II. The Essence and Mechanism of Compulsion Neurosis.
Sexual experiences of early childhood have the same significance in the etiology of the compulsion neurosis as in hysteria, still we no longer deal here with sexual passivity but with pleasurably accomplished aggressions, and with pleasurably experienced participation in sexual acts, that is, we deal here with sexual activity. It is due to this difference in the etiological relations that the masculine sex seems to be preferred in the compulsion neurosis.
In all my cases of compulsion neurosis I have found besides a subsoil of hysterical symptoms which could be traced to a pleasurable action of sexual passivity from a precedent scene. I presume that this coincidence is a lawful one, and that premature sexual aggression always presupposes an experience of seduction. But I am unable to present as yet a complete description of the etiology of the compulsion neurosis. I only believe that the final determination as to whether a hysteria or compulsion neurosis should originate on the basis of infantile traumas depends on the temporal relation of the development of the libido.
The essence of the compulsion neurosis may be expressed in the following simple formula: Obsessions are always transformed reproaches returning from consciousness which always refer to a pleasurably accomplished sexual action of childhood. In order to elucidate this sentence it will be necessary to describe the typical course of compulsion neurosis.
In a first period—period of childish immorality—the events containing the seeds of the later neurosis take place. In the earliest childhood there appear at first the experiences of sexual seduction which later makes the repression possible, and this is followed by the actions of sexual aggressions against the other sex which later manifest themselves as actions of reproach.
This period is brought to an end by the appearance of the—often self ripened—sexual “maturity.” A reproach then attaches itself to the memory of that pleasurable action, and the connection with the initial experience of passivity makes it possible—often only after conscious and recollected effort—to repress it and replace it by a primary symptom of defense. The third period, that of apparent healthiness but really of successful defense, begins with the symptoms of scrupulousness, shame and diffidence.
The next period, the disease is characterized by the return of the repressed reminiscences, hence, by the failure of the defense; but it remains undecided whether the awakening of the same is more frequently accidental and spontaneous, or whether it appears in consequence of actual sexual disturbances, that is, as additional influences of the same. But the revived reminiscences and the reproaches formed from them never enter into consciousness unchanged, but what becomes conscious as an obsession and obsessive affect and substitutes the pathogenic memory in the conscious life, are compromise formations between the repressed and the repressing ideas.
In order to describe clearly and probably convincingly the processes of repression, the return of the repression, and the formation of the pathological ideas of compromise, we would have to decide upon very definite hypotheses concerning the substratum of the psychic occurrence and consciousness. As long as we wish to avoid it we will have to rest content with the following rather figuratively understood observations. Depending on whether the memory content of the reproachful action alone forces an entrance into consciousness or whether it takes with it the accompanying reproachful affect, we have two forms of compulsion neurosis. The first represents the typical obsessions, the content of which attracts the patient’s attention; only an indefinite displeasure is perceived as an affect, whereas, for the content of the obsession the only suitable affect would be one of reproach. The content of the obsession is doubly distorted when compared to the content of the infantile compulsive act. First, something actual replaces the past experience, and second, the sexual is substituted by an analogous non-sexual experience. These two changes are the results of the constant tendency to repression still in force which we will attribute to the “ego.” The influence of the revived pathogenic memory is shown by the fact that the content of the obsession is still partially identical with the repressed, or can be traced to it by a correct stream of thought. If, with the help of the psychoanalytic method, we reconstruct the origin of one individual obsession we find that one actual impression instigated two diverse streams of thought, and that the one which passed over the repressed memory, though incapable of consciousness and correction, proves to be just as correctly formed logically as the other. If the results of the two psychic operations disagree, the contradiction between the two may never be brought to logical adjustment, but as a compromise between the resistance and the pathological result of thought an apparently absurd obsession enters into consciousness beside the normal result of the thought. If both streams of thought yield the same result, they reinforce each other so that the normally gained result of thought now behaves psychically like an obsession. Wherever neurotic compulsion manifests itself psychically it originates from repression. The obsessions have, as it were, a psychical course of compulsion which is due, not to their own validity, but to the source from which they originate, or to the source which furnishes a part of their validity.
