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CHAPTER IV.

THE PSYCHOTHERAPY OF HYSTERIA.

In our “Preliminary Communication” we have stated that while
investigating the etiology of hysterical symptoms we have also dis-
covered a therapeutic method which we consider of practical sig-
nificance. “We found, at first to our very greatest surprise, that
the individual hysterical symptoms immediately disappeared with
out returning if we succeeded in thoroughly awakening the memo-
ries of the causal process with its accompanying effect, and if the
patient circumstantially discussed the process giving free play to
the affect” (p. 4).

We furthermore attempted to explain how our psychothera-
peutic method acts. “It does away with the effects of the original
not ab-reacted to ideas by affording an outlet to the suppressed
affect through speech. It brings it into associative correction by
drawing it into normal consciousness (in mild hypnosis), or it is
done away with through the physician’s suggestion just as happens
in somnambulism with amnesia” (p. 13).

Although the essential features of this method have been enu-
merated in the preceding pages, a repetition is unavoidable, and I
shall now attempt to show connectedly how far-reaching this
method is, its superiority over others, its technique, and its
difficulties.

I.

I, for my part, may state that I can adhere to the “Preliminary
Communication,” but I must confess that after continuous occupa-
tion for years with the problems therein touched, I was confronted
with new views, as a result of which the former material under-
went at least a partial change in grouping and conception. It
would be unjust to impute too much of the responsibility for this
development to my honored friend, J. Breuer. I therefore take
the weight of responsibility upon myself.

In attempting to use Breuer’s method of treating hysterical
symptoms in a great number of patients by investigation and

76

ab-reaction in hypnosis, I encountered two obstacles, the pur-
suit of which led me to change the technique as well as the con-
ception. (1) Not all persons were hypnotizable who undoubtedly
showed hysterical symptoms, and in whom there most probably
existed the same psychic mechanism. (2) I had to question what
essentially characterizes hysteria, and in what it differs from other
neuroses.

How I overcame the first difficulty, and what it taught me, I
will show later. I will first state what position I have taken in
my daily practice towards the second problem. It is very difficult
to examine a case of neurosis before it has been subjected to
a thorough analysis, such as would result only through the ap-
plication of Breuer’s method. But before we have such a
thorough knowledge we are obliged to decide upon the diagnosis
and kind of treatment. Hence the only thing remaining for me
was to select such cases for the cathartic method which could,
for the time being, be diagnosed as hysteria, and which showed
some or many stigmata, or the characteristic symptoms of
hysteria. Yet it sometimes happened that in spite of the diag-
nosis of hysteria the therapeutic results were very poor, and even
the analysis revealed nothing of importance. At other times I
attempted to treat cases which no one took for hysteria by
Breuer’s method, and I found that I could influence them, and
even cure them. Such, for example, was my experience with
obsessions, the real obsessions of Westphal’s type, cases which
did not show a single feature of hysteria. Thus the psychic
mechanism revealed in the “Preliminary Communi-
cation” could not be pathognomonic of hysteria. Nor could I for the sake of
this mechanism throw so many neuroses into the same pot with
hysteria. From all the investigated doubts I finally seized upon
a plant to treat all the other neuroses in question just like hysteria,
to investigate the etiology and the form of psychic mechanisms,
and to leave the diagnosis of hysteria to be dependent upon the
result of this investigation.

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

77

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 char-
acteristics of the neuroses, and build up a sharp line of demarca-
tion 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 neuras-
thenia 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 of 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 recog-
nized by E. Hecker¹⁾ as having a common character. They are
either symptoms, or equivalents, or rudiments of anxiety mani-
festations, and it is for that reason that this complex, so dif-
ferent from neurasthenia, was called by me anxiety neurosis. I
maintain that it originates from an accumulation of physical ten-
sion 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 ex-
pectation, 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 re-
sembles 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 hypo-
chondria 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 at-
tention

¹⁾E. Hecker, Centralblatt für Nervenheilkunde, Dec., 1893.

78

tention 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 degenera-
tion under the caption of hysteria. Whenever a hysterical symp-
tom, such as an anesthesia or a characteristic attack, could he dis-
covered 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 contra-
distory 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 neu-
rosis, 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 etio-
logical 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 com-
plicated 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

79

THE PSYCHOTHERAPY OF HYSTERIA.

hysteria. Breuer’s patient, Anna O.,²⁾ seems to contradict this
and exemplifies a pure hysterical disease. Yet this case which
became so fruitful for the knowledge of hysteria was never con-
sidered 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,³⁾ 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 neuras-
thenia 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

²⁾See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 15.

³⁾See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 106.

80

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 case 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 wiuld 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 state-
ments are true. I believe that hysteria, purified of all admix-
tures, 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.

X X

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 promi-
nent place for our therapeutic method in the realm of the therapy