Selected papers on hysteria and other psychoneuroses · Sigmund Freud
EPICRISIS.
I was not always a psychotherapist but like other neuropathologists I was educated to the use of focal diagnosis and electrical prognosis so that even I myself am struck by the fact that the histories of the diseases which I write read like novels and, as it were, dispense with the serious features of the scientific character. Yet I must console myself with the fact that the nature of the subject is apparently more responsible for this issue than my own predilection. Focal diagnosis and electrical reactions are really not important in the study of hysteria, whereas a detailed discussion of the psychic processes, as one is wont to receive it from the poet, and the application of a few psychological formulæ, allows one to gain an insight into the course of events of hysteria. Such histories should be considered like psychiatrical ones, but they have the advantage over the latter in the fact that they give the intimate connection between the history of the disease and the morbid symptoms, a thing for which we still look in vain in the biographies of other psychoses.
With the description of the treatment I endeavored to interweave the explanations which I gave about the case of Miss Elisabeth v. R. and it will perhaps be superfluous to summarize here the essential features. I have discussed the character of the patient and the features which repeat themselves in so many hysterics, and which we really can not consider as degenerative. I mentioned the talent, the ambition, the moral sensitiveness, the immense yearning for love which found its gratification in the family, the independence of her nature reaching beyond the womanly ideal which manifested itself largely by obstinacy, readiness for fight, and inaccessibility. According to the information of my colleague no hereditary taints could be shown on either side of the family. Her mother, to be sure, suffered for years from some indefinite neurotic depression, but her brothers and sisters, her father and his family belonged to the even-tempered and not to the nervous. There was no serious case of neuropsychosis in the nearest relatives. This nature was acted upon by painful emotions, the foremost of which was the debilitating influence of a long attendance upon her beloved sick father.
That nursing of the sick plays such a significant rôle in the histories of hysterias has its good reasons. A number of effective moments which are found here are quite obvious, namely, the disturbance of the physical health through interrupted sleep, neglect of nourishment, and the reaction of a constantly gnawing worriment on the vegetative functions; but the most important factor, however, is, in my estimation, to be found elsewhere. He whose mind is occupied with the hundred different tasks of nursing which succeed each other continuously for weeks and months, becomes accustomed, on the one hand, to suppress all signs of his own emotions, and on the other, his attention is soon turned away from his own impressions because he has neither the time nor strength to do them justice. Thus the nurse accumulates for himself an over abundance of affective impressions which he barely perceived clearly enough, at any rate they were not weakened by ab-reaction, that is, he creates for himself the material for a retention hysteria. If the patient recovers these impressions naturally become reduced in value, but if he dies and the period of mourning comes during which only that which refers to the deceased seems of value, the impressions waiting for discharge appear in turn, and after a brief pause of exhaustion the hysteria, the germ of which originated during the nursing, bursts forth.
The same subsequent discharge of traumas accumulated during nursing is occasionally encountered where the general impression of the disease does not ensue, and yet the mechanism of hysteria can be noticed. Thus, I know a highly gifted but slightly nervous lady whose whole personality suggests the hysteric though she never became a burden to the doctor and was never obliged to interrupt the exercise of her duties. This lady had nursed three or four of her beloved ones until their death, causing her each time complete physical exhaustion, yet these sad duties never made her ill. However, shortly after the death of the patient she began the work of reproduction, bringing again to her view the scenes of the disease and death. Each day—one might say at her leisure—she went over again every impression, crying and consoling herself. Such adjustment she passed through daily in conjunction with her usual duties, without, however confusing the two activities. Everything passed before her chronologically. Whether the memory work of one day precisely corresponded to a day of the past I am unable to say. I presume that it depended on the leisure which was allowed to her by the current affairs of the household.
Aside from this “subsequent tear” which attached itself to these deaths at short intervals, this lady periodically observed annual anniversaries representing the time of the various catastrophes, and here her vivid visual reproduction and her affective manifestations followed faithfully the date. Thus, for example, I found her in tears, and on sympathetic inquiry as to what occurred that day, she half irritably remarked, “Nothing on that day except that Professor N. was again here and gave us to understand that things were hopeless—at that time I had no time to cry.” She referred to the last illness of her husband who died three years before. It would have been very interesting to know whether she always repeated the same scenes on these recurring anniversaries, or whether as I suppose in the interest of my theory other details presented themselves each time for ab-reaction. I was however, unable to find anything definite about that; the wise and courageous woman was ashamed of the intensity with which those reminiscences acted upon her.[19] I again repeat that this woman was not sick, that subsequent ab-reaction, despite all resemblance, is still not a hysterical process; one may ask why, after one nursing there results a hysteria and after another none. It cannot lie in personal predisposition for the lady that I have in mind showed it very remarkably.