A second form of compulsion neurosis results if the repressed reproach and not the repressed content of memory forces a replacement in the conscious psychic life. Through a psychic admixture, the affect of the reproach can change itself into any other affect of displeasure, and if this occurs there is nothing to hinder the substituting affect from becoming conscious. Thus, the reproach (of having performed in childhood some sexual actions) may be easily transformed into shame (if some one else becomes aware of it), into hypochondriacal anxiety (because of the physical harmful consequences of those reproachful acts), into social anxiety (fearing punishment from others), into religious anxiety, into delusions of observation (fear of betraying those actions to others), into fear of temptations (justified distrust in one’s own moral ability of resistance), etc. Besides, the memory content of the reproachful action may also be represented in consciousness, or it may be altogether concealed, which makes the diagnosis very difficult. Many cases which on superficial examination are taken as ordinary (neurasthenic) hypochondria often belong to this group of compulsive affects; the very frequently so called “periodic neurasthenia” or “periodic melancholia” especially seem to be explained by compulsive affects or obsessions, a recognition not unimportant therapeutically.
Beside these compromise symptoms which signify the return of the repression and hence a failure of the originally achieved defense, the compulsion neurosis forms a series of other symptoms of a totally different origin. The ego really tries to defend itself against those descendants of the initial repressed reminiscence, and in this conflict of defense it produces symptoms which may be comprehended as “secondary defense.” These are throughout “protective measures” which have performed good service in the struggle carried on against the obsessions and the obsessing affects. If these helps in the conflict of the defense really succeed in repressing anew the symptoms of return obtruding themselves on the ego, the compulsion then transmits itself on the protective measures themselves and produces a third form of the “compulsion neurosis,” the compulsive action. These are never primary, they never contain anything else but a defense, never an aggression. Psychic analysis shows that despite their peculiarity they can always be fully explained by reduction to the compulsive reminiscence which they oppose.[[51]]
The secondary defense of the obsessions can be brought about by a forcible deviation to other thoughts of possibly contrary content; hence, in case of success there is a compulsive reasoning, regularly concerning abstract and transcendental subjects, because the repressed ideas always occupied themselves with the sensuous. Or the patient tries to become master of every compulsive idea through logical labor and by appealing to his conscious memory; this leads to compulsive thinking and examination and to doubting mania. The priority of the perception before the memory in these examinations at first induce and then force the patient to collect and preserve all objects with which he comes in contact. The secondary defense against the compulsive affects results in a greater number of defensive measures which are capable of being transformed into compulsive actions. These can be grouped according to their tendency. We may have measures of penitence (irksome ceremonial and observation of numbers), of prevention (diverse phobias, superstition, pedantry, aggravation of the primary symptom of scrupulousness), measures of fear of betrayal (collecting papers and shyness), and measures of becoming unconscious (dipsomania). Among these compulsive acts and impulses the phobias play the greatest part as limitations of the patient’s existence.
There are cases in which we can observe how the compulsion becomes transferred from the idea or affect to the measure, and other cases in which the compulsion oscillates between the returning symptoms of secondary defense. But there are also cases in which no obsessions are really formed, but the repressed reminiscence immediately becomes replaced by the apparent primary defensive measure. Here that stage is attained at a bound which otherwise ends the course of the compulsion neurosis only after the conflict of the defense. Grave cases of this affection end either with a fixation of ceremonial actions, general doubting mania, or in an existence of eccentricity conditioned by phobias.
That the obsessions and everything derived from them are not believed is probably due to the fact that the defense symptom of scrupulousness was formed during the first repression and gained compulsive validity. The certainty of having lived morally throughout the whole period of the successful defense makes it impossible to give credence to the reproach which the obsession really involves. Only transitorily during the appearance of a new obsession, and now and then in melancholic exhaustive states of the ego do the morbid symptoms of the return also enforce the belief. The “compulsion” of the psychic formations here described has in general nothing to do with the recognition through belief, and is not to be mistaken for that moment which is designated as “strength” or “intensity” of an idea. Its main characteristic lies in its inexplicableness through psychic activities of conscious ability, and this character undergoes no change whether the idea to which the compulsion is attached is stronger or weaker, more or less intensively “elucidated,” “supplied with energy,” etc.
The reason for the unassailableness of the obsession or its derivative is due only to its connection with the repressed memory of early childhood, for as soon as we succeed in making it conscious, for which the psychotherapeutic methods already seem quite sufficient, the compulsion, too, becomes detached.