Freud’s Cases of Hysteria: Birth of Psychoanalysis
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Published: Fri, 23 Feb 2018
This thesis returns to the original case histories that Freud wrote on the patients he treated for hysteria. Here in these early works, the beginnings of psychoanalytical theory take shape in the acceptance of purely psychological theories of hysteria. Catharsis leads to the first inklings of repression which requires the use of free association, which again leads into Freud’s attempt to explain the strange neuroses he sees through seduction theory, which is again transformed as his thinking moves on. Through Anna O, Frau Emmy von N. and Dora, Freud discovered the seeds of what would become his all-encompassing theory of the human psyche. Modern reinterpretations (e.g. Rosenbaum & Muroff, 1984) of those early cases that form the basis of modern psychoanalysis have come and gone, but the original texts remain as historical testament to the fermenting of those fundamental ideas.
Hysteria has been a hugely popular subject for research in psychoanalysis and in the history of ideas. It’s roots are clearly signalled by the Greek word from which the word comes: uterus. Indeed the uterus was seen by Egyptians as a mobile organism that could move about of its own will – when it chose to do so this caused the disturbances only seen (or acknowledged) in women. Treatments for this disease included trying to entice the uterus back into the body with the use of attractive-smelling substances as well as the driving down of the uterus from above by the eating of noxious substances. Just under four thousand years later, the formulation and treatment of ‘hysterics’ had barely improved.
The history of hysteria shows how it has often been seen as a physical disorder, rather than a mental one. Borossa (2001) describes some of the most common symptoms of hysteria as involving paralysis of the limbs, coughing, fainting, the loss of speech and parallel to this the sudden proficiency in another language. The change of viewpoint that lead up to Freud’s analysis was slow in coming, and, as Bernheimer (1985) describes, only showed the first signs of changing in the seventeenth century with the first questions being raised that perhaps hysteria had its origins in a mental disturbance of some kind.
Antecedent to Freud’s interest in hysteria, it was the clinical neurologist, Charcot, who had a great influence on the field and accepted, by his methods, a more psychological explanation. Although sexual factors had long been implicated in the aetiology of hysteria (Ellenberger, 1970), Charcot did not agree that they were a sine qua non although he did maintain that they played an important part. He treated patients using a form of hypnosis and eventually his formulation of how hysteria was produced and treated was closely intertwined with the hypnosis itself. It was this use of hypnosis that interested Freud and it was the implication of sexual factors in hysteria that was eventually to become influential. It seemed that hysteria and hypnosis might offer Freud the chance to investigate the link between mind and body (Schoenwald, 1956).
Anna O: The First Psychoanalytical Patient
The literature often describes Anna O as the first ever patient of psychoanalysis. As it is notoriously difficult to define precisely what psychoanalysis might mean because of its shifting nature through time, this is a claim that is clearly interpretational. Still, the fact that this claim is made raises the interest into precisely what it was that marked out Anna O’s treatment and the theories accompanying it from what had gone before. Although Anna O was not a patient of Freud, but a patient of his close colleague at the time, Joseph Breuer, he took a great interest in her case and its treatment, and from it flowed some of the foundational aspects of psychoanalysis both through the analysis of this case and Freud’s reaction and reinterpretation of it.
One of the reasons that Freud was interested in Anna O was that she represented an extremely unusual case of hysteria. Anna O had first been taken ill while she had been taking care of her dying father. At first she suffered from a harsh cough which soon expanded into a range of other perplexing symptoms. Freud & Breuer (1991) describe these symptoms as going through four separate stages. The first stage, the ‘latent incubation’, occurred while she was nursing her dying father – she had become weak, was not eating and would spend much of the afternoons sleeping, which was then unexpectedly followed by a period of excited activity in the evenings. The second stage, which had begun around the time Breuer started treating her, contained a strange confluence of symptoms. Her vision was affected by a squint, she could no longer move any of the extremities on the right side of her body. The third stage, which roughly coincided with the death of her father, heralded alternating states of somnambulism with relative normality. The fourth stage, according to Breuer, is the slow leaking away of these symptoms up until June 1882, almost two years after she had first come to see her physician. The question is, how had these symptoms been interpreted and what had Breuer done in claiming to effect a cure?
