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Volume 2


Volume II: 
Studies on Hysteria (1893-1895)

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Studies on Hysteria (1955).
Editor’s introduction and prefaces to the first and second editions.
The present translation by James and Alix Strachey of Studies on Hysteria includes Breuer’s contributions, but is otherwise based on the German edition of 1925, containing Freud’s extra footnotes. Some historical notes on the Studies on Hysteria are presented including Breuer’s treatment of Fraulein Anna 0., on which the whole work is founded, and the case of Frau Emma von N. which was the first one treated by the cathartic method. It was through the study of the case of Frau Cacilie M. that led directly to publication of “Preliminary Communication”. The bearing of these studies of hysteria on psychoanalyses is discussed. It is thought that the most important of Freud’s achievements is his invention of the first instrument for the scientific examination of the human mind. In the years immediately following the Studies, Freud abandoned more and more of the machinery of deliberate suggestion and came to rely more and more on the patient’s flow of free associations. Freud originated the technical developments, together with the vital theoretical concepts of resistance, defense, and repression which arose from them. Breuer originated the notion of hypnoid states, and it seems possible that he was responsible for the terms catharsis and abreaction. The second edition of Studies on Hysteria appears without any alterations, though the opinions and methods which were put forward in the first edition have since undergone far reaching and profound developments. The initial views are not regarded as errors but as valuable first approximations to knowledge which could only be fully acquired after long and continuous efforts.

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Studies on Hysteria (1893-1895).
Chapter I. On the psychical mechanism of hysterical phenomena: Preliminary communication (1893) (Breuer and Freud).
A great variety of different forms and symptoms of hysteria which have been traced to precipitating factors include neuralgias and anesthesias of various kinds, contractures and paralyses, hysterical attacks and epileptoid convulsions, chronic vomiting and anorexia, etc. The connection between the precipitating event and the development of hysteria is often quite clear while at other times the connection is ‘symbolic.’ Observation of these latter cases establishes an analogy between the pathogenesis of common hysteria and that of traumatic neurosis and justify an extension of the concept of traumatic hysteria. It was found that each individual hysterical symptom immediately and permanently disappeared when the event by which it was provoked was clearly brought to light and when the patient described the event in great detail and had put the affect into words. The fading of a memory or the losing of its affect depends on various factors, the most important of these is whether there has been an energetic reaction to the event that provokes an affect. The memories correspond to traumas that have not been sufficiently abreacted. The splitting of consciousness which is so striking in the well known classical cases under the form of double conscience is present to a rudimentary degree in every hysteria. The basis of hysteria is the existence of hypnoid states. Charcot gave a schematic description of the major hysterical attack, according to which 4 phases can be distinguished in a complete attack: 1) the epileptoid phase, 2) the phase of large movements, 3) the phase of attitudes passionelles (the hallucinatory phase), and 4) the phase of terminal delirium. The psychotherapeutic procedure has a curative effect on hysteria: It brings to an end the operative force of the idea which was not abreacted in the first instance, by allowing its strangulated affect to find a way out through speech, and it subjects it to associative correction by introducing it into normal consciousness or by removing it through the physician’s suggestion.

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Studies on Hysteria (1893-1895).
Chapter II. Case histories: 1. Fraulein Anna 0. (Breuer).
The case history of Anna 0. is presented. Illness started at 21 years of age and the course of illness fell into several clearly separable phase: latent incubation; the manifest illness; a period of persisting somnambulism, subsequently alternating with more normal states; and gradual cessation of the pathological states and symptoms. Throughout her illness, Fraulein Anna 0. fell into a somnolent state every afternoon and after sunset this period passed into a deeper sleep or hypnosis called “clouds”. During the ‘other’ states of consciousness (called absences) she would complain of lost time and of a gap in her train of conscious thought. If she was able to narrate the hallucinations she had had in the course of the day, she would wake up with a clear mind, calm and cheerful. The essential features of this phenomenon, the mounting up and intensification of her absences into her autohypnosis in the evening, the effect of the products of her imagination as psychical stimuli, and the easing and removal of her state of stimulation when she gave utterance to them in her hypnosis, remained constant throughout the whole 18 months during which she was under observation. The psychical characteristics, present in Fraulein Anna 0. while she was still completely healthy, acted as predisposing causes for her subsequent hysterical illness. One was her monotonous family life and the absence of adequate intellectual occupation which left her with an unemployed surplus of mental liveliness and energy, and this found an outlet in the constant activity of her imagination. The second characteristic was her habit of daydreaming which laid the foundation for a dissociation of her mental personality.

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Studies on Hysteria (1893-1895).
Chapter II. Case histories: 2. Frau Emmy von N. (Freud).
The case history of Emmy von N. is discussed. On May 1, 1889, Freud took on the case of a woman whose symptoms and personality interested him so greatly that he devoted a large part of his time to her and determined to do all he could for her recovery. She was a hysteric and could be put into a state of somnambulism with the greatest ease. Delirium was the last considerable disturbance in Frau Emmy von N’s condition. Hypnosis was used primarily for the purpose of giving her maxims which were to remain constantly present in her mind and to protect her from relapsing into similar conditions when she got home. The mildness of her deliria and hallucinations, the change in her personality and store of memories when she was in a state of artificial somnambulism, the anesthesia in her painful leg, certain data revealed in her anamnesis, her ovarian neuralgia, etc., admit of no doubt as to the hysterical nature of the illness or of the patient. The psychical symptoms in this case of hysteria with very little conversion can be divided into alterations of mood, phobias, and abulias. These phobias and abulias were, for the most part, of traumatic origin. The distressing effects attached to her traumatic experiences had remained unresolved. Her memory exhibited a lively activity which brought her traumas with their accompanying affects bit by bit into her present day consciousness.

