Selected papers on hysteria and other psychoneuroses · Sigmund Freud
III. ANALYSIS OF A CASE OF CHRONIC PARANOIA.
For some length of time I entertained the idea that paranoia also—or the group of cases belonging to paranoia—is a defense psychosis, that is, like hysteria and obsessions it originates from the repression of painful reminiscences, and that the form of its symptoms is determined by the content of the repression. A special way or mechanism of repression must be peculiar to paranoia perhaps just as in hysteria which brings about the repression by way of conversion into bodily innervation, and perhaps like obsessions in which a substitution is accomplished (displacement along certain associative categories). I observed many cases which seemed to favor this interpretation, but I had not found any which demonstrated it until a few months ago when, through the kindness of Dr. J. Breuer, I subjected to psychoanalysis, with therapeutic aims, an intelligent woman of 32, whom no one will be able to refuse to designate as a chronic paranoiac. I report here some explanations gained in this work, because I have no prospects of studying paranoia except in very isolated examples, and because I think it possible that these observations may instigate a psychiatrist for whom conditions are more favorable, to give due justice to the moment of defense in the present animated discussion on the nature and psychic mechanism of paranoia. It is of course far from my thoughts to wish to show from the following single observation anything but that this case is a defense psychosis, and that in the group of “paranoia” there may be still others of a similar nature.
Mrs. P. thirty-two years old, married three years. She is the mother of a two-year-old child, and does not descend from nervous parents; but her sister and brother whom I know, are also neurotic. It was doubtful whether she was not transitorily depressed and mistaken in her judgment in the middle of her twentieth year. During the last years she was healthy and capacitated until she evinced the first symptoms of the present illness, six months after the birth of her child. She became secluded and suspicious, showing a disinclination towards social relations with the relatives of her husband, and complained that the neighbors in the little town now behaved towards her in a rather impolite and regardless manner. Gradually these complaints grew in intensity, she thought that there was something against her, though she had no notion what it could be. But there was no doubt that all the relatives and friends denied her respect, and did everything to aggravate her. She was trying very hard to find out whence this came but could not discover anything. Some time later she complained that she was watched, that her thoughts were guessed, and that everything that happened in her house was known. One afternoon she suddenly conceived the thought that she was watched during the evening while undressing.
Since then she applied while undressing the most complicated precautionary measures. She slipped into her bed in the darkness and undressed only under cover. As she avoided all social relations, and took but little nourishment, and was very depressed, she was sent in the summer of 1895 to a hydrotherapeutic institute. There new symptoms appeared and reinforced those already existing. As early as the spring, while she was alone with the servant girl, she suddenly perceived a sensation in her lap, and thought that the servant girl then had an unseemly thought. This sensation became more frequent in the summer, it was almost continuous, and she felt her genitals “as if one feels a heavy hand.” She then began to see pictures which frightened her; they were hallucinations of female nakedness, especially an exposed woman’s lap with hair; occasionally she also saw male genitals. The picture of the hairy lap and the organic sensation in the lap usually came conjointly. The pictures became very aggravating, as she regularly perceived them when she was in the company of a woman, and the thought accompanying them was that she sees the woman in an indecent exposure, and that in the same moment the woman sees the same picture of her (!) Simultaneously with these visual hallucinations, which, after their first appearance in the asylum, disappeared again for many months, she began to be troubled with voices which she did not recognize and could not explain. When she was in the street she heard, “This is Mrs. P.—Here she goes.—Where does she go?”. Every one of her movements and actions were commented upon. Occasionally she heard threats and reproaches. All these symptoms became worse when she was in society, or even in the street; she therefore hesitated about going out; she also stated that she experienced nausea for food, and as a result she became reduced in vitality.
