Selected Papers on Hysteria and Other Psychoneuroses/Chapter 7

by Sigmund Freud

CHAPTER VII.
Further Observations on the Defense-Neuropsychoses.

Under the caption of "Defense-Neuropsychoses" I have comprised hysteria, obsessions, as well as certain cases of acute hallucinatory confusion.^[1] All these affections evince one common aspect in the fact that their symptoms originated through the psychic mechanism of (unconscious) defense, that is, through the attempt to repress an unbearable idea which appeared in painful contrast to the ego of the patient. I was also able to explain and exemplify by cases reported in the preceding chapters in what sense this psychic process of "defense" or "repression" is to be understood. I have also discussed the laborious but perfectly reliable method of psychoanalysis of which I make use in my examinations, and which at the same time serves as a therapy.

My experiences during the last two years have strengthened my predilection for making the defense the essential point in the psychic mechanism of the mentioned neuroses, and on the other hand have permitted me to give a clinical foundation to the psychological theory. To my surprise I have discovered some simple but sharply circumscribed solutions for the problem of the neuroses which I shall provisionally briefly report in the following pages. It would be inconsistent with this manner of reporting to add to the assertions the required proofs, but I hope to be able to fulfill this obligation in a comprehensive discussion.

I. The "Specific" Etiology of Hysteria.

That the symptoms of hysteria become comprehensible only through a reduction to "traumatically" effective experiences, and that these psychic traumas refer to the sexual life has already been asserted by Breuer and me in former publications. What I have to add today as a uniform result of thirteen analyzed cases of hysteria concerns, on the one hand, the nature of these sexual traumas, and on the other, the period of life in which they occured. An experience occurring at any period of life, touching in any way the sexual life, and then becoming pathogenic through the liberation and suppression of a painful affect is not sufficient for the causation of hysteria. It must on the contrary belong to the sexual traumas of early childhood (the period of life before puberty), and its content must consist in a real irritation of the genitals (coitus-like processes).

This specific determination of hysteria—sexual passivity in pre-sexual periods—I have found fulfilled in all analyzed cases of hysteria (among which were two men). To what extent the determination of the accidental etiological moment diminishes the requirement of the hereditary predisposition needs only be intimated. We can, moreover, understand the disproportionately greater frequency of hysteria in the female sex, as even in childhood this sex is more subject to sexual assaults.

The objection most frequently advanced against this result may be to the purport, that sexual assaults on little children occur too frequently to give an etiological value to its verification, or that such experiences must remain ineffectual just because they concern a sexually undeveloped being; and that one must moreover be careful not to obtrude upon the patient through the examination such alleged reminiscences or believe in the romances which they themselves fabricate. To the latter objections I hold out the request that no one should really judge with great certainty this obscure realm unless he has made use of the only method which can clear it up (the method of psychoanalysis for bringing to consciousness the hitherto unconscious^[2]). The essential point in the first doubts is settled by the observation that it really is not the experiences themselves that act traumatically, but their revival as reminiscences after the individual has entered into sexual maturity.

My thirteen cases of hysteria were throughout of the graver kind, they were all of long duration, and some had undergone a lengthy and unsuccessful asylum treatment. Every one of the infantile traumas which the analysis revealed for their severe cases had to be designated as marked sexual injuries; some of them were indeed abominable. Among the persons who were guilty of such serious abuse we have in the first place nurses, governesses, and other servants to whom children are left much too carelessly, then in regrettable frequency come the teachers; but in seven of the thirteen cases we dealt with innocent childish offenders, mostly brothers who for years entertained sexual relations with their younger sisters. The course of events always resembled some of the cases which could with certainty be tracked, namely, that the boy had been abused by a person of the feminine sex, thus awakening in him prematurely the libido, and that after a few years he repeated in sexual aggression on his sister the same procedures to which he himself was subjected.

I must exclude active masturbation from the list of sexual injuries of early childhood as being pathogenic for hysteria. That it is so very frequently found associated with hysteria is due to the fact that masturbation in itself is more frequently the result of abuse or seduction than one supposes. It not seldom happens that both members of a childish pair later in life become afflicted by defense neuroses, the brother by obsessions and the sister by hysteria, which naturally gives the appearance of a familial neurotic predisposition. This pseudo-heredity is now and then solved in a surprising manner. I have had under observation a brother, sister, and a somewhat older cousin. The analysis which I have undertaken with the brother showed me that he suffered from reproaches for being the cause of his sister's malady; he himself was corrupted by his cousin, concerning whom it was known in the family that he fell a victim to his nurse.