It is in the case of Anna O that the most basic elements of a new ‘talking cure’ can be seen. As told by Breuer, it is a treatment that grew organically, as if by its own power, as he continued to see the patient. Often, in the afternoons, when the patient would habitually fall into an auto-hypnotic state, she would utter odd words or phrases, which, when questioned by those around her, would become elaborated into stories, sometimes taking the form of fairytales. These stories told to Breuer, changed in character over the period of Anna O’s treatment, moving from those that were light and poetic, through to those that contained dark and frightening imagery. The unusual thing about these stories was that after they were told, it was as though a demon had been released from the patient and she became calmer and open to reason, cheerful even, often for a period of twenty-four hours afterwards.
There seemed to be, staring Breuer in the face, some kind of connection between the stories that Anna O told him and the symptoms which she was manifesting. It was here that Freud was to find the roots of a purely psychological explanation of hysteria. Breuer describes numerous examples of this connection. On one occasion Anna O appeared to be suffering from an uncontrollable thirst and was given to demanding water, although when it was brought, she would refuse to touch it. After six weeks of this continuing, one day, again in an auto-hypnotic state, she started to tell a story about a friend who had allowed her dog to drink out of a glass. This had apparently caused the patient considerable distress and seemed to have led to pent-up anger, which was expressed on this occasion to Breuer. Afterwards Breuer was surprised to find that her previous craving and then abhorrence of water had disappeared. Other similar connections between symptoms and a story told by the patient were also seen by Breuer so that eventually he came up with the theory that the patient could be cured systematically by going through the symptoms to find the event that had caused their onset. Once the event had been described, as long as it was with sufficient emotional vigour, the patient would show remission of that symptom. It was by this method that Breuer claimed to have effected a cure of Anna O over the period of the treatment.
It is from this case, although not in the immediate reporting by Breuer, that some of the most fundamental principles of psychoanalysis begin to form. An element of the story that has now passed into psychoanalytic legend, with some accepting its truth while others rejecting it, provides a more dramatic ending to the therapeutic relationship than that presented by Breuer. According to Freud (1970) in his letters, he pieced together an alternative account of what had happened at the end of Anna O’s therapy. According to Freud, Breuer had been treating Anna O in the way he had discovered, as previously described, and had finally reached the point where her symptoms had been removed. Later that day he was called back to his patient to find her in considerable apparent pain in her abdomen. When she was asked what was wrong she replied that, “Dr. B’s child is coming!” This immediately sent Breuer away from her at the highest speed as he was not able to cope with this new revelation. He then passed her onto a colleague for further treatment as he had already realised that his wife was jealous of his treatment of Anna O and this new revelation only compounded the problem.
Forrester (1990) draws attention to the fact that Breuer acknowledged the importance of sexuality in the causes of neuroses. But despite this, he backed away from Anna O’s case as soon as it came to the surface. As Forrester (1990) points out, Freud sees this as Breuer’s mistake and sees in it the birth of a psychoanalysis, especially one of its most important aspects: transference, and more specifically: sexual transference.
Through the way that Breuer describes Anna O’s progress in his new type of therapy, the path which the theory of hysteria and its treatment takes gradually emerges. Although Anna O’s case was reported later it was Breuer & Freud (1893) that used her case as the basis for their theory of hysteria. Breuer & Freud (1893) state that they believe that the symptoms of hysteria have, at their root cause, some kind of causal event, perhaps occurring many years before the symptoms expose themselves. The patient is unlikely to easily reveal what this event is simply because they are not consciously aware of what it is, or that there is a causal connection. They are not worried by the seeming disproportionate nature of the precipitating event and subsequent symptoms. In fact they welcome this disproportionate nature as a defining characteristic of hysteria. Their analysis likens the root cause, or pathogenesis, of hysteria to that caused by a traumatic neurosis – perhaps similar to what we would now call post-traumatic stress disorder. The patient has, therefore, suffered a psychical trauma that manifests itself in this hysteria. The idea that the psychical trauma simply has a precipitating effect on the symptoms is dismissed by the authors referring to the evidence they have from the case studies of the remarkable progress their patient’s made after the memory of the psychical trauma has been exorcised through its explication and re-experiencing.
