Selected papers on hysteria and other psychoneuroses

by Sigmund Freud

A second form of compulsion neurosis results if the repressed reproach and not the repressed content of memory forces a replacement in the conscious psychic life. Through a psychic admixture, the affect of the reproach can change itself into any other affect of displeasure, and if this occurs there is nothing to hinder the substituting affect from becoming conscious. Thus, the reproach (of having performed in childhood some sexual actions) may be easily transformed into shame (if some one else becomes aware of it), into hypochondriacal anxiety (because of the physical harmful consequences of those reproachful acts), into social anxiety (fearing punishment from others), into religious anxiety, into delusions of observation (fear of betraying those actions to others), into fear of temptations (justified distrust in one’s own moral ability of resistance), etc. Besides, the memory content of the reproachful action may also be represented in consciousness, or it may be altogether concealed, which makes the diagnosis very difficult. Many cases which on superficial examination are taken as ordinary (neurasthenic) hypochondria often belong to this group of compulsive affects; the very frequently so called “periodic neurasthenia” or “periodic melancholia” especially seem to be explained by compulsive affects or obsessions, a recognition not unimportant therapeutically.

Beside these compromise symptoms which signify the return of the repression and hence a failure of the originally achieved defense, the compulsion neurosis forms a series of other symptoms of a totally different origin. The ego really tries to defend itself against those descendants of the initial repressed reminiscence, and in this conflict of defense it produces symptoms which may be comprehended as “secondary defense.” These are throughout “protective measures” which have performed good service in the struggle carried on against the obsessions and the obsessing affects. If these helps in the conflict of the defense really succeed in repressing anew the symptoms of return obtruding themselves on the ego, the compulsion then transmits itself on the protective measures themselves and produces a third form of the “compulsion neurosis,” the compulsive action. These are never primary, they never contain anything else but a defense, never an aggression. Psychic analysis shows that despite their peculiarity they can always be fully explained by reduction to the compulsive reminiscence which they oppose.[^[51]]

The secondary defense of the obsessions can be brought about by a forcible deviation to other thoughts of possibly contrary content; hence, in case of success there is a compulsive reasoning, regularly concerning abstract and transcendental subjects, because the repressed ideas always occupied themselves with the sensuous. Or the patient tries to become master of every compulsive idea through logical labor and by appealing to his conscious memory; this leads to compulsive thinking and examination and to doubting mania. The priority of the perception before the memory in these examinations at first induce and then force the patient to collect and preserve all objects with which he comes in contact. The secondary defense against the compulsive affects results in a greater number of defensive measures which are capable of being transformed into compulsive actions. These can be grouped according to their tendency. We may have measures of penitence (irksome ceremonial and observation of numbers), of prevention (diverse phobias, superstition, pedantry, aggravation of the primary symptom of scrupulousness), measures of fear of betrayal (collecting papers and shyness), and measures of becoming unconscious (dipsomania). Among these compulsive acts and impulses the phobias play the greatest part as limitations of the patient’s existence.

There are cases in which we can observe how the compulsion becomes transferred from the idea or affect to the measure, and other cases in which the compulsion oscillates between the returning symptoms of secondary defense. But there are also cases in which no obsessions are really formed, but the repressed reminiscence immediately becomes replaced by the apparent primary defensive measure. Here that stage is attained at a bound which otherwise ends the course of the compulsion neurosis only after the conflict of the defense. Grave cases of this affection end either with a fixation of ceremonial actions, general doubting mania, or in an existence of eccentricity conditioned by phobias.

That the obsessions and everything derived from them are not believed is probably due to the fact that the defense symptom of scrupulousness was formed during the first repression and gained compulsive validity. The certainty of having lived morally throughout the whole period of the successful defense makes it impossible to give credence to the reproach which the obsession really involves. Only transitorily during the appearance of a new obsession, and now and then in melancholic exhaustive states of the ego do the morbid symptoms of the return also enforce the belief. The “compulsion” of the psychic formations here described has in general nothing to do with the recognition through belief, and is not to be mistaken for that moment which is designated as “strength” or “intensity” of an idea. Its main characteristic lies in its inexplicableness through psychic activities of conscious ability, and this character undergoes no change whether the idea to which the compulsion is attached is stronger or weaker, more or less intensively “elucidated,” “supplied with energy,” etc.

The reason for the unassailableness of the obsession or its derivative is due only to its connection with the repressed memory of early childhood, for as soon as we succeed in making it conscious, for which the psychotherapeutic methods already seem quite sufficient, the compulsion, too, becomes detached.