I can not definitely state up to what age sexual damage occurs in the etiology of hysteria, but I doubt whether sexual passivity can cause repression after the eighth and tenth year unless qualified for it by previous experiences. The lower limit reaches as far as memory in general, that is, to the delicate age of one and one half or two years! (two cases). In a number of my cases the sexual trauma (or the number of traumas) occurred during the third and fourth year of life. I myself would not lend credence to this peculiar discovery if it were not for the fact that the later development of the neurosis furnished it with full trustworthiness. In every case there are a number of morbid symptoms, habits and phobias which are only explainable by returning to those youthful experiences, and the logical structure of the neurotic manifestation makes it impossible to reject the faithfully retained memories of childhood. Except through psychoanalysis it is of no avail to ask a hysterical patient about these infantile traumas; their remains can only be found in the morbid symptoms and not in conscious memory.

All the experiences and excitements which prepare the way for, or occasion the outburst of, hysteria in the period of life after puberty evidently act through the fact that they awaken the memory remnants of those infantile traumas which do not become conscious but lead to the liberation of affect and repression. It is quite in harmony with this role of the later traumas not to be subject to the strict limitation of the infantile traumas, but that both in intensity and quality they can vary from an actual sexual assault to a mere approximation of the sexual, such as perceiving the sexual acts of others, or receiving information concerning sexual processes.^[3]

In my first communication on the defense neuropsychoses I failed to explain how the exertion of a hitherto healthy individual to forget such traumatic happenings would result in the real intentional repression, and thus open the door for the defense neurosis. It can not depend on the nature of the experience, as other persons remain unaffected despite the same motives. Hysteria cannot therefore be fully explained by the effect of the trauma, and we are forced to admit that the capacity for hysteria already existed before the trauma.

This indefinite hysterical predisposition can now wholly or partially be substituted by the posthumous effect of the infantile sexual trauma. The "repression" of the memory of a painful sexual experience of maturer years can take place only in sons in whom this experience can bring into activity the memory remnants of an infantile trauma.^[4]

The prerequisite of obsessions is also a sexual infantile experience, but of a different nature than that of hysteria. The etiology of both defense neuropsychoses now shows the following relation to the etiology of both simple neuroses, neurasthenia and anxiety neurosis. As I have shown above, both the latter neuroses are the direct results of the sexual noxas alone, while both defense neuroses are the direct results of sexual noxas which acted before the appearance of sexual maturity that is, they are the results of the psychic memory remnants of these noxas. The actual causes producing neurasthenia and anxiety neurosis simultaneously play the rôle of inciting causes of the defense neuroses, and on the other hand, the specific causes of the defense neuroses, the infantile traumas, may simultaneously prepare the soil for the later developing neurasthenia. Finally it not seldom happens that the existence of a neurasthenia or anxiety neurosis is only preserved by continued recollection of an infantile trauma rather than by actual sexual injuries.

II. The Essence and Mechanism of Compulsion Neurosis.

Sexual experiences of early childhood have the same significance in the etiology of the compulsion neurosis as in hysteria, still we no longer deal here with sexual passivity but with pleasurably accomplished aggressions, and with pleasurably experienced participation in sexual acts, that is, we deal here with sexual activity. It is due to this difference in the etiological relations that the masculine sex seems to be preferred in the compulsion neurosis.

In all my cases of compulsion neurosis I have found besides a sub-soil of hysterical symptoms which could be traced to a pleasurable action of sexual passivity from a precedent scene. I presume that this coincidence is a lawful one and that premature sexual aggression always presupposes an experience of seduction. But I am unable to present as yet a complete description of the etiology of the compulsion neurosis. I only believe that the final determination as to whether a hysteria or compulsion neurosis should originate on the basis of infantile traumas depends on the temporal relation of the development of the libido.

The essence of the compulsion neurosis may be expressed in the following simple formula: Obsessions are always transformed 'reproaches returning from the repression which always refer to a pleasurably accomplished sexual action of childhood. In order to elucidate this sentence it will be necessary to describe the typical course of compulsion neurosis.