Importantly, in defining the problem, Breuer & Freud (1893) see the symptoms as a kind of failure of reaction to the original event. The memory of the event can only fade if the reaction to that event has not been suppressed. And it is here that there is a clear precursor to ideas central to later Freudian theory about the nature and causes of repression. In ‘normal’ reactions to psychical traumas, the authors talk of a cathartic effect resulting in a release of the energy. The reverse of this, the suppression of catharsis (Freeman, 1972), is seen here as the cause of the symptoms – adequately evidenced by the new treatment of a kind of delayed catharsis that appears to release the patient from their symptoms. What, then, are the mechanisms by which a psychical trauma of some kind is not reacted to sufficiently? Two answers are provided here, the first that because of the circumstances of the trauma, it was not possible to form a reaction – in other words the reactions is suppressed. The second is that a reaction may not have been possible due to the mental state of the person at that time – for example during a period of paralysing fear. The circumstances in which the failure of a reaction occurs is also instrumental in the burying of these thoughts and feelings and helps to explain why the patient themselves is not able to access them in the normal ways.
Frau Emmy von N.
Freud’s interest in hysteria and in hypnosis was certainly piqued by both Charcot and Breuer and having collaborated on the latter’s work with Anna O – including the belief that he had found a theory of practical benefit – it was only a matter of time before he became further involved in the treatment of hysteria himself. Reported as the second case history in ‘The Studies on Hysteria’, (Breuer & Freud, 1991) a patient of Freud’s, Frau Emmy von N., exhibited symptoms that typified hysteria and Freud resolved to treat her. He reports that the patient was 40 years old, was from a good family and of high education and intelligence. She had been widowed at a young age, leaving her to look after her two children – this she ascribed as the cause of her current malady. Freud describes her first meeting as being continually interrupted by the patient breaking off, and suddenly displaying signs of disgust and horror on her face while telling him to, “Keep still!” and other similar remonstrations. Apart from this the patient also had a series of tics, some facial, but the most pronounced being a ‘clacking’ sound which littered her utterances. Freud’s initial treatment was more physical than mental. She was told to take warm baths and be given massages. This was combined with hypnosis in which Freud simply suggested that she sleep well and that her symptoms would lessen. This was helped by the fact that Freud reports that Frau Emmy von N. was an extremely good hypnotic subject – he only had to raise his finger and make a few simple suggestions to put her into a trance. Freud wonders whether this compliance is due to previous exposure to hypnosis and a desire to please.
A week later Freud asked his patient why she was so easily frightened. She replied with a story about a traumatic experience that had occurred when she was younger – her older brothers and sisters had thrown dead animals at her. As she described these stories to Freud, he reports that she was, ‘panting for breath’ as well as displaying obvious difficulty with the emotions that she was dealing with. After these emotions have been expressed, she became calmer and more peaceful. Freud also uses touch to reinforce his suggestion that these unnerving images have been removed. Under hypnosis, Freud continued to elicit these stories that demonstrated why she was so often nervous. She explained to Freud that she had once had a maidservant who told her stories of life in an asylum including beatings and patients being tied to chairs. Freud then explained to her that this was not the usual situation in asylums. She had also apparently seen hallucinations at one point, seeing the same person in two places and being transfixed by it. While she had been nursing her dying brother, who was taking large quantities of morphine for the pain he was in, he would frequently grab her suddenly. Freud saw this as part of a pattern of her being seized against her will and resolved to investigate it further.
It was a few days after this that quite a significant point in the therapy came. Emmy von N. was again explaining about the frightening stories of the asylum and Freud stopped himself from correcting her, intuitively realising that he had to let her give full vent to her fears, without redirecting her course. This is perhaps a turning point in the way in which Freud treated his patient, made clearer by the historical context in which this scene operates. While still seen as authority figures now, physicians were much stronger authority figures then. This combined with the greater imbalance of power between men and women would have meant that the patient would be naturally hesitant about taking any control over their own treatment. Forrester (1990) sees this as a shift in the pattern of authority between the doctor and the patient that originated in Breuer’s treatment of Anna O – a move from the telling the patient what to do, to listening to what the patient has to say. Forrester (1990) constructs the relationship that Freud began to build with Emmy von N. as more of a framework of authority within which the patient was able to express her thoughts and feelings to the doctor and in this sense the doctor’s job is to help the patient keep up this outpouring of stories. At this stage of the development of the therapy, the facilitation of the story-telling is being achieved by hypnosis, although later Freud was to move away from this.
