivity and hysteria and between activity and obsessional neurosis shall be maintained. Accidental influences derived from experience having thus receded into the background, the factors of constitution and heredity necessarily gained the upper hand once more; but there was this difference between my views and those prevailing in other quarters, that on my theory the ‘sexual constitution’ took the place of a ‘general neuropathic disposition’. In my recently published Three Essays on the Theory of Sexuality (1905d) I have tried to give a picture of the variegated nature of this sexual constitution as well as of the composite character of the sexual instinct in general and its derivation from contributory sources from different parts of the organism.

As a further corollary to my modified view of ‘sexual traumas in childhood’, my theory now developed further in a direction which had already been indicated in my publications between 1894 and 1896. At that time, and even before sexuality had been given its rightful place as an aetiological factor, I had maintained that no experience could have a pathogenic effect unless it appeared intolerable to the subject’s ego and gave rise to efforts at defence (Freud, 1894a). It was to this defence that I traced back the split in the psyche (or, as we said in those days, in consciousness) which occurs in hysteria. If the defence was successful, the intolerable experience with its affective consequences was expelled from consciousness and from the ego’s memory. In certain circumstances, however, what had been expelled pursued its activities in what was now an unconscious state, and found its way back into consciousness by means of symptoms and the affects attaching to them, so that the illness corresponded to a failure in defence. This view had the merit of entering into the interplay of the psychical forces and of thus bringing the mental processes in hysteria nearer to normal ones, instead of characterizing the neurosis as nothing more than a mysterious disorder insusceptible to further analysis.

Further information now became available relating to people who had remained normal; and this led to the unexpected finding that the sexual history of their childhood did not necessarily differ in essentials from that of neurotics, and, in particular, that the part played by seduction was the same in both cases. As a consequence, accidental influences receded still further into the background as compared with ‘repression’ (as I now began to say instead of ‘defence’). Thus it was no longer a question of what sexual experiences a particular individual had had in his childhood, but rather of his reaction to those experiences - of whether he had reacted to them by ‘repression’ or not. It could be shown how in the course of development a spontaneous infantile sexual activity was often broken off by an act of repression. Thus a mature neurotic individual was invariably pursued by a certain amount of ‘sexual repression’ from his childhood; this found expression when he was faced by the demands of real life, and the psycho-analyses of hysterics showed that they fell ill as a result of the conflict between their libido and their sexual repression and that their symptoms were in the nature of compromises between the two mental currents.

I could not further elucidate this part of my theory without a detailed discussion of my views on repression. It will be enough here to refer to my Three Essays (1905d), in which I have attempted to throw some light - if only a feeble one - on the somatic processes in which the essential nature of sexuality is to be looked for. I have there shown that the constitutional sexual disposition of children is incomparably more variegated than might have been expected, that it deserves to be described as ‘polymorphously perverse’ and that what is spoken of as the normal behaviour of the sexual function emerges from this disposition after certain of its components have been repressed. By pointing out the infantile elements in sexuality I was able to establish a simple correlation between health, perversion and neurosis. I showed that normality is a result of the repression of certain component instincts and constituents of the infantile disposition and of the subordination of the remaining constituents under the primacy of the genital zones in the service of the reproductive function. I showed that perversions correspond to disturbances of this coalescence owing to the overpowering and compulsive development of certain of the component instincts, while neuroses can be traced back to an excessive repression of the libidinal trends. Since almost all the perverse instincts of the infantile disposition can be recognized as the forces concerned in the formation of symptoms in neuroses, though in a state of repression, I was able to describe neurosis as being the ‘negative’ of perversion.

I think it is worth emphasizing the fact that, whatever modifications my views on the aetiology of the psychoneuroses have passed through, there are two positions which I have never repudiated or abandoned - the importance of sexuality and of infantilism. Apart from this, accidental influences have been replaced by constitutional factors and ‘defence’ in the purely psychological sense has been replaced by organic ‘sexual repression’. The question may, however, be raised of where convincing evidence is to be found in favour of the alleged aetiological importance of sexual factors in the psychoneuroses, in view of the fact that the onset of these illnesses may be observed in response to the most commonplace emotions or even to somatic precipitating causes, and since I have had to abandon a specific aetiology depending on the particular form of the childhood experiences concerned. To such a question I would reply that the psycho-analytic examination of neurotics is the source from which this disputed conviction of mine is derived. If we make use of that irreplaceable method of research, we discover that the patient’s symptoms constitute his sexual activity (whether wholly or in part), which arises from the sources of the normal or perverse component instincts of sexuality. Not only is a large part of the symptomatology of hysteria derived directly from expressions of sexual excitement, not only do a number of erotogenic zones attain the significance of genitals during neuroses owing to an intensification of infantile characteristics, but the most complicated symptoms are themselves revealed as representing, by means of ‘conversion’, phantasies which have a sexual situation as their subject-matter. Anyone who knows how to interpret the language of hysteria will recognize that the neurosis is concerned only with the patient’s repressed sexuality. The sexual function must, however, be understood in its true extent, as it is laid down by disposition in infancy. Wherever some commonplace emotion must be included among the determinants of the onset of the illness, analysis invariably shows that it is the sexual component of the traumatic experience - a component that is never lacking which has produced the pathogenic result.