I obtained this from her when she came under my care in the winter of 1895. I present this case in detail in order to make the impression that we really deal here with a very frequent form of chronic paranoia, which diagnosis will agree with the details of the symptoms and their behavior to be mentioned later. At that time she either concealed from me the delusions for the interpretation of the hallucinations or they really had not as yet occurred. Her intelligence was undiminished. It was reported to me as peculiar that she had a number of rendezvous with her brother who lived in the neighborhood, in order to confide something to him, but this she never told him. She never spoke about her hallucinations, and towards the end she did not say much about the aggravations and persecutions from which she suffered. What I have to report about this patient concerns the etiology of the case and the mechanism of the hallucinations. I discovered the etiology by applying Breuer’s method exactly as in hysteria, for the investigation and removal of the hallucinations. I started with the presupposition that just as in the two other defense neuroses known to me this paranoia must contain unconscious thoughts and repressed reminiscences which have to be brought to consciousness, in the same manner as in the others, by overcoming a certain resistance. The patient immediately corroborated this expectation by behaving during the analysis exactly like a hysteric, and under attention to the pressure of my hand she reproduced thoughts which she could not remember having had, which she at first could not understand, and which contradicted her expectations. The occurrence of important unconscious ideas was therefore also demonstrated in a case of paranoia, and I could hope to reconduct the compulsion of paranoia to repression. It was only peculiar that the assertions which originated in the unconscious were usually heard inwardly or hallucinated by her as her voices.
Concerning the origin of the visual hallucinations, or at least the vivid pictures, I discovered the following: The picture of the female lap occurred almost always together with the organic sensation in the lap. The latter, however, was more constant and often occurred without the picture. The first pictures of feminine laps appeared in the hydrotherapeutic institute a few hours after she had actually seen a number of women naked in the bath house. They were therefore only simple reproductions of a real impression. It may be assumed that these impressions repeated themselves because something of great interest was connected with them. She stated that she was at that time ashamed of these women, and that since she recalled it she is ashamed of having been seen naked. Having been obliged to look upon this shame as something compulsive, I concluded that according to the mechanism of defense an experience must have here been repressed in which she was not ashamed, and I requested her to allow those reminiscences to emerge which belonged to the theme of shame. She promptly reproduced a series of scenes from her seventeenth to her eighth year, during which while bathing before her mother, her sister, and her physician she was ashamed of her nakedness. This series, however, reached back to a scene in her sixth year when she undressed in the children’s room before going to sleep without feeling ashamed of her brother who was present. On questioning her it was found that there were a number of such scenes, and that for years the brothers and sisters were in the habit of showing themselves naked to one another before retiring. I now understood the significance of the sudden thought of being watched on going to sleep. It was an unchanged fragment of the old reproachful reminiscence, and she was now trying to make up in shame what she lost as a child.
The supposition that we dealt here with an amour of childhood so frequent in the etiology of hysteria was strengthened by the further progress of the analysis which also showed simultaneous solutions for individual frequently recurring details in the picture of paranoia. The beginning of her depression commenced at the time of a disagreement between her husband and her brother on account of which the latter no longer visited her. She was always much attached to this brother and missed him very much at this time. Besides this she spoke about a moment in the history of her disease during which for the first time “everything became clear,” that is, during which she became convinced that her assumption about being generally despised and intentionally annoyed was true. She gained this assurance during a visit of her sister-in-law, who in the course of conversation dropped the words, “If such a thing should happen to me I would not mind it.” Mrs. P. at first took this utterance unsuspectingly, but when her visitor left her it seemed to her that these words contained a reproach meaning that she was in the habit of taking serious matters lightly, and since that hour she was sure that she was a victim of common slander.
On asking her why she felt justified in referring those words to herself she answered that the tone in which her sister-in-law spoke convinced her of it—to be sure subsequently—This is really a characteristic detail of paranoia. I now urged her to recall her sister-in-law’s conversation before the accusing utterance, and it was found that she related that in her father’s home there were all sorts of difficulties with the brothers, and added the wise remark, “In every family many things happen which one would rather keep under cover, and that if such a thing should happen to her she would take it lightly.” Mrs. P. had to acknowledge that her depression was connected with the sentences before the last utterance. As she repressed both sentences which could recall her relations with her brother, and retained only the last meaningless one, she was forced to connect with it the feeling of being reproached by her sister-in-law; but, inasmuch as the contents of this sentence offered absolutely no basis for such assumption she disregarded it and laid stress on the tone with which the words were pronounced. It is probably a typical illustration for the fact that the misinterpretations of paranoia depend on repression. In a most surprising manner it also explains her peculiar behavior in making appointments with her brother and then refusing to tell him anything. Her explanation was that she thought that if she only looked at him he must understand her suffering, as he knew the cause of it. As this brother was really the only person who could know anything about the etiology of her disease it followed that she acted from a motive which, though she did not consciously understand, seemed perfectly justified as soon as a new sense was put on it from the unconscious.