How great the shift in the power balance was, it is difficult to tell a this distance, but what is clear from the case report is that Emmy von N.’s case provided a much more convoluted series of psychical traumas and symptoms than that presented by Anna O. While Anna O’s symptoms seemed to match the traumatic events rather neatly, Emmy von N’s mind was not nearly as well organised. At one point Freud discovers that taking the lift to his office causes his patient a considerable amount of stress. To try and examine where this comes from he explores whether she has had any previous traumatic experiences in lifts – a logical first step within the theoretical framework. Coincidentally, it appears, the patient mentions that she is very worried about her daughter in relation to elevators. The next logical step then should be that talking about this fear should release the affect and lead to catharsis, but this is not what Freud finds. The next part of the puzzle is revealed when he finds out that she is currently menstruating, then finally the last part falls into place when he finds out that as her daughter has been suffering ovarian problems, she has had to travel in a lift in order to meet with her doctor. After some deliberation Freud realises that there is in fact a false connection between the patient’s menstruation and the worry at her daughter using a lift. It is this confusion of connections that Freud begins to realise is a form of defence to the traumatic thoughts.
Freud’s Treatment of Hysteria
In the final part of ‘Studies in Hysteria’ Freud sets out his theory of hysteria and what he has learnt about its treatment. Not only does this part of the book recap some of the themes already discussed but it also highlights some future direction in which Freud’s work would travel. Two key signposts are seen: first in his stance on hypnotism, and secondly in his view on what constitutes hysteria. In an attempt to be of benefit to patients with hysteria, who he believed this treatment would help, he tried to treat as many as possible. The problem for him was how to tell the difference between a patient with hysteria and one without. Freud chose an interesting solution to what might have been a protracted problem of diagnosis. He simply treated patients who seemed to have hysteria and let the results of that treatment speak for themselves. What this immediately did was to widen out the object of his enquiry to ‘neuroses’ in general. Picking up on the lightly touched theme of sexual transference between Breuer and Anna O mentioned earlier, Freud made his feelings about the roots of neurotic problems quite clear, and in the process set the agenda for psychoanalysis for the next century or more. He believed that one of the primal factors in neuroses lay in sexual matters. In particular Freud came to acknowledge that people’s neuroses rarely came in a pure form, as the early and almost impossibly neat case of Anna O had signposted, and that in fact people were more of a mixed bag. Looking back through the cases reported in ‘Studies on Hysteria’ Freud explains that he came to see a sexual undercurrent in his notes that had not been at the forefront of his mind when he had treated the patients. Especially in the case of Anna O – as already noted – Freud felt Breuer had missed a trick.
What these ideas seem to be adding up to is almost a rejection of hysteria, if not as a separate diagnosis, certainly as a category of disease practically amenable to treatment. Freud, however, is defensive about rejecting the idea of hysteria as a separate diagnosis, despite the fact that that is the direction in which his thoughts are heading. At this stage he believes it can be treated as a separate part of a patient’s range of symptoms and the effect of this treatment will be governed by its relative importance overall. Those patients, like Anna O, who have relatively pure cases of hysteria will respond well to the cathartic treatment, while those diluted cases will not.
