What I have here said concerning obsessions I will explain by some examples which are probably of a typical nature:
1. A young girl suffers from obsessive reproaches. If she reads anything in the journal about false coiners she conceives the thought that she too, made counterfeit money; if a murder was anywhere committed by an unknown assassin she anxiously asked herself whether she had not committed this crime. At the same time she is perfectly aware of the absurdity of these obsessive reproaches. For a time the consciousness of her guilt gained such a power over her that her judgment was suppressed, and she accused herself before her relatives and physician of having really committed all these crimes (Psychosis through simple aggravation—overwhelming psychosis—Uberwältigungspsychose). A thorough examination revealed the source of the origin of this guilty conscience. Accidentally incited by a sensual feeling she allowed herself to be allured by a friend to masturbate. She practiced it for years with the full consciousness of her wrong doing, and under the most violent but useless self reproaches.—The girl was cured after a few months’ treatment and strict watching.
2. Another girl suffered from the fear of getting sudden desires of micturition and of being forced to wet herself. This began after such a desire had really forced her to leave a concert hall during the performance. This phobia had gradually caused her to become quite incapable of any enjoyment and social relationship. She felt secure only when she knew that there was a toilet in the neighborhood to which she could repair unobserved. An organic suffering which might have justified this lack of confidence of the control of the bladder was excluded. At home among quiet surroundings and during the night there was no such desire to micturate. Detailed examination showed that the desire to micturate appeared for the first time under the following conditions: A gentleman to whom she was not indifferent took a seat in the concert hall not far from her. She began to think and to picture to herself how she would sit near him as his wife. In this erotic revery she experienced that physical feeling which must be compared to erection in the man, and which in her—I do not know whether it is general—ended in a slight desire to micturate. She now became extremely frightened over her otherwise accustomed sexual sensation because she had determined to overcome this as well as every desire, and in the next moment the affect transposed itself to the accompanying desire to micturate and forced her to leave the hall after a very painful struggle. In her life she was so prudish that she experienced an intensive horror for all things sexual, and could not conceive the thought of ever marrying; on the other hand she was sexually so hyperesthetic that during every erotic revery, which she gladly allowed herself, there appeared sensual feeling. The erection was always accompanied by the desire to micturate, and up to the time of the scene in the concert hall it had made no impression on her. The treatment led to an almost complete control of the phobia.
3. A young woman who had only one child after five years of married life complained of obsessive impulses to throw herself from the window or balcony, and of fears lest at the sight of a sharp knife she might kill her child. She admitted that the marriage relations were seldom practised and then only with caution against conception; but she added that she did not miss this as she was not of a sensual nature. I then ventured to tell her that at the sight of a man she conceives erotic ideas, and that she therefore lost confidence in herself and imagined herself a depraved person fit for anything. The retranslation of the obsession into the sexual was successful; weeping, she soon admitted her long concealed marital misery, and then mentioned painful ideas of an unchanged sexual character such as the often recurring sensation of something forcing itself under her skirts.
I have made use of such experiences in the therapy of phobias and obsessions, and despite the patient’s resistances I have redirected the attention to the repressed sexual ideas, and wherever feasible I have blocked the sources from which the same originated. To be sure I cannot maintain that all phobias and obsessions originate in the manner here revealed; first, my experience, in proportion to the abundance of these neuroses, embraces only a limited amount, and second, I, myself, know that these “psychasthenic” symptoms (according to Janet’s designation) are not all of the same value.[[40]] Thus, for instance, there are pure hysterical phobias. But I believe that the mechanism of the transposition of the affect will be demonstrated in the greater part of the phobias and obsessions, and I must assert that these neuroses, which are found just as often isolated as combined with hysteria and neurasthenia, are not to be thrown together with the ordinary neurasthenia for which fundamental symptom a psychic mechanism is not all to be assumed.
III.
In both cases thus far considered the defense of the unbearable idea was brought about by the separation of the same from its affect; the idea though weakened and isolated remained in consciousness. There exists, however, a far more energetic and more successful form of defense wherein the ego misplaces the unbearable idea with its affect, and behaves as though the unbearable idea had never approached the ego. But at the moment when this is brought about the person suffers from a psychosis which can only be classified as an “hallucinatory confusion.” A single example will explain this assertion. A young girl gives her first impulsive love to a man who she firmly believed reciprocated her love. As a matter of fact she was mistaken; the young man had other motives for visiting her. It was not long before she was disappointed; at first she defended herself against it by converting hysterically the corresponding experience, and thus came to believe that he would come some day to ask her in marriage; but in consequence of the imperfect conversion and the constant pressure of new painful impressions, she felt unhappy and ill. She finally expects him with the greatest tension on a definite day, it is the day of a family reunion. The day passes but he does not come. After all the trains on which he could have come have passed she suddenly merged into an hallucinatory confusion. She thought that he did come, she heard his voice in the garden, and hastened down in her night gown to receive him. For two months after she lived in a happy dream, the content of which was that he was there, that he was always with her, and that everything was as before (before the time of the painfully defended disappointment). The hysteria and depression were thus conquered; during her sickness she never mentioned anything about the last period of doubt and suffering; she was happy as long as she was left undisturbed, and frenzied only when a regulation of her environment prevented her from accomplishing something which she thought quite natural as a result of her blissful dream. This psychosis, unintelligible as it was in its time, was revealed ten years later through hypnotic analysis.
The fact to which I call attention is this: That the content of such an hallucinatory psychosis consists in directly bringing into prominence that idea which was threatened by the motive of the disease. One is therefore justified in saying that through its flight into the psychosis the ego defended the unbearable idea; the process through which this has been brought about withdraws itself from self perception as well as from the psychological-clinical analysis. It is to be considered as the expression of a higher grade of pathological disposition, and can perhaps be explained as follows: The ego tears itself away from the unbearable idea, but as it hangs inseparably together with a part of reality, the ego while accomplishing this performance also detaches itself wholly or partially from reality. The latter is, in my opinion the condition under which hallucinatory vividness is decreed to particular ideas, and hence after very successful defense the person finds himself in a hallucinatory confusion.
I have but very few analyses of such psychoses at my disposal; but I believe that we deal with a very frequently employed type of psychic illness. For analogous examples such as the mother who becoming sick after the loss of her child continues to rock in her arms a piece of wood, or the jilted bride who in full dress expects her bridegroom, can be seen in every insane asylum.
It will perhaps not be superfluous to mention that the three forms of defense here considered, and hence the three forms of disease to which this defense leads may be united in the same person. The simultaneous occurrence of phobias and hysterical symptoms, so frequently observed in praxis, really belongs to those moments which impede a pure separation of hysteria from other neuroses and urge the formation of the “mixed neuroses.” To be sure the hallucinatory confusion is not frequently compatible with the continuation of hysteria and not as a rule with obsessions; but on the other hand it is not rare that a defense psychosis should episodically break through the course of a hysteria or mixed neurosis.