Selected papers on hysteria and other psychoneuroses

by Sigmund Freud

I.

I, for my part, may state that I can adhere to the “Preliminary Communication,” but I must confess that after continuous occupation for years with the problems therein touched, I was confronted with new views, as a result of which the former material underwent at least a partial change in grouping and conception. It would be unjust to impute too much of the responsibility for this development to my honored friend, J. Breuer. I therefore take the weight of responsibility upon myself.

In attempting to use Breuer’s method of treating hysterical symptoms in a great number of patients by investigation and ab-reaction in hypnosis, I encountered two obstacles, the pursuit of which led me to change the technique as well as the conception. (1) Not all persons were hypnotizable who undoubtedly showed hysterical symptoms, and in whom there most probably existed the same psychic mechanism. (2) I had to question what essentially characterizes hysteria, and in what it differs from other neuroses.

How I overcame the first difficulty, and what it taught me, I will show later. I will first state what position I have taken in my daily practice towards the second problem. It is very difficult to examine a case of neurosis before it has been subjected to a thorough analysis, such as would result only through the application of Breuer’s method. But before we have such a thorough knowledge we are obliged to decide upon the diagnosis and kind of treatment. Hence the only thing remaining for me was to select such cases for the cathartic method which could, for the time being, be diagnosed as hysteria, and which showed some or many stigmata, or the characteristic symptoms of hysteria. Yet it sometimes happened that in spite of the diagnosis of hysteria the therapeutic results were very poor, and even the analysis revealed nothing of importance. At other times I attempted to treat cases which no one took for hysteria by Breuer’s method, and I found that I could influence them, and even cure them. Such, for example, was my experience with obsessions, the real obsessions of Westphal’s type, cases which did not show a single feature of hysteria. Thus the psychic mechanism revealed in the “Preliminary Communication” could not be pathognomonic of hysteria. Nor could I for the sake of this mechanism throw so many neuroses into the same pot with hysteria. From all the investigated doubts I finally seized upon a plan to treat all the other neuroses in question just like hysteria, to investigate the etiology and the form of psychic mechanisms, and to leave the diagnosis of hysteria to be dependent upon the result of this investigation.

It thus happened that, proceeding from Breuer’s methods, I occupied myself mostly with the etiology and the mechanism of the neuroses. After a relatively brief period I was fortunate in obtaining useful results. I then became cognizant of the fact that if we may speak of a reason for the acquirement of neuroses the etiology must be sought for in the sexual moments. This agrees with the fact that, generally speaking, various sexual moments may also produce various pictures of neurotic disease. Similarly we now venture to employ the etiology for the characteristics of the neuroses, and build up a sharp line of demarcation between the morbid pictures of the neuroses. If the etiological characters constantly agreed with the clinical ones, this was justified.

In this way it was found that neurasthenia really corresponds to a monotonous morbid picture in which, as shown by the analysis, “psychic mechanisms” play no part. From neurasthenia we sharply distinguished the compulsion neurosis (Zwangsneurose), [obsessions, doubts, impulses], the neurosis of the genuine obsessions, in which we can recognize a complicated psychic mechanism, an etiology resembling the one of hysteria, and a far reaching possibility of an involution by psychotherapy. On the other hand it seemed to me undoubtedly imperative to separate from neurasthenia a neurotic symptom-complex which depends on a totally divergent, strictly speaking, on a contrary etiology. The partial symptoms of this complex have been recognized by E. Hecker[^[27]] as having a common character. They are either symptoms, or equivalents, or rudiments of anxiety manifestations, and it is for that reason that this complex, so different from neurasthenia, was called by me anxiety neurosis. I maintain that it originates from an accumulation of physical tension which is in turn of a sexual origin. This neurosis, too, has no psychic mechanism, but regularly influences the psychic life, so that among its regular manifestations we have anxious expectation, phobias, hyperesthesias to pain, and other symptoms. This anxiety neurosis, as I take it, certainly corresponds in part to the neurosis called hypochondria, which in some features resembles hysteria and neurasthenia. Yet in none of the earlier works can I consider the demarcation of this neurosis as correct, and moreover, I find that the usefulness of the name hypochondria is impaired by its close relation to the symptom of “nosophobia.”

After I had thus constructed for myself the simple picture of neurasthenia, anxiety neuroses, and obsessions, I turned my attention to the commonly occurring cases of neuroses which enter into the diagnosis of hysteria. I now said to myself that it would not do to mark a neurosis as hysterical on the whole, merely because its symptom complex evinced some hysterical signs. I could readily explain this practice by the fact that hysteria is the oldest, the most familiar, and the most striking neurosis under consideration, but still it was an abuse which allowed the placing of many features of perversion and degeneration under the caption of hysteria. Whenever a hysterical symptom, such as anesthesia or a characteristic attack, could be discovered in a complicated case of psychic degeneration, the whole thing was called “hysteria,” and hence one could naturally find united under this same trade mark the worst and most contradictory features. As certain as this diagnosis was incorrect it is also certain that our classification must be made from the neurotic standpoint, and as we know neurasthenia, anxiety neurosis, and similar conditions in the pure state, there is no need of overlooking them in combination.