I now return to Miss Elisabeth v. R. While nursing her father there occurred for the first time an hysterical symptom in the form of a pain in a definite location on the right thigh. The mechanism of this symptom is fully explained on an analytical basis. It occurred in a moment during which the ideas of her duties towards her sick father came into conflict with the content of her erotic yearning which she then entertained. Under vivid self reproach she decided in favor of the former and created for herself the hysterical pain. According to the conception explained by the theory of conversion in hysteria, the process could be described as follows: She repressed the erotic idea from her consciousness and changed the sum of the affect into somatic sensations of pain. Whether this first conflict occurred only once, or repeated itself is not clear. The latter is more probable. Quite a similar conflict—of a higher moral significance, and even better demonstrated by the analysis—repeated itself after years and led to the aggravation of the same pain and to its dissemination beyond its original limits.
Again, it was an erotic idea which came into conflict with all her moral conceptions, for her affection for her brother-in-law, both during the life and after the death of her sister, and the thought that she should yearn just for this man, was to her very disagreeable. This analysis gives detailed information about this conflict which represents the pivotal point in the history of her malady. The patient’s affection for her brother-in-law might have begun to germinate long ago, but in favor of its development was the physical exhaustion through the recent nursing, and her moral exhaustion through years of disillusionment which then began to break down her reserve and she confessed to herself the need of the love of a man. During a friendly intercourse continuing for weeks (in the summer resort) this erotic inclination reached its full development simultaneously with the pain. The analysis shows a special psychic condition of the patient at that time, which in connection with her inclination and the pain, seems to afford an understanding of the process in the sense of the conversion theory.
I place reliance on the opinion that the patient’s affection for her brother-in-law, intensive as it was, was not clearly known to her except on certain rare occasions and then only momentarily. If that were not so she would have become conscious of the inconsistency between this fondness and her moral ideas and would have had to endure the same mental agony which I saw her suffer after the analysis. Her reminiscences gave us no information concerning such suffering. These she spared herself and as a result the love itself did not become clear to her. At that time, as well as during the analysis, her love for her brother-in-law existed in the form of a foreign body in her consciousness without entering into any relationship with her other ideation. In reference to this love there existed the peculiar condition of knowing and simultaneously not knowing, it was the condition of the split off psychic group. When we assert that this love was not “clearly known” to her we mean exactly what we say. We do not mean a lower quality or a lesser degree of consciousness, but a separation of the free associative thinking process from the rest of ideation. How does it come about that such an intensively accentuated presentation group should be kept so isolated? As a rule the rôle played by an idea in the association really increases with the sum of its affect.
This question can be answered if we bear in mind two facts which we can make use of as a safeguard: (1) That the hysterical pains originated simultaneously with the formation of these separate psychic groups, (2) that the patient exerted great resistance against the attempt to bring about the association between the separate psychic groups and the rest of the content of consciousness, and when the union was finally effected she perceived excessive psychic pain. Our conception of hysteria brings together these two moments with the fact of the splitting of consciousness, for (2) contains the indication for the motive for the splitting of consciousness while (1) shows the mechanism of the same. The motive was that of defense, it was the striving of the whole ego to agree with this presentation group and the mechanism was that of conversion, that is, instead of psychic pains which she spared herself there appeared physical pains. Thus a transformation occurred through which gain the patient had escaped an unbearable psychic state, though it was at the cost of a psychic anomaly in the form of a splitting of consciousness and a physical suffering, pains, upon which an astasia-abasia was constructed. To be sure I can give no instruction as to how one can bring about such a conversion. It is not apparently done as one intentionally does an arbitrary action, it is a process which is executed in the individual under the impulse of the motive of defense if an adaptation for it exists in his organization or is brought about by temporary modification.
One has the right to attack the theory more closely by asking what it is that is transformed into physical pains. The cautious reply will be something out of which psychic pains could have and should have been formed. If we wish to venture further and attempt a kind of algebraic formulation of the presentation mechanism we may attribute to the presentation complex of this unconsciously remaining love a certain amount of affect and designate the latter quantity as the thing converted. Direct deduction of this conception would be the fact that the “unconscious love” has through such conversion forfeited so much of its intensity that it was reduced to a weak idea. Its existence as a separate psychic group would only be made possible through such weakening. Yet this present case is not suitable to afford us any clearness in this delicate matter. It probably corresponds to an imperfect conversion only. From other cases it seems quite probable that perfect conversions also occur and that in these the unbearable idea actually becomes repressed as only an idea of very little intensity could be repressed. After an associative union has been consummated the patients assure us that since the origin of the hysterical symptoms their unbearable thoughts never occupied their minds.