The second key signpost for the future of psychoanalysis was Freud’s use of hypnosis. What he found was that many of the patients he saw were simply not hypnotisable – Freud claims unwillingness on their part but other writers are of the opinion that he was simply not that good at it (Forrester, 1990). This was a problem for Freud because Breuer’s formulation of the treatment for hysteria required that events were recollected that were not normally available to a person. Hypnosis had originally proved a good method – and indeed in Anna O’s case the only method – for gaining access to these past events. In response, Freud now turned away from hypnosis to develop his own techniques for eliciting the patient’s traumatic events. These were quite simple: he insisted that the patient remember what the traumatic event was, and if they still could not, he would ask the patient to lie down and close their eyes – nowadays one of the archetypal images of patient and analyst. Freud saw the patient’s reluctance of his patient’s to report their traumatic events as a one of the biggest hurdles in his coalescing form of therapy. He came up with the idea that there was some psychical force within the patient that stopped the memories from being retrieved. From the patients he had treated, he had found that the memories that were being held back were often of an embarrassing or shameful nature. If was for this reason that the patient was activating psychical defence mechanisms. At this stage he hoped to be able to show in the future that it was this defence or repulsion of the traumatic event to the depths of the memory that was causing so much psychical pain to the patient.
Overcoming this psychical force, Freud found, was not as simple as insisting, and he developed some further techniques. Patients would easily drift off their point or simply dry up and it needed more powerful persuasion to return them to the traumatic event. One particular technique he found extremely useful and would almost invariably use it when treating patients. This involved placing his hand on the patient’s head and instructing them that when they feel the pressure they will also see an image of their traumatic event. Having assured the patient that whatever they see, they should not worry that this image is inappropriate or too shameful to discuss, then they are asked to attempt a description of the image. Freud believed that this system worked by distracting the patient, in a similar way as hypnosis, from their conscious searching for the psychical trauma and allowed their mind to float free.
Even using the new technique of applying pressure, it did not provide direct access to the psychical trauma. What Freud found was that it tended to signal a jumping off point or a way-station, somewhere on the way to or from the trauma. Sometimes the image produced would provide a new starting point from which the patient could work, sometimes it fitted into the flow of the subject of discussion. Occasionally the new image would bring a long-forgotten idea to the patient’s mind which would surprise them and initially seem to be unrelated, but later turn out to have a connection. Freud was so pleased with his new pressure technique that, in complex cases, he would often use it continuously on the patient. This procedure would bring to light memories that had been hitherto completely forgotten, as well as new connections between these memories – and even, sometimes, thoughts that the patient doesn’t even believe to be their own.
Freud is careful to point out that although his pressure technique was useful, there were a number of very strong forms of defence that stopped him gaining easy access to the patient’s psychical trauma. He often found that in the first instance, applying pressure by his hand to the patient would not work, but when he insisted to the patient that it would work the next time, it often would. Still, the patient would sometimes immediately reinterpret or, indeed, begin to edit what was seen, thus making the reporting much less useful. Freud makes it clear that sometimes the most useful observations or memories of the patient are those that they consider to be of least use or relevance. Also, the memories will tend to emerge in a haphazard fashion, only later, and with the skill of the analyst, being fitted together into a coherent picture. Freud refers to this as a kind of censoring of the traumatic events, as though it can only be glimpsed in a mirror or partially occluded around a corner. Slowly but sure the analyst begins to build up a picture with the accretion of material. There is nothing, Freud believed that is not relevant – every piece of information is a link in the chain, another clue to the event that has traumatised the psyche.
Another major component of psychoanalysis makes its first appearance in the Studies on Hysteria. Freud describes a final defence or block against the work of treating hysteria in the very relationship between the patient and doctor. Indeed, Freud sees this defence is sure to arise, and perhaps the most difficult defence of all to overcome. The first of the three circumstances in which it may arise is a simple, probably small, breakdown in the relationship between the physician and patient. It might be that the patient is unsure about the physician’s techniques or alternatively has felt slighted in the treatment in some way. This can be rectified with a sensitive discussion. The second of the three circumstances occurs when the patient becomes fearful that they will lose their independence because of a reliance on their treating physician. As almost all of Freud’s patients who had hysteria were women, this could be conceived as a sexual reliance. The third circumstance is where the patient begins to take the problem that they are trying to resolve and transfer it onto the physician, thereby seeing their problem there instead of where it really exists. Freud provides the straightforward example of the sexual transference of a female patient of his who suddenly developed the vision of kissing him. He reports that the patient could not be analysed any further until this block had been addressed. The mechanism by which this transference happens, he posits, is that the patient creates a false connection between the compulsion which is the basis for their treatment and the therapist, rather than its original recipient. In treating these defences Freud makes it clear that the main aim should be to make the patient aware that this problem exists, and then once they are aware of it, the problem is largely dealt with. The challenge, then, is getting the patient to admit to these potentially embarrassing feelings.