In a first period—period of childish immorality—the events containing the seeds of the later neurosis take place. In the earliest childhood there appear at first the experiences of sexual seduction which later makes the repression possible, and this is followed by the actions of sexual aggressions against the other sex which later manifest themselves as actions of reproach.

This period is brought to an end by the appearance of the—often self ripened—sexual "maturity." A reproach then attaches itself to the memory of that pleasurable action, and the connection with the initial experience of passivity makes it possible—often only after conscious and recollected effort—to repress it and replace it by a primary symptom of defense. The third period, that of apparent healthiness but really of successful defense, begins with the symptoms of scrupulousness, shame and diffidence.

The next period, the disease is characterized by the return of the repressed reminiscences, hence, by the failure of the defense; but it remains undecided whether the awakening of the same is more frequently accidental and spontaneous, or whether it appears in consequence of actual sexual disturbances, that is, as additional influences of the same. But the revived reminiscences and the reproaches formed from them never enter into consciousness unchanged, but what becomes conscious as an obsession and obsessive affect and substitutes the pathogenic memory in the conscious life, are compromise formations between the repressed and the repressing ideas.

In order to describe clearly and probably convincingly the processes of repression, the return of the repression, and the formation of the pathological ideas of compromise, we would have to decide upon very definite hypotheses concerning the substratum of the psychic occurrence and consciousness. As long as we wish to avoid it we will have to rest content with the following rather figuratively understood observations. Depending on whether the memory content of the reproachful action alone forces an entrance into consciousness or whether it takes with it the accompanying reproachful affect, we have two forms of compulsion neurosis. The first represents the typical obsessions, the content of which attracts the patient's attention; only an indefinite displeasure is perceived as an afifect, whereas, for the content of the obsession the only suitable affect would be one of reproach. The content of the obsession is doubtly distorted when compared to the content of the infantile compulsive act. First, something actual replaces the past experience, and second, the sexual is substituted by an analogous non-sexual experience. These two changes are the results of the constant tendency to the repression still in force which we will attribute to the "ego." The influence of the revived pathogenic memory is shown by the fact that the content of the obsession is still partially identical with the repressed, or can be traced to it by a correct stream of thought. If, with the help of the psychoanalytic method, we reconstruct the origin of one individual obsession we find that one actual impression instigated two diverse streams of thought, and that the one which passed over the repressed memory, though incapable of consciousness and correction, proves to be just as correctly formed logically as the other. If the results of the two psychic operations disagree, the contradiction between the two may never be brought to logical adjustment, but as a compromise between the resistance and the pathological result of thought an apparently absurd obsession enters into consciousness beside the normal result of the thought. If both streams of thought yield the same result, they reinforce each other so that the normally gained result of thought now behaves psychically like an obsession. Wherever neurotic compulsion manifests itself psychically it originates from repression. The obsessions have, as it were, a psychical course of compulsion which is due, not to their own validity, but to the source from which they originate, or to the source which furnishes a part of their validity.

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 compusion 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 througout "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.^[5]

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 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 psycho-therapeutic 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 begain 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?" Everyone 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 1 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.

Concerning the origin of the visual hallucinations, or at least the vivid pictures, I discovered the following: The picture of the female lap occurred almost always together with the organic sensation in the lap. The latter, however, was more constant and often occurred without the picture.

The first pictures of feminine laps appeared in the hydro-therapeutic institute a few hours after she had actually seen a number of women naked in the bath house. They were therefore only simple reproductions of a real impression. It may be assumed that these impressions repeated themselves because something of great interest was connected with them. She stated that she was at that time ashamed of these women, and that since she recalled it she is ashamed of having been seen naked. Having been obliged to look upon this shame as something compulsive, I concluded that according to the mechanism of defense an experience must have here been repressed in which she was not ashamed, and I requested her to allow those reminiscences to emerge which belonged to the theme of shame. She promptly reproduced a series of scenes from her seventeenth to her eighth year, during which while bathing before her mother, her sister, and her physician she was ashamed of her nakedness. This series, however, reached back to a scene in her sixth year when she undressed in the children's room before going to sleep without feeling ashamed of her brother who was present. On questioning her it was found that there were a number of such scenes, and that for years the brothers and sisters were in the habit of showing themselves naked to one another before retiring. I now understood the significance of the sudden thought of being watched on going to sleep. It was an unchanged fragment of the old reproachful reminiscence and she was now trying to make up in shame what she lost as a child.