I have stated above that on certain occasions, though only transitorily, the patient consciously recognized the love for her brother-in-law. Such a moment occurred when for example, at the death bed of her sister the thought flashed through her mind, “Now he is free and I can become his wife.” I must discuss the significance of these moments for the conception of the whole neurosis. However, I think that the assumption of a defense hysteria (abwehr hysterie) includes the requisite that at least one such moment has already occurred. For consciousness does not know in advance when such an unbearable idea will present itself. The unbearable idea which with its appendix is later excluded for the formation of a separate psychic group must have been originally in the mind, otherwise no conflict would have resulted leading to its exclusion.[20] Just such moments should be designated as “traumatic.” It is in them that the conversion takes place which results in the splitting of consciousness and the hysterical symptoms. Everything tends to show that in Miss Elisabeth v. R. there were a number of such moments (the scenes of the walking, morning meditation, bath, and at the bed of her sister) and perhaps new moments of this kind occurred during the treatment. The multiplicity of such traumatic moments is made possible by the fact that an experience similar to the one which at first initiated the unbearable idea, introduces new emotions to the separated psychic groups and thus transitorily abolishes the success of the conversion. The ego is forced to occupy itself with this suddenly enforced and lighted-up idea, and then to restore the former state by means of new conversions. Miss Elisabeth who was in constant relation with her brother-in-law must have been particularly exposed to the appearance of new traumas.
I must now occupy myself with the point which I have designated as a difficulty for the understanding of the afore mentioned history. On the analytical basis I assume that the first conversion took place in the patient while she nursed her father, at the time when her duties as nurse came into conflict with her erotic yearnings, and that this process was the prototype for the later ones which led to the outbreak of the disease in the Alpine watering place. But then we have it from the patient’s statement that at the time of nursing and the period following which I designated as the “first period” she had not suffered at all from the pains and weakness. To be sure, during the illness of her father she was once bedridden for a few days with pains in her legs, but it is doubtful whether this attack already belonged to the hysteria. A causal relation between these first pains and any psychic impressions could not be demonstrated by analysis; it is possible, even probable, that at that time we dealt with a common rheumatic muscular pain. Even if we should assume that this first attack of pain was the result of a hysterical conversion in consequence of the rejection of the erotic thoughts then existing, the fact nevertheless remains that the pains disappeared after a few days so that the patient actually behaved differently than she did during the analysis. During the reproduction of the so called first period all her statements concerning the illness and death of her father, the impressions relating to her first brother-in-law, etc., all these were accompanied by manifestations of pain, while at the time she really experienced these impressions she perceived no pains. Is this not a contradiction tending to considerably diminish the confidence in the explanatory value of such an analysis?
I believe that I can explain the contradiction by assuming that the pains—the product of the conversion—did not originate while the patient experienced the impressions during the first period, but subsequently, that is in the second period when the patient reproduced these impressions in her mind. The conversion did not follow the fresh impressions but the memories of them. I even believe that such a process is not at all unusual in hysteria and regularly participates in creating hysterical symptoms. Nevertheless, as such an assertion does not seem plausible I shall attempt to make it more credible by citing other experiences. It once happened to me during a similar analysis that a new hysterical symptom was formed during the treatment so that I could attempt its removal on the day after its origin. I will describe the essential features of the history of this patient. They are simple but not without interest.
Miss Rosalia H., twenty-three years old, who for a number of years made great effort to educate herself as a singer, complained that her beautiful voice did not obey her in certain notes. There appeared choking and tightening sensations in the throat so that the tones sounded strained, and her teacher could therefore not allow her to appear in public. Although this imperfection affected only her middle notes it could not be explained to be due to a defect of her vocal organs, for at times this disturbance was absent and her teacher was very pleased with her, but at other times the slightest excitement, seemingly without any provocation, evoked the choking sensation, and prevented free expansion of the voice. It was not difficult to recognize in this annoying sensation an hysterical conversion. Whether there really appeared a contracture of certain muscles of the vocal chords I have not verified.[21] In the hypnotic analysis which I undertook with this girl I found out the following concerning her vicissitudes and her ailments occasioned through them. She became an orphan at an early age and was brought up at the house of an aunt who had many children of her own, and she thus shared the life of a most unfortunate family.