I then succeeded in causing her to reproduce different scenes the culminating points of which were the sexual relations with her brother at least from her sixth to her tenth year. During this work of reproduction the organic sensation in the lap “joined in the discussion,” precisely as regularly observed in the analysis of memory remnants of hysterical patients. The picture of a naked female lap (but now reduced to childish proportions and without hair) immediately appeared or stayed away in accordance with the occurrence of the scene in question in full light or in darkness. The disgust for eating, too, was explained by a repulsive detail of these actions. After we had gone through this series, the hallucinatory sensations and pictures disappeared without having thus far returned.[52] I have thus learned that these hallucinations were nothing other than fragments from the content of the repressed experiences of childhood, that is, symptoms of the return of the repressed material. I now turned to the analysis of the voices. Here it must before all be explained why such indifferent remarks as, “Here goes Mrs. P.—She now looks for apartments, etc.” could be so painfully perceived, and how these harmless sentences managed to become distinguished by hallucinatory enforcement. To begin with, it was clear that these “voices” could not be hallucinatory reproduced reminiscences like the pictures and sensations, but rather thoughts which “became loud.”
She heard the voices for the first time under the following circumstances. With great tension she read the pretty story, “The Heiterethei” by O. Ludwig, and noticed that while reading she was preoccupied with incoming thoughts. Immediately after she took a walk on the highway and suddenly while passing a peasant’s cottage the voices told her, “That is how the house of the Heiterethei looked! Here is the well, and here is the bush! How happy she was in all her poverty!” The voices then repeated whole paragraphs of what she had just read, but it remained incomprehensible why house, bush, and well of the Heiterethei, and just such indifferent and most irrelevant passages of the romance should have obtruded themselves upon her attention with pathological strength. The analysis showed that while reading she at the same time entertained extraneous thoughts, and that she was excited by totally different passages of the book. Against this material analogy between the couple of the romance and herself and her husband, the reminiscence of intimate things of her married life and family secrets, against all these there arose a repressive resistance because they were connected with her sexual shyness by very simple and demonstrable streams of thought, and finally resulted in the awakening of old experiences of childhood.
In consequence of the censorship exercised by the repression the harmless and idyllic passages connected with the objectionable ones by contrast and vicinity, became reinforced in consciousness, enabling them to become audible. For example, the first repressed thought referred to the slander to which the secluded heroine was subjected by her neighbors. She readily found in this an analogy to herself. She, too, lived in a small place, had no intercourse with anybody and considered herself despised by her neighbors. The suspicion against the neighbors was founded on the fact that in the beginning of her married life she was obliged to content herself with a small apartment. The wall of the bedroom, near which stood the nuptial bed of the young couple, adjoined the neighbors’ room. With the beginning of her marriage there awakened in her a great sexual shyness. This was apparently due to an unconscious awakening of some reminiscences of childhood of having played husband and wife. She was very careful lest the neighbors might hear through the adjacent wall either words or noises and this shyness changed into suspicion against the neighbors.
