Selected papers on hysteria and other psychoneuroses

by Sigmund Freud

I now return to Miss Elisabeth v. R. While nursing her father there occurred for the first time an hysterical symptom in the form of a pain in a definite location on the right thigh. The mechanism of this symptom is fully explained on an analytical basis. It occurred in a moment during which the ideas of her duties towards her sick father came into conflict with the content of her erotic yearning which she then entertained. Under vivid self reproach she decided in favor of the former and created for herself the hysterical pain. According to the conception explained by the theory of conversion in hysteria, the process could be described as follows: She repressed the erotic idea from her consciousness and changed the sum of the affect into somatic sensations of pain. Whether this first conflict occurred only once, or repeated itself is not clear. The latter is more probable. Quite a similar conflict—of a higher moral significance, and even better demonstrated by the analysis—repeated itself after years and led to the aggravation of the same pain and to its dissemination beyond its original limits. Again, it was an erotic idea which came into conflict with all her moral conceptions, for her affection for her brother-in-law, both during the life and after the death of her sister, and the thought that she should yearn just for this man, was to her very disagreeable. This analysis gives detailed information about this conflict which represents the pivotal point in the history of her malady. The patient’s affection for her brother-in-law might have begun to germinate long ago, but in favor of its development was the physical exhaustion through the recent nursing, and her moral exhaustion through years of disillusionment which then began to break down her reserve and she confessed to herself the need of the love of a man. During a friendly intercourse continuing for weeks (in the summer resort) this erotic inclination reached its full development simultaneously with the pain. The analysis shows a special psychic condition of the patient at that time, which in connection with her inclination and the pain, seems to afford an understanding of the process in the sense of the conversion theory.

I place reliance on the opinion that the patient’s affection for her brother-in-law, intensive as it was, was not clearly known to her except on certain rare occasions and then only momentarily. If that were not so she would have become conscious of the inconsistency between this fondness and her moral ideas and would have had to endure the same mental agony which I saw her suffer after the analysis. Her reminiscences gave us no information concerning such suffering. These she spared herself and as a result the love itself did not become clear to her. At that time, as well as during the analysis, her love for her brother-in-law existed in the form of a foreign body in her consciousness without entering into any relationship with her other ideation. In reference to this love there existed the peculiar condition of knowing and simultaneously not knowing, it was the condition of the split off psychic group. When we assert that this love was not “clearly known” to her we mean exactly what we say. We do not mean a lower quality or a lesser degree of consciousness, but a separation of the free associative thinking process from the rest of ideation.

How does it come about that such an intensively accentuated presentation group should be kept so isolated? As a rule the rôle played by an idea in the association really increases with the sum of its affect.

This question can be answered if we bear in mind two facts which we can make use of as a safeguard: (1) That the hysterical pains originated simultaneously with the formation of these separate psychic groups, (2) that the patient exerted great resistance against the attempt to bring about the association between the separate psychic groups and the rest of the content of consciousness, and when the union was finally effected she perceived excessive psychic pain. Our conception of hysteria brings together these two moments with the fact of the splitting of consciousness, for (2) contains the indication for the motive for the splitting of consciousness while (1) shows the mechanism of the same. The motive was that of defense, it was the striving of the whole ego to agree with this presentation group and the mechanism was that of conversion, that is, instead of psychic pains which she spared herself there appeared physical pains. Thus a transformation occurred through which gain the patient had escaped an unbearable psychic state, though it was at the cost of a psychic anomaly in the form of a splitting of consciousness and a physical suffering, pains, upon which an astasia-abasia was constructed.

To be sure I can give no instruction as to how one can bring about such a conversion. It is not apparently done as one intentionally does an arbitrary action, it is a process which is executed in the individual under the impulse of the motive of defense if an adaptation for it exists in his organization or is brought about by temporary modification.