It seemed therefore that the following conception was more warrantable. The neuroses usually occurring are generally to be designated as “mixed.” Neurasthenia and anxiety neurosis can be found without effort in pure forms, and most frequently in young persons. Pure cases of hysteria and compulsion neurosis “Zwangsneurose” (obsessions, doubts, impulses) are rare, they are usually combined with an anxiety neurosis. This frequent occurrence of mixed neuroses is due to the fact that their etiological moments are frequently mixed, now only accidentally, and now in consequence of a causal relation between the processes which give rise to the etiological moments of the neuroses. This can be sustained and proven in the individual cases without any difficulty. But it follows from this that it is hardly possible to take hysteria out of connection with the sexual neuroses, that hysteria as a rule presents only one side, one aspect of the complicated neurotic case, and that only, as it were, in the borderline case can it be found and treated as an isolated neurosis. In a series of cases we can perhaps say a potiori fit denominatio.

I shall now examine the cases reported to see whether they speak in favor of my conception of the clinical dependence of hysteria. Breuer’s patient, Anna O.,[^[28]] seems to contradict this and exemplifies a pure hysterical disease. Yet this case which became so fruitful for the knowledge of hysteria was never considered by its observer under the guise of a sexual neurosis, and hence cannot at present be utilized as such. When I began to analyze the second patient, Mrs. Emmy v. N., the idea of a sexual neurosis on a hysterical basis was far from my mind. I had just returned from the Charcot school, and considered the connection of hysteria with the sexual theme as a sort of insult—just as my patients were wont to do. But when I today review my notes on this case there is absolutely no doubt that I have to consider it as a severe case of anxiety neurosis with anxious expectations and phobias, which was due to sexual abstinence and was combined with hysteria.

The third case, Miss Lucy R., could perhaps be called the first borderline case of pure hysteria. It is a short episodic hysteria based on an unmistakably sexual etiology. It corresponds to an anxiety neurosis in an over-ripe, amorous girl, whose love was too rapidly awakened through a misunderstanding. Yet the anxiety neurosis could either not be demonstrated or had escaped me. Case IV, Katharina,[^[29]] is really a model of what I have called virginal anxiety; it is a combination of an anxiety neurosis and hysteria, the former produces the symptoms, while the latter repeats them and works with them. At all events, it is a typical case of many juvenile neuroses called “hysteria.” Case V, Miss Elisabeth v. R., was again not investigated as a sexual neurosis. I could only suspect that there was a spinal neurasthenia at its basis but I could not confirm it. I must, however, add that since then pure hysterias have become still rarer in my experience. That in grouping together these four cases of hysteria I could disregard in the discussion the decisive factors of sexual neuroses was due to the fact that they were older cases in which I had not as yet carried out the purposed and urgent investigation for the neurotic sexual subsoil. Moreover the reason for my reporting four instead of twelve cases of hysteria, the analysis of which would have confirmed our claims of psychic mechanism for hysterical phenomena, is due to one circumstance, namely that the analysis of these cases would have simultaneously revealed them as sexual neuroses, though surely no diagnostician would have denied them the name “hysteria.” However, the discussion of such sexual neuroses would have overstepped the limits of our joint publication.

I do not wish to be misunderstood and give the impression that I refuse to accept hysteria as an independent neurotic affection, that I conceive it only as a psychic manifestation of the anxiety neurosis, that I ascribe to it “ideogenous” symptoms only, and that I attribute the somatic symptoms, like hysterogenic points and anesthesias, to the anxiety neurosis. None of these statements are true. I believe that hysteria, purified of all admixtures, can be treated independently in every respect except in therapy. For in the treatment we deal with a practical purpose, namely, we have to do away with the whole diseased state, and even if the hysteria occurs in most cases as a component of a mixed neurosis, the case merely resembles a mixed infection where the task is to preserve life, and not merely to combat the effect of one inciting cause of the disease.

I, therefore, find it important to separate the hysterical part in the pictures of the mixed neuroses from neurasthenia, anxiety neurosis, etc., for after this separation I can express concisely the therapeutic value of the cathartic method. I would venture to assert that—principally—it can readily dispose of any hysterical symptom, whereas, as can be easily understood, it is perfectly powerless in the presence of neurasthenic phenomena, and can only seldom, and through detours, influence the psychic results of the anxiety neurosis. Its therapeutic efficacy in the individual case will depend on whether or not the hysterical components of the morbid picture can claim a practical and significant position in comparison to the other neurotic components.