The husband of this aunt, seemingly a pathological personality, abused his wife and children in the most brutal manner and especially pained her by his sexual preference for the servant girl in the house. This became even more obnoxious as the children grew older. When the aunt died Rosalia became the protectress of the orphaned children who were harassed by their father. She took her duties seriously, fought through all conflicts and had to exert her greatest efforts to suppress the manifestations of her contempt for her uncle. It was then that the choking sensation in her throat originated. Whenever she was compelled to swallow an affront, whenever she had to remain silent on hearing a provoking accusation she perceived a scratching in her throat, the tightening and failure of her voice, in brief she had all the localized sensations in her larynx and pharynx which now disturbed her in singing. It was conceivable that she sought the possibility of making herself independent in order to escape the excitement and painful impressions which were daily occurrences in her uncle’s house. An efficient music teacher took an unselfish interest in her, assuring her that her voice entitled her to choose the profession of singing.
She began secretly to take lessons of him and because she often went for her lessons with the choking sensation in her throat following some violent scene in the house, a connection was formed between the singing and the hysterical paresthesia for which a way was prepared by the sensitiveness of the organ during singing. The apparatus of which she should have had free control was filled with the remnants of innervation after those numerous scenes of repressed excitement. Since then she has left the house of her uncle, having moved to another city so as to be away from the family, but her ailments were not benefited by it. No other hysterical symptoms were discovered in this pretty and unusually bright girl.
I endeavored to cure this “retention hysteria” by a reproduction of all the exciting impressions and by subsequent ab-reaction. I afforded her the opportunity of railing against her uncle in long speeches and of telling him the bare truth to his face, etc. The treatment benefited her, but unfortunately she lived here under quite unfavorable conditions. She had no luck with her relatives. She was the guest of another uncle who treated her with friendliness, but just for that reason she incurred the displeasure of her aunt. The latter believed that her husband evinced too marked an interest in his niece and made it a point of opposing the girl’s stay in Vienna. She herself in her youth was obliged to relinquish a desire of becoming an artist and was now jealous of her niece because she had the opportunity to develop her talent not considering that it was not mere desire but a wish to become independent which led her niece to take this step. Rosalia felt so uncomfortable in the house that she for instance, did not dare to sing or play the piano when her aunt was within hearing distance, and carefully avoided either singing or playing anything for her aged uncle—brother of her mother—whenever her aunt was home. While I was endeavoring to efface the traces of the old excitements, new ones originated through these relations with her host and finally interfered with the success of my treatment and prematurely interrupted the cure.
One day the patient came to me with a new symptom hardly twenty-four hours old. She complained of a disagreeable prickling sensation in the fingertips which had manifested itself every few hours since the day before and forced her to make very peculiar jerky movements with the fingers. I could not see the attack, otherwise I would have guessed its meaning on seeing the finger movements but I immediately endeavored to trace through hypnotic analysis the causation of this symptom (it was really a minor hysterical attack). As the whole thing only existed for a short time I hoped to be able to explain it and quickly remove it. To my surprise without any hesitation she reproduced in chronological order a whole row of scenes beginning in her early childhood. All these had perhaps the same characteristics in the fact that she had suffered an injustice without defense, something which could make her fingers jerk, for example, scenes like the one of being forced to hold out her hand in school while her teacher struck it with a ruler. But they were all banal causes the right of which to enter into the etiology of an hysterical symptom I have already opposed. It was different, however, with one scene of her early girlhood which was connected with the others.
The bad uncle who suffered from rheumatism asked her to massage his back. She did not dare refuse him. He was in bed while she was doing it and suddenly threw off the covers, jumped up, attempting to get hold of her and throw her down. Naturally she stopped the massage and in a moment escaped and locked herself within her own room. She evidently did not like to recall this experience and could not say whether she had seen anything when the man suddenly exposed himself. The sensations of the fingers could be explained as due to the suppressed impulse to punish him, or it might simply have originated from the fact that she was at that time massaging him. Only after this scene did she begin to talk about the one experienced yesterday after which the sensitiveness and jerkiness of the fingers appeared as a recurring memory symbol. The uncle with whom she now lived begged her to play something for him. She sat at the piano and accompanied herself singing, believing that her aunt was out. Suddenly she appeared in the doorway, Rosalie jumped up, closed the piano, and flung away the sheet of music. We can guess what memories came to her mind, and the train of thought which she tried to ward off at that moment, for the exasperation brought on by the unjust accusation should have really urged her to leave the house, but on account of her illness she was forced to remain in Vienna and had no other shelter. The movement of the fingers which I saw during the reproduction of this scene resembled a continuous jerking as if one literally and figuratively would reject something like throwing away a sheet of music or rejecting an unreasonable demand.
Text from Project Gutenberg, public domain in the United States.