Studies On Hysteria
15
We have nothing new to say on the
question of the origin of these dispositional hypnoid states. They
often, it would seem, grow out of the day-dreams which are so
common even in healthy people and to which needlework and similar
occupations render women especially prone. Why it is that the
‘pathological associations’ brought about in these
states are so stable and why they have so much more influence on
somatic processes than ideas are usually found to do - these
questions coincide with the general problem of the effectiveness of
hypnotic suggestions. Our observations contribute nothing fresh on
this subject. But they throw a light on the contradiction between
the dictum ‘hysteria is a psychosis’ and the fact that
among hysterics may be found people of the clearest intellect,
strongest will, greatest character and highest critical power. This
characterization holds good of their waking thoughts; but in their
hypnoid states they are insane, as we all are in dreams. Whereas,
however, our dream-psychoses have no effect upon our waking state,
the products of hypnoid states intrude into waking life in the form
of hysterical symptoms.
IV
What we have asserted of chronic
hysterical symptoms can be applied almost completely to hysterical
attacks
. Charcot, as is well known, has given us a schematic
description of the ‘major’ hysterical attack, according
to which four phases can be distinguished in a complete attack: (1)
the epileptoid phase, (2) the phase of large movements, (3) the
phase of ‘
attitudes passionelles
’ (the
hallucinatory phase), and (4) the phase of terminal delirium.
Charcot derives all those forms of hysterical attack which are in
practice met with more often than the complete ‘
grande
attaque
’, from the abbreviation, absence or isolation of
these four distinct phases.
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Our attempted explanation takes
its start from the third of these phases, that of the
‘
attitudes passionelles
’. Where this is present
in a well-marked form, it exhibits the hallucinatory reproduction
of a memory which was of importance in bringing about the onset of
the hysteria - the memory either of a single major trauma (which we
find
par excellence
in what is called traumatic hysteria) or
of a series of interconnected part-traumas (such as underlie common
hysteria). Or, lastly, the attack may revive the events which have
become emphasized owing to their
coinciding
with a moment of
special disposition to trauma.
There are also attacks, however,
which appear to consist exclusively of motor phenomena and in which
the phase of
attitudes passionelles
is absent. If one can
succeed in getting into
rapport
with the patient during an
attack such as this of generalized clonic spasms or cataleptic
rigidity, or during an
attaque de somneil
[attack of sleep]
- or if, better still, one can succeed in provoking the attack
under hypnosis - one finds that here, too, there is an underlying
memory of the psychical trauma or series of traumas, which usually
comes to our notice in a hallucinatory phase.
Thus, a little girl suffered for
years from attacks of general convulsions which could well be, and
indeed were, regarded as epileptic. She was hypnotized with a view
to a differential diagnosis, and promptly had one of her attacks.
She was asked what, she was seeing and replied 'The dog! the
dog’s coming!’; and in fact it turned out that she had
had the first of her attacks after being chased by a savage dog.
The success of the treatment confirmed the choice of diagnosis.
Again, an employee who had become
a hysteric as a result of being ill-treated by his superior,
suffered from attacks in which he collapsed and fell into a frenzy
of rage, but without uttering a word or giving any sign of a
hallucination. It was possible to provoke an attack under hypnosis,
and the patient then revealed that he was living through the scene
in which his employer had abused him in the street and hit him with
a stick. A few days later the patient came back and complained of
having had another attack of the same kind. On this occasion it
turned out under hypnosis that he had been re-living the scene to
which the actual onset of the illness was related: the scene in the
law-court when he failed to obtain satisfaction for his
maltreatment.
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17
In all other respects, too, the
memories which emerge, or can be aroused, in hysterical attacks
correspond to the precipitating causes which we have found at the
root of
chronic
hysterical symptoms. Like these latter
causes, the memories underlying hysterical attacks relate to
psychical traumas which have not been disposed of by abreaction or
by associative thought activity. Like them, they are, whether
completely or in essential elements, out of reach of the memory of
normal consciousness and are found to belong to the ideational
content of hypnoid states of consciousness with restricted
association. Finally, too, the therapeutic test can be applied to
them. Our observations have often taught us that a memory of this
kind which has hitherto provoked attacks, ceases to be able to do
so after the process of reaction and associative correction have
been applied to it under hypnosis.
The motor phenomena of hysterical
attacks can be interpreted partly as universal forms of reaction
appropriate to the affect accompanying the memory (such as kicking
about and waving the arms and legs, which even young babies do),
partly as a direct expression of these memories; but in part, like
the hysterical stigmata found among the chronic symptoms, they
cannot be explained in this way.
Hysterical attacks, furthermore,
appear in a specially interesting light if we bear in mind a theory
that we have mentioned above, namely, that in hysteria groups of
ideas originating in hypnoid states are present and that these are
cut off from associative connection with the other ideas, but can
be associated among themselves, and thus form the more or less
highly organized rudiment of a second consciousness, a
condition
seconde
. If this is so, a chronic hysterical symptom will
correspond to the intrusion of this second state into the somatic
innervation which is as a rule under the control of normal
consciousness. A hysterical attack, on the other hand, is evidence
of a higher organization of this second state. When the attack
makes its first appearance, it indicates a moment at which this
hypnoid consciousness has obtained control of the subject’s
whole existence - it points, that is, to an acute hysteria; when it
occurs on subsequent occasions and contains a memory it points to a
return of that moment. Charcot has already suggested that
hysterical attacks are a rudimentary form of a
condition
seconde
. During the attack, control over the whole of the
somatic innervation passes over to the hypnoid consciousness.