Another limitation placed on the efficacy of the cathartic method we have already mentioned in our “Preliminary Communication.” It does not influence the causal determinations of hysteria, and hence it can not prevent the origin of new symptoms in the place of those removed. Hence, on the whole, I must claim a prominent place for our therapeutic method in the realm of the therapy of neuroses, but I would caution against attaching any importance to it, or putting it into practice outside of this connection. As I am unable to give here a “Therapy of Neuroses” as would be required by the practicing physician, the preceding statements are put on a level with the deferred reference to a later communication; still, for purposes of discussion and elucidation, I can add the following remarks:

1. I do not claim that I have actually removed all the hysterical symptoms which I have undertaken to influence by the cathartic method, but I believe that the obstacles were due to the personal circumstances of the cases, and not to the general principles. In passing sentence, these cases of failure may be left out of consideration, just as the surgeon puts aside all cases who die as a result of narcosis, hemorrhage, accidental sepsis, etc., when deciding upon a new technique. I will again consider the failures of such origin in my later discussions on the difficulties and drawbacks of this method.

2. The cathartic method does not become valueless simply because it is symptomatic and not causal. For a causal therapy is really in most cases only prophylactic; it stops the further progress of the injury, but it does not necessarily remove the products which have already resulted from it. To do this it requires, as a rule, a second agent, and in cases of hysteria the cathartic method is really unsurpassable for such purposes.

3. Where the period of hysterical production, or the acute hysterical paroxysm, has subsided, and the only remnant manifestations left are hysterical symptoms, the cathartic method fulfills all indications, and achieves a full and lasting success. Such a favorable constellation for the therapy does not seldom result on the basis of the sexual life, in consequence of the marked fluctuations in the intensity of the sexual desire and the complications of the required determination for a sexual trauma. Here the cathartic method accomplishes all that is required of it, for the physician can not resolve to change a hysterical constitution. He must rest content if he can remove the disease for which such a constitution shows a tendency, and which can arise through the assistance of external determinants. He must be satisfied if the patient will again become capacitated. Moreover, he can have some hopes for the future, if the possibility of a relapse be considered, for he knows the main character of the etiology of the neuroses, namely, that their origin is mostly over-determined, and that many moments must unite to produce this result. He can hope that this union will not take place very soon, if individual etiological moments remain in force.

It may be argued that in such subsided cases of hysteria the remaining symptoms would spontaneously disappear without anything else, but this can be answered by the fact that such spontaneous cures very often terminate neither rapidly nor fully, and that the cure will be extraordinarily advanced by the treatment. Whether the cathartic treatment cures only that which is capable of spontaneous recovery, or incidentally also, that which would not cease spontaneously, that question may surely be left open for the present.

4. Where we encounter an acute hysteria during the most acute production of hysterical symptoms, and the consecutive overwhelming of the ego by the morbid products (hysterical psychosis), even the cathartic method will change little the expression and course of the disease. One finds himself in the same position to the neurosis as the doctor to an acute infectious disease. For some time past, now beyond the reach of influence, the etiological moments exerted a sufficient amount of effect, which becomes manifest after overcoming the interval of incubation. The affection can not be warded off, it has to run its course, but meanwhile one must bring about the most favorable conditions for the patient. If during such an acute period one can remove the morbid products, the newly formed hysterical symptoms, it may be expected that their places will be taken by new ones. The physician will not be spared the depressing impression of fruitless effort, the enormous expenditure of exertion, and the disappointment of the relatives, to whom the idea of the necessary duration of time of an acute neurosis is hardly as familiar as in the analogous case of an acute infectious disease; these, and many other things, will probably make most impossible the consequent application of the cathartic method in the assumed case. Nevertheless, it still remains to be considered whether, even in an acute hysteria, the frequent removal of the morbid products does not exercise a curative influence by supporting the normal ego which is occupied with the defense, and thus preventing it from merging into a psychosis or into ultimate confusion.

That the cathartic method can accomplish something, even in an acute hysteria, and that it can even reduce the new productions of the morbid symptoms quite practically and noticeably, is undoubtedly evident from the case of Anna O., in which Breuer first learned to exercise this process.[^[30]]

5. Where we deal with chronic progressive hysterias with moderate or continued productions of hysterical symptoms, we learn to regret the lack of a causally effective therapy, but we also learn to value the indications of the cathartic method as a symptomatic remedy. We then deal with an injury produced by an etiology which continues to act chronically. We have to strengthen the capacity for resistance of the nervous system of our patient, and we must bear in mind that the existence of an hysterical symptom signifies a weakening of resistance of the nervous system, and represents a predisposing moment. From the mechanism of monosymptomatic hysteria we know that a new hysterical symptom generally originates as an addition to and as an analogy of one already in existence. The location once penetrated represents the weak spot which can be penetrated again. The split off psychic group plays the part of the provoking crystal from which a formerly omitted crystallization emerges with great facility. To remove the already existing symptoms, to do away with the psychic alterations lying at their basis, is the return to the patients the full measure of their resistance capacity, with which they are successfully able to resist the noxious influences. One can do a great deal for the patient by such long continued watchfulness and occasional “chimney-sweeping.”

