"4. The hysterical symptom is the realization of an unconscious fancy serving as a wish fulfilment.
"5. The hysterical symptom serves as a sexual gratification, and represents a part of the sexual life of the individual (corresponding to one of the components of his sexual impulse).
"6. The hysterical symptom, in a fashion, corresponds to the return of the sexual gratification which was real in infantile life but had been repressed since then.
"7. The hysterical symptom results as a compromise between two opposing affects or impulse incitements, one of which strives to bring to realization a partial impulse, or a component of the sexual constitution, while the other strives to suppress the same.
"8. The hysterical symptom may undertake the representation of diverse unconscious nonsexual incitements, but can not lack the sexual significance."
The practical application of these theories of Freud is illustrated by the line of treatment suggested. By his method of "catharsis" the repressed and forgotten painful idea is restored to the conscious sphere of the mind and a normal reaction brought about by "affording an outlet to the strangulated affect through speech." To accomplish this result it is obviously necessary to find out what the psychic trauma was that originally caused the repression. For this purpose he uses psychoanalysis, hypnosis and the study of dreams. Psychoanalysis is nothing more or less, as Campbell says, than a sort of "scientific confessional", a complete analysis of the mental mechanisms of the individual in a search for the buried complexes. It has largely been preferred by Freud to hypnosis, the latter often being impracticable for various reasons. The association test of Sommer was very successfully adapted to the determination and explanation of buried complexes by Jung. Freud's views as to the analysis of dreams in the unravelling of mental mechanisms are set forth in full in his "Traumdeutung" (1900). He describes a dream as being "the more or less disguised fulfilment of a suppressed wish." Owing to the activities of the psychic censor we may have either manifest or latent dreams. The former are recalled on waking; the latter are distorted or forgotten and indicate the repressed wish. He classifies dreams as, those which represent an unexpressed wish as being fulfilled, those which represent the realization of the wish in some entirely concealed form and those which represent it in a form insufficiently or partly concealed. Freud justified his emphasis of the sexual element in his studies of the psychoneuroses by the publication of his "Drei Abhandlungen zur Sexualtheorie." In this he calls attention to the neglected importance of sexual factors in the developing mentality of the child and shows that these influences are manifested long before the age of puberty. He even maintains that the normal child is homosexual as well as incestuous at a certain stage. These erotic impulses are largely unconscious and become submerged, playing an important part later in the development of the neuroses.
Kraepelin has devoted one hundred and sixty pages of his work on psychiatry to a consideration of the subject of hysteria. The mental symptoms of the disease are all described as being definitely associated with twilight or dream states (Dämmerzustände). These he refers to as including somnambulisms, definite excitements, attacks assuming a characteristic silly or "puerile" form, confusions, deliria of various kinds, the Ganser complex, prison stupors and double personalities (retrograde amnesia). He does not accept Freud's views as to the influence of the sexual life in the etiology of hysteria.
Neurasthenia was first described by Beard of New York in 1880. As has already been shown, it was referred to by Kraepelin as one of the psychogenic neuroses. Freud is much inclined to question the existence of such an entity as the classic neurasthenia described by Beard. He feels that most of the cases can be traced to a definite association with some other psychosis. He does, however, recognize a neurasthenic complex which is entirely sexual in origin and attributes it to the excessive masturbation of adult life. The symptoms, according to Freud, are a result of the inadequate sexual relief afforded by the habit, and are those of nervous exhaustion, a sense of pressure or fulness in the head, spinal irritation, hyperesthesias, paresthesias, diminished sexual power, and occasionally a mild form of emotional depression. He would also differentiate another psychoneurosis of sexual origin—the anxiety neurosis (Angstneurose). He mentions an increased irritability as a prominent symptom often in the form of an oversensitiveness to noises. The characteristic feature, however, is a state of anxious expectation. This may manifest itself in a mere uneasiness and general tendency towards pessimism or may approach a state of hypochondriasis with paresthesia and annoying somatic sensations. Fear of sudden death may be experienced. There may be physical symptoms such as disturbed heart action (palpitation or tachycardia), disturbance of respiration (dyspnea or asthmatic attacks), profuse perspiration, periods of trembling, dizziness, attacks of inordinate appetite, diarrhea, etc. Nocturnal frights are common. The symptoms as outlined above are accompanied by a marked anxiety. He finds anxious psychoses usually in women, in the form of virginal fears in adults, the anxiety of the newly married, similar states occurring in widows or intentional abstainers, and fears occurring at the climacterium. This condition in women he believes to be due as a rule to coitus interruptus or ejaculatio praecox. Similar anxieties in men, according to Freud, are due to abstinence, frustrated sexual excitement, coitus interruptus or senile conditions. Masturbation may also be a factor. He also admits that there are causes other than sexual, in the form of overwork, serious illnesses, etc. The mental mechanism involved is a "deviation of the somatic sexual excitement from the psychic, and in the abnormal utilization of this excitement occasioned by the former."
In 1903 Janet formulated his conception of psychasthenia, describing it as a clinical entity. In this grouping he included the obsessions of doubt, phobias, imperative ideas, impulsive obsessions, compulsions and other conditions described by various authors. The essential mechanism to be considered, according to Janet, is a "lowering of the psychological tension." This results, as White expresses it, in an inadequate perception of the realities of the outside world. Meyer has spoken of psychasthenia as "a lowering of general interest and tendency to rumination over what is accessible to the patient in his memory, but is not squarely met, and where the normal reaction is replaced by rumination, substitutive acts and panics." These conditions are described by Freud as belonging to the "Zwangsneurose" or compulsion neuroses. The obsessing ideas force themselves into the consciousness of the individual, who is perfectly clear as to their inconsistency but cannot escape them. These he also looks upon as being of sexual origin and due to repression as in hysteria. After the unpleasant idea is repressed, however, the mechanism is different. Instead of converting the concept into a bodily symbol, a defense reaction displaces the affect from the painful thought, connecting it with some entirely disinterested and innocuous idea. This process he spoke of as substitution. This transference, as in hysteria, takes place in the subconscious and is not recognized by the patient as having anything to do with his peculiar symptoms. Compulsive ideas prevent the recurrence in thought, of the repressed etiological factor. It must be conceded that these mechanisms are exceedingly interesting from a psychological point of view. Freud's theories have, however, met with a great deal of opposition, due apparently to the fact that all of his conceptions are based almost exclusively on the influence of the sexual life on the human mind. The characteristic and entirely consistent Freudian answer to this objection is that it is a "defense reaction." Without attempting to determine the exact basis of the psychoneuroses the fact remains that their importance from a psychiatric point of view cannot be questioned. They constitute in a large measure the field of observation covered by the out-patient clinics and psychopathic hospitals. They played an exceedingly important part in the psychiatry of the late war.
Leaving out of consideration the mental mechanisms involved, the American Psychiatric Association has endeavored to collect statistical data relating to the various psychoneuroses generally recognized, as is shown by the suggestions regarding their delimitation, in the manual:—