Normal consciousness, as well-known observations show, is not
always entirely repressed. It may even be aware of the motor
phenomena of the attack, while the accompanying psychical events
are outside its knowledge.
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18
The typical course of a severe
case of hysteria is, as we know, as follows. To begin with, an
ideational content is formed during hypnoid states; when this has
increased to a sufficient extent, it gains control, during a period
of ‘acute hysteria’, of the somatic innervation and of
the patient’s whole existence, and creates chronic symptoms
and attacks; after this it clears up, apart from certain residues.
If the normal personality can regain control, what is left over
from the hypnoid ideational content recurs in hysterical attacks
and puts the subject back from time to time into similar states,
which are themselves once more open to influence and susceptible to
traumas. A state of equilibrium, as it were, may then be
established between the two psychical groups which are combined in
the same person: hysterical attacks and normal life proceed side by
side without interfering with each other. An attack will occur
spontaneously: just as memories do in normal people; it is,
however, possible to provoke one, just as any memory can be aroused
in accordance with the laws of association. It can be provoked
either by stimulation of a hysterogenic zone or by a new experience
which sets it going owing to a similarity with the pathogenic
experience. We hope to be able to show that these two kinds of
determinant, though they appear to be so unlike, do not differ in
essentials, but that in both a hyperaesthetic memory is touched
on.
In other cases this equilibrium
is very unstable. The attack makes its appearance as a
manifestation of the residue of the hypnoid consciousness whenever
the normal personality is exhausted and incapacitated. The
possibility cannot be dismissed that here the attack may have been
divested of its original meaning and may be recurring as a motor
reaction without any content.
It must be left to further
investigation to discover what it is that determines whether a
hysterical personality manifests itself in attacks, in chronic
symptoms or in a mixture of the two.
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19
V
It will now be understood how it is
that the psychotherapeutic procedure which we have described in
these pages has a curative effect.
It brings to an end the
operative force of the idea which was not abreacted in the first
instance, by allowing its strangulated affect to find a way out
through speech; and it subjects it to associative correction by
introducing it into normal consciousness (under light hypnosis) or
by removing it through the physician’s suggestion, as it is
done in somnambulism accompanied by amnesia
.
In our opinion the therapeutic
advantages of this procedure are considerable. It is of course true
that we do not cure hysteria in so far as it is a matter of
disposition. We can do nothing against the recurrence of hypnoid
states. Moreover, during the productive stage of an acute hysteria
our procedure cannot prevent the phenomena which have been so
laboriously removed from being at once replaced by fresh ones. But
once this acute stage is past, any residues which may be left in
the form of chronic symptoms or attacks are often removed, and
permanently so, by our method, because it is a radical one; in this
respect it seems to us far superior in its efficacy to removal
through direct suggestion, as it is practised to-day by
psychotherapists.
If by uncovering the psychical
mechanism of hysterical phenomena we have taken a step forward
along the path first traced so successfully by Charcot with his
explanation and artificial imitation of hystero-traumatic
paralyses, we cannot conceal from ourselves that this has brought
us nearer to an understanding only of the
mechanism
of
hysterical symptoms and not of the internal causes of hysteria. We
have done no more than touch upon the aetiology of hysteria and in
fact have been able to throw light only on its acquired forms - on
the bearing of accidental factors on the neurosis.
VIENNA
,
December
1892
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20
II
CASE HISTORIES
(BREUER AND FREUD)
Studies On Hysteria
21
II
CASE HISTORIES
(BREUER AND FREUD)
CASE
1
FRÄULEIN ANNA O.
(Breuer)
At the time of her falling ill (in 1880)
Fräulein Anna O. was twenty-one years old. She may be regarded
as having had a moderately severe neuropathic heredity, since some
psychoses had occurred among her more distant relatives. Her
parents were normal in this respect. She herself had hitherto been
consistently healthy and had shown no signs of neurosis during her
period of growth. She was markedly intelligent, with an
astonishingly quick grasp of things and penetrating intuition. She
possessed a powerful intellect which would have been capable of
digesting solid mental pabulum and which stood in need of it -
though without receiving it after she had left school. She had
great poetic and imaginative gifts, which were under the control of
a sharp and critical common sense. Owing to this latter quality she
was
completely unsuggestible
; she was only influenced by
arguments, never by mere assertions. Her willpower was energetic,
tenacious and persistent; sometimes it reached the pitch of an
obstinacy which only gave way out of kindness and regard for other
people.
One of her essential character
traits was sympathetic kindness. Even during her illness she
herself was greatly assisted by being able to look after a number
of poor, sick people, for she was thus able to satisfy a powerful
instinct. Her states of feeling always tended to a slight
exaggeration, alike of cheerfulness and gloom; hence she was
sometimes subject to moods. The element of sexuality was
astonishingly undeveloped in her. The patient, whose life became
known to me to an extent to which one person’s life is seldom
known to another, had never been in love; and in all the enormous
number of hallucinations which occurred during her illness that
element of mental life never emerged.