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.