The Aetiology of Hysteria
The development of Freud’s theory of the aetiology of hysteria provides one of the most insightful, and sometimes controversial, areas of his work. The formation of the theory, like the work on its treatment, provided another important testing ground for some of the basic elements of what would later become psychoanalysis.
Previous authors, including Breuer in the joint work with Freud in ‘Studies on Hysteria’, gave great weight to the heredity factors in the causes of hysteria. Freud meanwhile acknowledged these ideas, but in ‘Heredity and the Aetiology of the Neuroses’ (Freud, 1896b) set out the three factors he believed were important and began to formulate a new theory. The causes of hysteria could be broken down into: (1) Preconditions – this would include hereditary factors, (2) concurrent causes – which are generalised causes and (3) specific causes, these being specific to the hysteria itself. It is in these specific causes he believed he had found an important contribution to aetiology of the condition.
One of the common factors of the patients Freud was seeing, and the one he was coming to see as defining, was in their sexual problems. He reports that while many suffered from a range of different symptoms such as constipation, dyspepsia and fatigue, almost all of them had some kind of sexual problems. These ranged from the inability to achieve orgasm to a more general inability to have a satisfying sexually relationship. Freud saw this as a very significant problem as he maintains that the nervous systems needs to be regularly purged of sexual tension. This pattern across his patients, and the development of his theory of traumatic psychical events, led him to wonder what past events could have caused the sexual dysfunction the patients with hysteria were manifesting. Radically, and expecting no small amount of opposition to the idea, Freud advanced the theory that these neuroses were caused by sexual abuse before the age of sexual maturity. Of the thirteen cases that Freud had treated at the time of the paper, all of them had been subject to sexual abuse at an early age. However, Freud does make it clear that the information about their sexual lives is not obtained without some considerable pressure, and it only emerges in a fragmentary way that has later to be pieced together by the therapist. At this early stage of the theory, Freud believed that the sexual abuse left a psychical trace and formed the traumatic experience which was locked away in the depths of the mind.
These ideas were much further developed and expanded on in ‘Further remarks on the neuro-psychoses of defence’ (Freud, 1896a). Earlier Freud had grouped together hysteria with hallucinatory states and obsessions (Freud, 1894) and had begun to formulate the idea that all of these conditions had a common aetiology. In particular, Freud felt these were all part of an area where the ideas of psychological defences and psychological repression were important. Freud had found that patients he had seen had suffered sexual abuse sometimes as early as two years old and up to the age of ten, which he drew as an artificial cut-off point. What other theorists saw as a heredity, Freud saw as the confluence of factors – for example if a boy had been sexually abused when he was five then it was likely that his brother would have been abused by the same person. Rather than seeing heredity as a separate factor in hysteria, he saw the sexual abuse as a replacement for heredity, sometimes exclusively, as the root cause in itself. The theory shows an interesting divergence in the analysis of obsessional neuroses. Here, Freud believed that the obsessional neuroses were caused by a sexual activity in childhood rather than the sexual passivity typical of abuse. These ideas linked in neatly to the greater preponderance of obsessional neuroses in males. A logical division is therefore made with the females, the apparently more passive sex suffering from hysteria, while the apparently more active sex suffering from obsessions. In searching for the aetiology of these two conditions, it is here that Freud prefigures his future thinking on stages of sexual development by introducing the idea that the development of neuroses and/or hysteria is/are dependent on when the sexual abuse occurs in the developmental stages of the child, with sexual maturation providing the cut-off point.
In ‘The Aetiology of Hysteria’ Freud again makes clear his divergence from his mentor, Charcot, in claiming that heredity is not the most important factor in the aetiology of hysteria (Freud 1896c). Freud (1896c) travels back through the life-histories of the patients he has treated looking for the original source of the psychical trauma, discounting all sexual experiences at puberty and later. It is only in pre-pubescent children, when the potential for harm is at its greatest that there lies a sufficient cause. Freud’s theory revolves around the idea that at a
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