Selected papers on hysteria and other psychoneuroses

by Sigmund Freud

I still have something more to report about the further course of Miss Elisabeth v. R.’s disease. A few weeks after our parting I received a despairing letter from her mother informing me that at the first attempt to draw Elisabeth into a conversation about her love affairs she became very excited and refused to talk, and since then had suffered from violent pains. She was very indignant at my having betrayed her confidence and was perfectly inaccessible so that the treatment seemed a complete failure. She wished to know what was to be done, for of me she would hear nothing. I made no reply. It was to be expected that after she was relieved from my discipline she would make another attempt to reject her mother’s interference and return to her inaccessibility. I was, however, quite certain that everything would adjust itself and that my efforts had not been in vain. Two months later they returned to Vienna and the colleague to whom I was grateful for the case informed me that Elisabeth was perfectly well, and that her behavior was normal although occasionally she had slight pains. Since then she has repeatedly sent me similar messages, each time promising to visit me, which she has never done. This is quite characteristic of the personal relationship formed during such treatment. My colleague then assured me that she could be considered cured. The relation of the brother-in-law to the family underwent no change.

In the spring of 1894 I was informed that she would be present at a private ball to which I could gain access. I did not let the opportunity escape me and saw my former patient gliding along in a rapid dance. Since then, following her own inclination, she has married a stranger.

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.