We have been led on imperceptibly from the question of the causation of the psychoneuroses to the problem of their essential nature. If we are prepared to take into account what has been learnt from psycho-analysis, we can only say that the essence of these illnesses lies in disturbances of the sexual processes, the processes which determine in the organism the formation and utilization of sexual libido. It is scarcely possible to avoid picturing these processes as being in the last resort of a chemical nature; so that in what are termed the ‘actual’ neuroses we may recognize the somatic effects of disturbances of the sexual metabolism, and in the psychoneuroses the psychical effects of those disturbances as well. The similarity of the neuroses to the phenomena of intoxication and abstinence after the use of certain alkaloids, as well as to Graves’ disease and Addison’s disease, is forced upon our notice clinically. And just as these last two illnesses should no longer be described as ‘nervous diseases’, so also the ‘neuroses’ proper, in spite of their name, may soon have to be excluded from that category as well.

Accordingly, the aetiology of the neuroses comprises everything which can act in a detrimental manner upon the processes serving the sexual function. In the forefront, then, are to be ranked the noxae which affect the sexual function itself - in so far as these are regarded as injurious by the sexual constitution, varying as it does with different degrees of culture and education. In the next place comes every other kind of noxa and trauma which, by causing general damage to the organism, may lead secondarily to injury to its sexual processes. It should not, however, be forgotten that the aetiological problem in the case of the neuroses is at least as complicated as the causative factors of any other illness. A single pathogenic influence is scarcely ever sufficient; in the large majority of cases a number of aetiological factors are required, which support one another and must therefore not be regarded as being in mutual opposition. For this reason a state of neurotic illness cannot be sharply differentiated from health. The onset of the illness is the product of a summation and the necessary total of aetiological determinants can be completed from any direction. To look for the aetiology of the neuroses exclusively in heredity or in the constitution would be just as one-sided as to attribute that aetiology solely to the accidental influences brought to bear upon sexuality in the course of the subject’s life - whereas better insight shows that the essence of these illnesses lies solely in a disturbance of the organism’s sexual processes.

VIENNA, June 1905

PSYCHICAL (OR MENTAL) TREATMENT (1905)

‘Psyche’ is a Greek word which may be translated ‘mind’. Thus ‘psychical treatment’ means ‘mental treatment’. The term might accordingly be supposed to signify ‘treatment of the pathological phenomena of mental life’. This, however, is not its meaning. ‘Psychical treatment’ denotes, rather, treatment taking its start in the mind, treatment (whether of mental or physical disorders) by measures which operate in the first instance and immediately upon the human mind.

Foremost among such measures is the use of words; and words are the essential tool of mental treatment. A layman will no doubt find it hard to understand how pathological disorders of the body and mind can be eliminated by ‘mere’ words. He will feel that he is being asked to believe in magic. And he will not be so very wrong, for the words which we use in our everyday speech are nothing other than watered-down magic. But we shall have to follow a roundabout path in order to explain how science sets about restoring to words a part at least of their former magical power.

It is only comparatively recently, too, that physicians with a scientific training have learnt to appreciate the value of mental treatment. And we can easily see why this was so when we reflect on the evolution of medicine during the last half-century. After a somewhat unfruitful period during which it was dependent on what was known as ‘Natural Philosophy’, it came under the happy influence of the natural sciences and has achieved the greatest advances alike as a science and as an art: it has shown that the organism is built up from microscopically small elements (the cells), it has learnt to understand the physics and chemistry of the various vital processes (functions), it has distinguished the visible and observable modifications which are brought about in the bodily organs by different morbid processes, and has discovered, on the other hand, the signs that reveal the operation of deep-lying morbid processes in the living body; moreover it has identified a great number of the micro-organisms which cause illness and, with the help of its newly acquired knowledge, it has reduced to a quite extraordinary degree the dangers arising from severe surgical operations. All of these advances and discoveries were related to the physical side of man, and it followed, as a result of an incorrect though easily understandable trend of thought, that physicians came to restrict their interest to the physical side of things and were glad to leave the mental field to be dealt with by the philosophers whom they despised.