The supposition that we dealt here with an amour of childhood so frequent in the etiology of hysteria was strengthened by the further progress of the analysis which also showed simultaneous solutions for individual frequently recurring details in the picture of paranoia. The beginning of her depression commenced at the time of a disagreement between her husband and her brother on account of which the latter no longer visited her. She was always much attached to this brother and missed him very much at this time. Besides this she spoke about a moment in the history of her disease during which for the first time "everything became clear," that is, during which she became convinced that her assumption about being generally despised and intentionally annoyed was true. She gained this assurance during a visit of her sister-in-law, who in the course of conversation dropped the words, " If such a thing should happen to me I would not mind it." Mrs. P. at first took this utterance unsuspectingly, but when her visitor left her it seemed to her that these words contained a reproach meaning that she was in the habit of taking serious matters lightly, and since that hour she was sure that she was a victim of common slander. On asking her why she felt justified in referring those words to herself she answered that the tone in which her sister-in-law spoke convinced her of it—to be sure subsequently—This is really a characteristic detail of paranoia. I now urged her to recall her sister-in-law's conversation before the accusing utterance, and it was found that she related that in her father's home there were all sorts of difficulties with the brothers, and added the wise remark, "In every family many things happen which one would rather keep under cover, and that if such a thing should happen to her she would take it lightly." Mrs. P. had to acknowledge that her depression was connected with the sentences before the last utterance. As she repressed both sentences which could recall her relations with her brother and retained only the last meaningless one, she was forced to connect with it the feeling of being reproached by her sister-in-law; but, inasmuch as the contents of this sentence offered absolutely no basis for such assumption she disregarded it and laid stress on the tone with which the words were pronounced. It is probably a typical illustration for the fact that the misinterpretations of paranoia depend on repression.

In a most surprising manner it also explains her peculiar behavior in making appointments with her brother and then refusing to tell him anything. Her explanation was that she thought that if she only looked at him he must understand her suffering, as he knew the cause of it. As this brother was really the only person who could know anything about the etiology of her disease it followed that she acted from a motive which, though she did not consciously understand, seemed perfectly justified as soon as a new sense was put on it from the unconscious.

I then succeeded in causing her to reproduce different scenes the culminating points of which were the sexual relations with her brother at least from her sixth to her tenth year. During this work of reproduction the organic sensation in the lap "joined in the discussion," precisely as regularly observed in the analysis of memory remnants of hysterical patients. The picture of a naked female lap (but now reduced to childish proportions and without hair) immediately appeared or stayed away in accordance with the occurrence of the scene in question in full light or in darkness. The disgust for eating, too, was explained by a repulsive detail of these actions. After we had gone through this series, the hallucinatory sensations and pictures disappeared without having thus far returned.^[6]

I have thus learned that these hallucinations were nothing other than fragments from the content of the repressed experiences of childhood, that is, symptoms of the return of the repressed material.

I now turned to the analysis of the voices. Here it must before all be explained why such indifferent remarks as, "Here goes Mrs. P.—She now looks for apartments, etc.," could be so painfully perceived, and how these harmless sentences managed to become distinguished by hallucinatory enforcement. To begin with, it was clear that these " voices " could not be hallucinatory reproduced reminiscences like the pictures and sensations, but rather thoughts which "became loud."