6. I still have to mention the apparent contradiction arising between the admission that not all hysterical symptoms are psychogenic, and the assertion that they can all be removed by psychotherapeutic procedures. The solution lies in the fact that some of these non-psychogenic symptoms, though they represent morbid symptoms, as, for instance, the stigmata, should nevertheless not be designated as affections, and hence it cannot be practically noticed even if they remain after the treatment is finished. Other symptoms of a similar nature seem to be taken along indirectly by the psychogenic symptoms, for indirectly they really depend on some psychic causation.

I shall now mention those difficulties and inconveniences of our therapeutic method which are not evident from the preceding histories, or from the following remarks concerning the technique of the method.—I will rather enumerate and indicate than carry them out. The process is toilsome and wearisome for the physician, it presupposes a profound interest for psychological incidents, as well as a personal sympathy for the patient. I could not conceive myself entering deeply into the psychic mechanism of a hysteria in a person who appeared to me common and disagreeable, and who would not, on closer acquaintanceship, be able to awaken in me human sympathy; whereas I can well treat a tabetic or a rheumatic patient regardless of such personal liking. Not less are the requisites on the patient’s side. The process is especially inapplicable below a certain niveau of intelligence. It is rendered extremely difficult wherever there is any tinge of weakmindedness. It requires the full consent and the attention of the patients, but, above all, their confidence, for the analysis regularly leads to the inmost and most secretly guarded psychic processes. A large proportion of the patients suitable for such treatment withdraw from the physician as soon as they become cognizant whither his investigations tend; to them the physician remains a stranger. In others who have determined to give themselves up to the physician and bestow their confidence upon him, something usually voluntarily given but never demanded, in all those, I say, it is hardly avoidable that the personal relation to the physician should not become unduly prominent, at least for some time. Indeed, it seems as if such an influence exerted by the physician is a condition under which alone a solution of the problem is made possible. I do not believe that it makes any essential difference in this condition whether we make use of hypnosis or have to avoid or substitute it. Yet fairness demands that we emphasize the fact that although these inconveniences are inseparable from our method, they, nevertheless, cannot be charged to it. It is much more evident that they are formed in the preliminary states of the neurosis to be cured, and that they then attach themselves to every medical activity which intensively concerns itself with the patient, and produce in him a psychic change. I could see no harm or danger in the application of hypnosis even in those cases where it was used excessively. The causes for the harm produced lay elsewhere and deeper. When I review the therapeutic efforts of those years since the communications of my honored teacher and friend, J. Breuer, gave me the cathartic method, I believe that I have more often produced good than harm, and brought about some things which could not have been produced by any other therapeutic means. On the whole it was, as expressed in the “Preliminary Communication,” “a distinct therapeutic gain.”

I must mention still another gain in the application of this method. No severe case of complicated neurosis, with either an excessive or slight tinge of hysteria can better be explained than by subjecting it to an analysis by Breuer’s method. In making this analysis I find that whatever shows the hysterical mechanism disappears first, while the rest of the manifestations I meanwhile learn to interpret and refer to their etiology. I thereby gained the essential factors indicated by the instrument of the therapy of the neurosis in question. When I think of the usual differences between my opinion of a case of neurosis before and after such an analysis, I am almost tempted to maintain that the analysis is indispensable for the knowledge of a neurotic disease. I have furthermore made it a practice of applying the cathartic psychotherapy in conjunction with a rest cure, which when required is changed to a full Weir-Mitchell treatment. This advantage lies in the fact that, on the one side I avoid the very disturbing intrusion of new psychic impressions produced during psychotherapy; on the other hand, I exclude the monotony of the Weir-Mitchell treatment, during which the patient not seldom merges into harmful reveries. One might expect that the very considerable psychic labor often imposed upon the patient during the cathartic cure, and the excitement resulting from the reproduction of traumatic events, would run counter to the sense of the Weir-Mitchell rest cure, and would prevent the successes which one is wont to obtain from it. But the contrary happens; through the combination of the Breuer and the Weir-Mitchell therapy, we obtain all the physical improvements which we expect from the latter, and such marked psychic improvement as never occurs in the rest cure without psychotherapy.