One has the right to attack the theory more closely by asking what it is that is transformed into physical pains. The cautious reply will be something out of which psychic pains could have and should have been formed. If we wish to venture further and attempt a kind of algebraic formulation of the presentation mechanism we may attribute to the presentation complex of this unconsciously remaining love a certain amount of affect and designate the latter quantity as the thing converted. Direct deduction of this conception would be the fact that the “unconscious love” has through such conversion forfeited so much of its intensity that it was reduced to a weak idea. Its existence as a separate psychic group would only be made possible through such weakening. Yet this present case is not suitable to afford us any clearness in this delicate matter. It probably corresponds to an imperfect conversion only. From other cases it seems quite probable that perfect conversions also occur and that in these the unbearable idea actually becomes repressed as only an idea of very little intensity could be repressed. After an associative union has been consummated the patients assure us that since the origin of the hysterical symptoms their unbearable thoughts never occupied their minds.

I have stated above that on certain occasions, though only transitorily, the patient consciously recognized the love for her brother-in-law. Such a moment occurred when for example, at the death bed of her sister the thought flashed through her mind, “Now he is free and I can become his wife.” I must discuss the significance of these moments for the conception of the whole neurosis. However, I think that the assumption of a defense hysteria (abwehr hysterie) includes the requisite that at least one such moment has already occurred. For consciousness does not know in advance when such an unbearable idea will present itself. The unbearable idea which with its appendix is later excluded for the formation of a separate psychic group must have been originally in the mind, otherwise no conflict would have resulted leading to its exclusion.[^[20]] Just such moments should be designated as “traumatic.” It is in them that the conversion takes place which results in the splitting of consciousness and the hysterical symptoms. Everything tends to show that in Miss Elisabeth v. R. there were a number of such moments (the scenes of the walking, morning meditation, bath, and at the bed of her sister) and perhaps new moments of this kind occurred during the treatment. The multiplicity of such traumatic moments is made possible by the fact that an experience similar to the one which at first initiated the unbearable idea, introduces new emotions to the separated psychic groups and thus transitorily abolishes the success of the conversion. The ego is forced to occupy itself with this suddenly enforced and lighted-up idea, and then to restore the former state by means of new conversions. Miss Elisabeth who was in constant relation with her brother-in-law must have been particularly exposed to the appearance of new traumas.

I must now occupy myself with the point which I have designated as a difficulty for the understanding of the afore mentioned history. On the analytical basis I assume that the first conversion took place in the patient while she nursed her father, at the time when her duties as nurse came into conflict with her erotic yearnings, and that this process was the prototype for the later ones which led to the outbreak of the disease in the Alpine watering place. But then we have it from the patient’s statement that at the time of nursing and the period following which I designated as the “first period” she had not suffered at all from the pains and weakness. To be sure, during the illness of her father she was once bedridden for a few days with pains in her legs, but it is doubtful whether this attack already belonged to the hysteria. A causal relation between these first pains and any psychic impressions could not be demonstrated by analysis; it is possible, even probable, that at that time we dealt with a common rheumatic muscular pain. Even if we should assume that this first attack of pain was the result of a hysterical conversion in consequence of the rejection of the erotic thoughts then existing, the fact nevertheless remains that the pains disappeared after a few days so that the patient actually behaved differently than she did during the analysis. During the reproduction of the so called first period all her statements concerning the illness and death of her father, the impressions relating to her first brother-in-law, etc., all these were accompanied by manifestations of pain, while at the time she really experienced these impressions she perceived no pains. Is this not a contradiction tending to considerably diminish the confidence in the explanatory value of such an analysis?

I believe that I can explain the contradiction by assuming that the pains—the product of the conversion—did not originate while the patient experienced the impressions during the first period, but subsequently, that is in the second period when the patient reproduced these impressions in her mind. The conversion did not follow the fresh impressions but the memories of them. I even believe that such a process is not at all unusual in hysteria and regularly participates in creating hysterical symptoms. Nevertheless, as such an assertion does not seem plausible I shall attempt to make it more credible by citing other experiences.

It once happened to me during a similar analysis that a new hysterical symptom was formed during the treatment so that I could attempt its removal on the day after its origin.