She heard the voices for the first time under the following circumstances. With great tension she read the pretty story, "The Heiterethei" by O. Ludwig, and noticed that while reading she was preoccupied with incoming thoughts. Immediately after she took a walk on the highway and suddenly while passing a peasant's cottage the voices told her, "That is how the house of the Heiterethei looked! Here is the well, and here is the bush! How happy she was in all her poverty! "The voices then repeated whole paragraphs of what she had just read, but it remained incomprehensible why house, bush, and well of the Heiterethei, and just such indifferent and most irrelevant passages of the romance should have obtruded themselves upon her attention with pathological strength. The analysis showed that while reading she at the same time entertained extraneous thoughts, and that she was excited by totally different passages of the book. Against this material analogy between the couple of the romance and herself and her husband, the reminiscence of intimate things of her married life and family secrets, against all these there arose a repressive resistance because they were connected with her sexual shyness by very simple and demonstrable streams of thought, and finally resulted in the awakening of old experiences of childhood. In consequence of the censorship exercised by the repression the harmless and idyllic passages connected with the objectionable ones by contrast and vicinity, became reinforced in consciousness, enabling them to become audible. For example, the first repressed thought referred to the slander to which the secluded heroine was subjected by her neighbors. She readily found in this an analogy to herself. She, too, lived in a small place, had no intercourse with anybody and considered herself despised by her neighbors. The suspicion against the neighbors was founded on the fact that in the beginning of her married life she was obliged to content herself with a small apartment. The wall of the bedroom, near which stood the nuptial bed of the young couple, adjoined the neighbors' room. With the beginning of her marriage there awakened in her a great sexual shyness. This was apparently due to an unconscious awakening of some reminiscences of childhood of having played husband and wife. She was very careful lest the neighbors might hear through the adjacent wall either words or noises and this shyness changed into suspicion against the neighbors.

The voices therefore owed their origin to the repression of thoughts which in the last analysis really signified reproaches on the occasion of an experience analogous to the infantile trauma; they were accordingly symptoms of the return of the repression, but at the same time they were results of a comparison between the resistance of the ego and the force of the returning repression which in this case produce a distortion beyond recognition. On other occasions when analyzing voices in Mrs. P. the distortion was less marked, still the words heard always showed a character of diplomatic uncertainty. The annoying allusion was generally deeply hidden, the connection of the individual sentences was masked by a strange expression, unusual forms of speech, etc., characteristics generally common to the auditory hallucinations of paranoiacs, and in which I noticed the remnant of the compromise distortion. The expression, "There goes Mrs. P., she is looking for apartments in the street," signified, for example, the threat that she will never recover, for I promised her that after the treatment she would be able to return to the little city where her husband was employed. She rented temporary quarters in Vienna for a few months.

On some occasions Mrs. P. also perceived more distinct threats, for example, concerning the relatives of her husband, the restrained expression of which still continued to contrast with the grief which such voices caused her. Considering all that we otherwise know of paranoiacs I am inclined to assume a gradual relaxation of that resistance which weakens the reproaches so that finally the defense fails completely and the original reproach, the insulting word, which one wanted to save himself returns in unchanged form. I do not, however, know whether this is a constant course, whether the censor of the expressions of reproach can not from the beginning stay away, or persist to the end.

It is left for me to utilize the explanations gained in this case of paranoia for the comparison of paranoia with compulsion neurosis. Here, as there, the repression was shown to be the nucleus of the psychic mechanism, and in both cases the repression is a sexual experience of childhood. The origin of every compulsion in this paranoia is in the repression, and the symptoms of paranoia allow a similar classification as the one found justified in compulsion neurosis. Some symptoms also originate from the primary defense among which are all delusions of distrust, suspicion and persecution by others. In the compulsion neurosis the initial reproach became repressed through the formation of the primary symptom of defense, self-distrust, moreover, the reproach was recognized as justified, and for the purpose of adjustment the validity acquired by the scrupulousness during the normal interval now guards against giving credence to the returning reproach in the form of an obsession. By the formation of the defense-symptom of distrust in others, the reproach in paranoia is repressed in a way which may be designated as projection; the reproach is also deprived of recognition, and as a retaliation there is no protection against the returning reproaches contained in the delusions.

The other symptoms in my case of paranoia are therefore to be designated as symptoms of the return of the repression, and as in the compulsion neurosis they show the traces of the compromise which alone permits an entrance into consciousness. Such are the delusions of being observed while undressing, the visual hallucination, the perceptual hallucinations and the hearing of voices. The memory content existing in the delusion mentioned is almost unchanged and appears only uncertain through utterance. The return of the repression into visual pictures comes nearer to the character of hysteria than to the character of compulsion neurosis; still, hysteria is wont to repeat its memory symbols without modification, whereas the paranoic memory hallucination undergoes a distortion similar to those in compulsion neurosis. An analogous modern picture takes the place of the one repressed (instead of a child's lap it was the lap of a woman upon which the hairs were particularly distinct because they were absent in the original impression). Quite peculiar to paranoia but no further elucidated in this comparison is the fact that the repressed reproaches return as loud thoughts, this must yield to a double distortion: (1) a censor, which either leads to a replacement through other associated thoughts or to a concealment by indefinite expressions, and (2) the reference to the modern which is merely analogous to the old.

