Selected papers on hysteria and other psychoneuroses

by Sigmund Freud

3. From the anamnesis of the patients we often find that the symptoms of the anxiety neurosis are relieved at a certain time by another neurosis, perhaps a neurasthenia which has supplanted it. It can then be regularly demonstrated that shortly before this change of the picture there occurred a corresponding change in the form of a sexual injury.

Whereas such experiences, which can be augmented at pleasure, plainly obtrude upon the physician the sexual etiology for a certain category of cases, other cases which would have otherwise remained incomprehensible can at least without gainsaying be solved and classified by the key of the sexual etiology. We refer to those numerous cases in which everything exists that has been found in the former category, such as the appearance of anxiety neurosis on the one hand, and the specific moment of the coitus interruptus on the other, but yet something else slips in, namely, a long interval between the assumed etiology and its effect, and perhaps other etiological moments of a non-sexual nature. We have here, for example, a man who was seized with an attack of palpitation on hearing of his father’s death, and who since that time suffered from an anxiety neurosis. The case cannot be understood, for up to that time this man was not nervous. The death of the father, well advanced in years, did not occur under any peculiar circumstances, and it must be admitted that the natural expected death of an aged father does not belong to those experiences which are wont to make a healthy adult sick. The etiological analysis will perhaps seem clearer if I add that out of regard for his wife this man practiced coitus interruptus for eleven years. At all events the manifestations are precisely the same as those appearing in other persons after a short sexual injury of this nature, and without the intervention of another trauma. The same judgment may be pronounced in the case of a woman who merges into an anxiety neurosis after the death of her child, or in the case of the student who becomes disturbed by an anxiety neurosis while preparing for his final state examination. I find that here, as there, the effect is not explained by the reported etiology. One must not necessarily “overwork” himself studying, and a healthy mother is wont to react to the death of her child with normal grief. But, above all, I would expect that the overworked student would acquire a cephalasthenia, and the mother in our example a hysteria. That both became afflicted with anxiety neurosis causes me to attach importance to the fact that the mother lived for eight year in marital coitus interruptus, and that the student entertained for three years a warm love affair with a “respectable” girl whom he was not allowed to impregnate.

These examples tend to show that where the specific sexual injury of the coitus interruptus is in itself unable to provoke an anxiety neurosis it at least predisposes to its acquisition. The anxiety neurosis then comes to light as soon as the effect of another banal injury enters into the latent effect of the specific moment. The former can quantitatively substitute the specific moment but not supplant it qualitatively. The specific moment always remains that which determines the form of neurosis. I hope to be able to prove to a greater extent this proposition for the etiology of the neurosis.

Furthermore, the last discussions contain the, not in itself, improbable assumption that a sexual injury like coitus interruptus asserts itself through summation. The time required before the effect of this summation becomes visible depends upon the predisposition of the individual and the former burdening of his nervous system. The individuals who bear coitus interruptus manifestly without disadvantage really become predisposed by it to the disturbance—anxiety neurosis—which can at any time burst forth spontaneously or after a banal, otherwise inadequate, trauma, just as the chronic alcoholic finally develops a cirrhosis or another disease by summation, or under the influence of a fever he merges into a delirium.

III. Addenda to the Theory of Anxiety Neurosis.

The following discussions claim nothing but the value of a first tentative experiment, which judgment should not influence the acceptance of the facts mentioned above. The estimation of this “Theory of Anxiety Neurosis” is rendered still more difficult by the fact that it merely corresponds to a fragment of a more comprehensive representation of the neuroses.

The facts hitherto expressed concerning the anxiety neurosis already contain some starting points for an insight into the mechanism of this neurosis. In the first place it contains the assumption that we deal with an accumulation of excitement, and then the very important fact that the anxiety underlying the manifestations of the neurosis is not of psychic derivation. Such, for example, would exist if we found as a basis for the anxiety neurosis a justified fright happening once or repeatedly which has since supplied the source of the preparedness for the anxiety neurosis. But this is not the case; a former fright can perhaps cause a hysteria or a traumatic neurosis but never an anxiety neurosis. As the coitus interruptus is rendered so prominent among the causes of anxiety neurosis I have thought at first that the source of the continuous anxiety was perhaps the repeated fear during the sexual act lest the technique will fail and conception follow. But I have found that this state of mind of the man or woman during the coitus interruptus plays no part in the origin of anxiety neurosis, that the women who are really indifferent to the possibilities of conception are just as exposed to the neurosis as those who are trembling at the possibility of it, it all depends on which person suffers the loss of sexual gratification.

Another starting point presents itself in the as yet unmentioned observation that in a whole series of cases the anxiety neurosis goes along with the most distinct diminution of the sexual libido or the psychic desire, so that on revealing to the patients that their affliction depends on “insufficient gratification,” they regularly reply that this is impossible as just now their whole desire is extinguished. The indications that we deal with an accumulation of excitement, that the anxiety which probably corresponds to such accumulated excitement is of somatic origin, so that somatic excitement becomes accumulated, and furthermore, that this somatic excitement is of a sexual nature, and that it is accompanied by a decreased psychic participation in the sexual processes—all these indications, I say, favor the expectation that the mechanism of the anxiety neurosis is to be found in the deviation of the somatic sexual excitement from the psychic, and in the abnormal utilization of this excitement occasioned by the former.

This conception of the mechanism of anxiety neurosis will become clearer if one accepts the following view concerning the sexual process in man. In the sexually mature male organism, the somatic sexual excitement is—probably continuously—produced, and this becomes a periodic stimulus for the psychic life. To make our conceptions clearer we will add that this somatic sexual excitement manifests itself as a pressure on the wall of the seminal vesicle which is provided with nerve endings. This visceral excitement thus becomes continuously increased, but not before attaining a certain height is it able to overcome the resistances of the intercalated conduction as far as the cortex, and manifest itself as psychic excitement. Then the group of sexual ideas existing in the psyche becomes endowed with energy and results in a psychic state of libidinous tension which is accompanied by an impulse to remove this tension. Such psychic unburdening is possible only in one way which I wish to designate as specific or adequate action. This adequate action for the male sexual impulse consists of a complicated spinal reflex-act which results in the unburdening of those nerve endings, and of all psychically formed preparations for the liberation of this reflex. Anything else except the adequate action would be of no avail, for after the somatic sexual excitement has once reached the liminal value, it continuously changes into psychic excitement; that must by all means occur which frees the nerve endings from their heavy pressure, and thus abolish the whole somatic excitement existing at the time and allow the subcortical conduction to reestablish its resistance.

I will desist from presenting in a similar manner more complicated cases of the sexual process. I will merely formulate the statement that this scheme can essentially be transferred to the woman despite the problem of the perplexity, artificial retardation, and stunting of the female sexual impulse. In the woman, too, it can be assumed that there is a somatic sexual excitement and a state in which this excitement becomes psychic, evoking libido and the impulse to specific action which is accompanied by the sensual feeling. But we are unable to state what analogy there may be in the woman to the unburdening of the seminal vesicles.