Modern medicine, it is true, had reason enough for studying the indisputable connection between the body and the mind; but it never ceased to represent mental events as determined by physical ones and dependent on them. Thus stress was laid on the fact that intellectual functioning was conditional upon the presence of a normally developed and sufficiently nourished brain, that any disease of that organ led to disturbances of intellectual functioning, that the introduction of toxic substances into the circulation could produce certain states of mental illness, or - to descend to more trivial matters - that dreams could be modified by stimuli brought to bear upon a sleeper for experimental purposes.

The relation between body and mind (in animals no less than in human beings) is a reciprocal one; but in earlier times the other side of this relation, the effect of the mind upon the body, found little favour in the eyes of physicians. They seemed to be afraid of granting mental life any independence, for fear of that implying an abandonment of the scientific ground on which they stood.

This one-sided attitude of medicine towards the body has undergone a gradual change in the course of the last decade and a half, a change brought about directly by clinical experience. There are a large number of patients, suffering from affections of greater or less severity, whose disorders and complaints make great demands on the skill of their physicians, but in whom no visible or observable signs of a pathological process can be discovered either during their life or after their death, in spite of all the advances in the methods of investigation made by scientific medicine. One group of these patients are distinguished by the copiousness and variety of their symptoms: they are incapable of intellectual work because of headaches or inability to concentrate their attention, their eyes ache when they read, their legs become fatigued when they walk, develop dull pains or go to sleep, their digestion is disturbed by distressing sensations, by eructations or gastric spasms, they cannot defaecate without aperients, they are subject to sleeplessness, and so on. They may suffer from all these disorders simultaneously or in succession, or from only a selection of them; but in every case the illness is evidently the same. Moreover, its signs are often variable and replace one another. A patient who has hitherto been incapacitated by headaches but has had a fairly good digestion may next day enjoy a clear head but may thenceforward be unable to manage most kinds of food. Again, his sufferings may suddenly cease if there is a marked change in the circumstances of his existence. If he is travelling he may feel perfectly well and be able to enjoy the most varied diet without any ill effects, but when he gets home he may once more have to restrict himself to sour milk. In a few cases the disorder - whether it is a pain or a weakness resembling a paralysis - may suddenly pass from one side of the body to the other: it may jump from his right side to the corresponding part of the body on his left side. But in every instance it is to be observed that the symptoms are very clearly influenced by excitement, emotion, worry, etc., and also that they can disappear and give place to perfect health without leaving any traces, even if they have persisted over a long period.

Medical research has at last shown that people of this kind are not to be looked upon as suffering from a disease of the stomach or of the eyes or whatever it may be, but that it must be a question in their case of an illness of the nervous system as a whole. Examination of the brain and nerves of these patients has so far, however, revealed no perceptible changes; and, indeed, some of the features of their symptomatology prohibit any expectation that even more accurate methods of investigation could ever discover changes of a sort that would throw light upon the illness. This condition has been described as ‘nervousness’ (neurasthenia or hysteria) and has been characterized as a merely ‘functional’ disorder of the nervous system.¹ Incidentally, an exhaustive examination of the brain (after the patient’s death) has been equally without results in the case of many more permanent nervous disorders, as well as in illnesses with exclusively mental symptoms, such as what are known as obsessions and delusional insanity.

¹ See Volume II, Part X, Chapter 4 [of the work, Die Gesundheit, in which this paper of Freud’s first appeared.]8

Physicians were thus faced by the problem of investigating the nature and origin of the symptoms shown by these nervous or neurotic patients. In the course of this investigation it was found that in some at least of these patients the signs of their illness originate from nothing other than a change in the action of their minds upon their bodies and that the immediate cause of their disorder is to be looked for in their minds. What may be the remoter causes of the disturbance which affects their minds is another question, with which we need not now concern ourselves. But medical science was here provided with an opportunity for directing its full attention to what had previously been the neglected side of the mutual relation between body and mind.

It is not until we have studied pathological phenomena that we can get an insight into normal ones. Many things which had long been known of the influence of the mind on the body were only now brought into their true perspective. The commonest, everyday example of the mind’s action on the body, and one that is to be observed in everyone, is offered by what is known as the ‘expression of the emotions’. A man’s states of mind are manifested, almost without exception, in the tensions and relaxations of his facial muscles, in the adaptations of his eyes, in the amount of blood in the vessels of his skin, in the modifications in his vocal apparatus and in the movements of his limbs and in particular of his hands. These concomitant physical changes are for the most part of no advantage to the person concerned; on the contrary, they often stand in his way if he wishes to conceal his mental processes from other people. But they serve these other people as trustworthy indications from which his mental processes can be inferred and in which more confidence can be placed than in any simultaneous verbal expressions that may be made deliberately. If we are able to submit anyone to a more accurate examination during certain of his mental activities, we come upon further physical consequences, in the shape of changes in his heart-action, alterations in the distribution of blood in his body, and so on.

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