The third group of symptoms found in compulsion neurosis, the symptoms of the secondary defense, cannot exist as such in paranoia, for no defense asserts itself against the returning symptoms which really find credence. As a substitute for this we find in paranoia another source of symptom formation; the delusions (symptom of return) reaching consciousness through the compromise demand a great deal of the thinking work of the ego until they can be unconditionally accepted. As they themselves are not to be influenced the ego must adapt itself to them, and hence the combining delusional formation, the delusion of interpretation which results in the transformation of the ego, corresponds here to the symptoms of secondary defense of compulsion neurosis. In this respect my case was imperfect as it did not at that time show any attempt at interpretation, this only appeared later. I do not doubt, however, that if psychoanalysis were also applied to that stage of paranoia, another important result would be established. It would probably be found that even the so called weakness of memory in paranoiacs is purposeful, that is, it depends on the repression and serves its purpose. Subsequently even those non-pathogenic memories which stand in opposition to the transformation of the ego become repressed and replaced; this the symptoms of return imperatively demand.

1. Neurologisches Centralblatt, 1896, Nr. 10.
2. I myself surmise that the so frequently fabricated assaults of hysterical persons are obsessional confabulations emanating from the memory traces of infantile traumas.
3. In an article on the anxiety neurosis (Neurologisches Centralblatt, 1895, Nr. 2) I stated that "an anxiety neurosis which can almost typically be combined with hysteria can be evoked in maturing girls at the first encounter with the sexual problem." I know today that the occasion in which such virginal anxiety breaks out does not really correspond to the first encounter with sexuality, but that in such persons there was in childhood a precedent experience of sexual passivity which memory was awakened at the "first encounter."
4. A psychological theory of the repression ought also to inform us why only ideas of a sexual content can be repressed. It may be formulated as follows: It is known that ideas of a sexual content produce exciting processes in the genitals resembling the actual sexual experience. It may be assumed that this somatic excitement becomes transformed into psychic. As a rule the activity referred to is much stronger at the time of the occurrence than at the recollection of the same. But if the sexual experience takes place during the time of sexual immaturity and the recollection of the same is awakened during or after maturity, the recollection then acts disproportionately more exciting than the previous experience, for puberty has in the mean time incomparably increased the reactive capacity of the sexual apparatus. But such an inverse proportion seems to contain the psychological determination of repression. Through the retardation of the pubescent maturity in comparison with the psychic function, the sexual life offers the only existing possibility for that inversion of the relative efficacy. The infantile traumas subsequently act like fresh experiences, but they are then unconscious. Deeper psychological discussions I will have to postpone for another time. I moreover call attention to the fact that the here considered time of "sexual maturity" does not coincide with puberty, but occurs before the same (eight to ten years).
5. One example instead of many: An eleven-year-old boy has obsessively arranged for himself the following ceremonial before going to bed: He could not fall asleep unless he related to his mother most minutely all experiences of the day; not the smallest scrap of paper or any other rubbish was allowed in the evening on the carpet of his bedroom. The bed had to be moved close to the wall, three chairs had to stand in front of it, and the pillows had to lie in just such a position. In order to fall asleep he had to kick with both legs a number of times, and then had to lie on the side. This was explained as follows : Years before while putting this pretty boy to sleep, the servant girl made use of this opportunity to lay over him and assault him sexually. When this reminiscence was later awakened by a recent experience it made itself known to consciousness by the compulsion in the above mentioned ceremonial which sense could really be surmised and the details verified by psychoanalysis. The chairs before the bed which was close to the wall—so that no one could have access to it; the arrangement of the pillows in a definite manner—so that they should be differently arranged than they were on that evening; the motion with the legs—to kick away the person lying on him; sleeping on the side—because during that scene he lay on his back; the detailed confession to his mother—because in consequence of the prohibition of his seductress he concealed from his mother this and other sexual experiences; finally, keeping the floor of his bedroom clean—because this was the main reproach which he had to hear from his mother up to that time.
6. When the meagre success of this treatment was later removed by an exacerbation, she did not again see the offensive pictures of strange genitals, but she had the idea that strangers saw her genitals as soon as they were behind her.