III. Analysis of a Case of Chronic Paranoia.

For some length of time I entertained the idea that paranoia also—or the group of cases belonging to paranoia—is a defense psychosis, that is, like hysteria and obsessions it originates from the repression of painful reminiscences, and that the form of its symptoms is determined by the content of the repression. A special way or mechanism of repression must be peculiar to paranoia perhaps just as in hysteria which brings about the repression by way of conversion into bodily innervation, and perhaps like obsessions in which a substitution is accomplished (displacement along certain associative categories). I observed many cases which seemed to favor this interpretation, but I had not found any which demonstrated it until a few months ago when, through the kindness of Dr. J. Breuer, I subjected to psychoanalysis, with therapeutic aims, an intelligent woman of 32, whom no one will be able to refuse to designate as a chronic paranoiac. I report here some explanations gained in this work, because I have no prospects of studying paranoia except in very isolated examples, and because I think it possible that these observations may instigate a psychiatrist for whom conditions are more favorable, to give due justice to the moment of defense in the present animated discussion on the nature and psychic mechanism of paranoia. It is of course far from my thoughts to wish to show from the following single observation anything but that this case is a defense psychosis, and that in the group of “paranoia” there may be still others of a similar nature.

Mrs. P. thirty-two years old, married three years. She is the mother of a two-year-old child, and does not descend from nervous parents; but her sister and brother whom I know, are also neurotic. It was doubtful whether she was not transitorily depressed and mistaken in her judgment in the middle of her twentieth year. During the last years she was healthy and capacitated until she evinced the first symptoms of the present illness, six months after the birth of her child. She became secluded and suspicious, showing a disinclination towards social relations with the relatives of her husband, and complained that the neighbors in the little town now behaved towards her in a rather impolite and regardless manner. Gradually these complaints grew in intensity, she thought that there was something against her, though she had no notion what it could be. But there was no doubt that all the relatives and friends denied her respect, and did everything to aggravate her. She was trying very hard to find out whence this came but could not discover anything. Some time later she complained that she was watched, that her thoughts were guessed, and that everything that happened in her house was known. One afternoon she suddenly conceived the thought that she was watched during the evening while undressing. Since then she applied while undressing the most complicated precautionary measures. She slipped into her bed in the darkness and undressed only under cover. As she avoided all social relations, and took but little nourishment, and was very depressed, she was sent in the summer of 1895 to a hydrotherapeutic institute. There new symptoms appeared and reinforced those already existing. As early as the spring, while she was alone with the servant girl, she suddenly perceived a sensation in her lap, and thought that the servant girl then had an unseemly thought. This sensation became more frequent in the summer, it was almost continuous, and she felt her genitals “as if one feels a heavy hand.” She then began to see pictures which frightened her; they were hallucinations of female nakedness, especially an exposed woman’s lap with hair; occasionally she also saw male genitals. The picture of the hairy lap and the organic sensation in the lap usually came conjointly. The pictures became very aggravating, as she regularly perceived them when she was in the company of a woman, and the thought accompanying them was that she sees the woman in an indecent exposure, and that in the same moment the woman sees the same picture of her (!) Simultaneously with these visual hallucinations, which, after their first appearance in the asylum, disappeared again for many months, she began to be troubled with voices which she did not recognize and could not explain. When she was in the street she heard, “This is Mrs. P.—Here she goes.—Where does she go?”. Every one of her movements and actions were commented upon. Occasionally she heard threats and reproaches. All these symptoms became worse when she was in society, or even in the street; she therefore hesitated about going out; she also stated that she experienced nausea for food, and as a result she became reduced in vitality.

I obtained this from her when she came under my care in the winter of 1895. I present this case in detail in order to make the impression that we really deal here with a very frequent form of chronic paranoia, which diagnosis will agree with the details of the symptoms and their behavior to be mentioned later. At that time she either concealed from me the delusions for the interpretation of the hallucinations or they really had not as yet occurred. Her intelligence was undiminished. It was reported to me as peculiar that she had a number of rendezvous with her brother who lived in the neighborhood, in order to confide something to him, but this she never told him. She never spoke about her hallucinations, and towards the end she did not say much about the aggravations and persecutions from which she suffered. What I have to report about this patient concerns the etiology of the case and the mechanism of the hallucinations. I discovered the etiology by applying Breuer’s method exactly as in hysteria, for the investigation and removal of the hallucinations. I started with the presupposition that just as in the two other defense neuroses known to me this paranoia must contain unconscious thoughts and repressed reminiscences which have to be brought to consciousness, in the same manner as in the others, by overcoming a certain resistance. The patient immediately corroborated this expectation by behaving during the analysis exactly like a hysteric, and under attention to the pressure of my hand she reproduced thoughts which she could not remember having had, which she at first could not understand, and which contradicted her expectations. The occurrence of important unconscious ideas was therefore also demonstrated in a case of paranoia, and I could hope to reconduct the compulsion of paranoia to repression. It was only peculiar that the assertions which originated in the unconscious were usually heard inwardly or hallucinated by her as her voices.