The voices therefore owed their origin to the repression of thoughts which in the last analysis really signified reproaches on the occasion of an experience analogous to the infantile trauma; they were accordingly symptoms of the return of the repression, but at the same time they were results of a comparison between the resistance of the ego and the force of the returning repression which in this case produce a distortion beyond recognition. On other occasions when analyzing voices in Mrs. P. the distortion was less marked, still the words heard always showed a character of diplomatic uncertainty. The annoying allusion was generally deeply hidden, the connection of the individual sentences was masked by a strange expression, unusual forms of speech, etc., characteristics generally common to the auditory hallucinations of paranoiacs, and in which I noticed the remnant of the compromise distortion. The expression, “There goes Mrs. P., she is looking for apartments in the street,” signified, for example, the threat that she will never recover, for I promised her that after the treatment she would be able to return to the little city where her husband was employed. She rented temporary quarters in Vienna for a few months. On some occasions Mrs. P. also perceived more distinct threats, for example, concerning the relatives of her husband, the restrained expression of which still continued to contrast with the grief which such voices caused her. Considering all that we otherwise know of paranoiacs I am inclined to assume a gradual relaxation of that resistance which weakens the reproaches so that finally the defense fails completely and the original reproach, the insulting word, which one wanted to save himself returns in unchanged form. I do not, however, know whether this is a constant course, whether the censor of the expressions of reproach can not from the beginning stay away, or persist to the end.
It is left for me to utilize the explanations gained in this case of paranoia for the comparison of paranoia with compulsion neurosis. Here, as there, the repression was shown to be the nucleus of the psychic mechanism, and in both cases the repression is a sexual experience of childhood. The origin of every compulsion in this paranoia is in the repression, and the symptoms of paranoia allow a similar classification as the one found justified in compulsion neurosis. Some symptoms also originate from the primary defense among which are all delusions of distrust, suspicion and persecution by others. In the compulsion neurosis the initial reproach became repressed through the formation of the primary symptom of defense, self-distrust, moreover, the reproach was recognized as justified, and for the purpose of adjustment the validity acquired by the scrupulousness during the normal interval now guards against giving credence to the returning reproach in the form of an obsession. By the formation of the defense symptom of distrust in others, the reproach in paranoia is repressed in a way which may be designated as projection; the reproach is also deprived of recognition, and as a retaliation there is no protection against the returning reproaches contained in the delusions.
The other symptoms in my case of paranoia are therefore to be designated as symptoms of the return of the repression, and as in the compulsion neurosis they show the traces of the compromise which alone permits an entrance into consciousness. Such are the delusions of being observed while undressing, the visual hallucinations, the perceptual hallucinations and the hearing of voices. The memory content existing in the delusion mentioned is almost unchanged and appears only uncertain through utterance. The return of the repression into visual pictures comes nearer to the character of hysteria than to the character of compulsion neurosis; still, hysteria is wont to repeat its memory symbols without modification, whereas the paranoiac memory hallucination undergoes a distortion similar to those in compulsion neurosis. An analogous modern picture takes the place of the one repressed (instead of a child’s lap it was the lap of a woman upon which the hairs were particularly distinct because they were absent in the original impression). Quite peculiar to paranoia but no further elucidated in this comparison is the fact that the repressed reproaches return as loud thoughts, this must yield to a double distortion: (1) a censor, which either leads to a replacement through other associated thoughts or to a concealment by indefinite expressions, and (2) the reference to the modern which is merely analogous to the old.
The third group of symptoms found in compulsion neurosis, the symptoms of the secondary defense, cannot exist as such in paranoia, for no defense asserts itself against the returning symptoms which really find credence. As a substitute for this we find in paranoia another source of symptom formation; the delusions (symptoms of return) reaching consciousness through the compromise demand a great deal of the thinking work of the ego until they can be unconditionally accepted. As they themselves are not to be influenced the ego must adapt itself to them, and hence the combining delusional formation, the delusion of interpretation which results in the transformation of the ego, corresponds here to the symptoms of secondary defense of compulsion neurosis. In this respect my case was imperfect as it did not at that time show any attempt at interpretation, this only appeared later. I do not doubt, however that if psychoanalysis were also applied to that stage of paranoia, another important result would be established. It would probably be found that even the so called weakness of memory in paranoiacs is purposeful, that is, it depends on the repression and serves its purpose. Subsequently even those nonpathogenic memories which stand in opposition to the transformation of the ego become repressed and replaced; this the symptoms of return imperatively demand.
Text from Project Gutenberg, public domain in the United States.