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Studies on Hysteria (1893-1895).
Chapter II. Case histories: 3. Miss Lucy R. (Freud).
At the end of the year 1892, Miss Lucy R. was referred to Freud by an acquaintance who was treating her for chronically recurrent suppurative rhinitis. She was suffering from depression and fatigue and was tormented by subjective sensations of smell. Freud concluded that experiences which have played an important pathogenic part, and all their subsidiary concomitants, were accurately retained in the patient’s memory even when they seemed to be forgotten, when he is unable to call them to mind. Before hysteria can be acquired for the first time, one essential condition must be fulfilled: an idea must be intentionally repressed from consciousness and excluded from associative modification. This intentional repression is also the basis for the conversion, whether total or partial, of the sum of excitation. The sum of excitation, being cut off from psychical association, finds its way all the more easily along the wrong path to a somatic innervation. The basis for repression itself can only be a feeling of unpleasure, the incompatibility between the single idea that is to be repressed and the dominant mass of ideas constituting the ego. It was found that as one symptom was removed, another developed to take its place. The case history of Miss Lucy R. was regarded as a model instance of one particular type of hysteria, namely the form oft his illness which can be acquired even by a person of sound heredity, as a result of appropriate experiences. The actual traumatic moment is the one at which the incompatibility forces itself upon the ego and at which the latter decides on the repudiation of the incompatible idea. When this process occurs for the first time there comes into being a nucleus and center of crystallization for the formation of a psychical group divorced from the ego, a group around which everything which would imply an acceptance of the incompatible idea subsequently collects. The splitting of consciousness in these cases of acquired hysteria is accordingly a deliberate and intentional one. It was concluded that the therapeutic process in this case consisted in compelling the psychical group that had been split off to unite once more with the ego-consciousness.

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Studies on Hysteria. (1893-1895).
Chapter II. Case histories: 4. Katharina (Freud).
The case history of Katharina, an employee at a mountain retreat that Freud visited, is presented. The girl approached him with a problem of an anxiety attack that had first appeared 2 years previously. Katharina realized that her uncle had been making advances to her and that he had also been involved with her cousin. It was hoped that she, Katharina, whose sexual sensibility had been injured at an early age, derived some benefit from the conversation with Freud. Katharina agreed that what Freud interpolated into her story was probably true; but she was not in a position to recognize it as something she had experienced. The case was fitted into the schematic picture of an acquired hysteria. In every analysis of a case of hysteria based on sexual traumas, the impressions from the presexual period which produce no effect on the child attain traumatic power at a later date as memories, when the girl or married women acquires an understanding of sexual life. The anxiety which Katharina suffered in her attacks was a hysterical one; that is, it was a reproduction of the anxiety which had appeared in connection with each of the sexual traumas.

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Studies on Hysteria (1893-1895).
Chapter II. Case histories: 5. Fraulein Elisabeth von R. (Freud):
The case of Fraulein Elisabeth von R., a young patient of 24, who walked with the upper part of her body bent forward, but without making use of any support, is studied. The diagnosis of hysteria was proposed for the following reasons: 1) The descriptions and character of her pains were indefinite. 2) If the hyperalgesic skin and muscles of her legs were touched, her face assumed a peculiar expression, which was one of pleasure rather than pain. For a long time, Freud was unable to grasp the connection between the events in her illness and her actual symptoms, the obscurity due to the fact that analysis pointed to the occurrence of a conversion of psychical excitation into physical pain. It was thought that the conversion did not take place in connection with her impressions when they were fresh, but in connection with her memories of them. Such a course of events is not unusual in hysteria and plays a regular part in the genesis of hysterical symptoms. This assertion is substantiated by the following instances. Fraulein Rosalia H., 23 years old, had for some years been undergoing training as a singer, had a good voice, but complained that in certain parts of its compass it was not under her control. A connection was established between her singing and her hysterical paraesthesia, a connection for which the way was prepared by the organic sensations set up by singing. To rid her of this retention hysteria Freud tried to get her to reproduce all her agitating experiences and to abreact them after the event. Frau Cacilie M. suffered from an extremely violent facial neuralgia which appeared suddenly 2 or 3 times a year, and lasted from 5 to 10 days, resisted any kind of treatment and then ceases abruptly. Her case involved conflict and defense. The neuralgia had come to be indicative of a particular psychical excitation by the usual method of conversion, but afterwards, it could be set going through associative reverberations from her mental life, or symbolic conversion, in fact the same behavior found in the case of Elisabeth von R.

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Studies on Hysteria (1893-1895).
Chapter III. Theoretical Section (Breuer): 1. Are all hysterical phenomena ideogenic?
It is not believed that all the phenomena of hysteria are all ideogenic, that is, determined by ideas. This theory differs from Moebius who defined as hysterical all pathological phenomena that are caused by ideas. Hysteria is regarded as a clinical picture which has been empirically discovered and is based on observation. Hysteria must remain a clinical unity even if it turns out that its phenomena are determined by various causes, and that some of them are brought about by a psychical mechanism and others without it. It seems certain that many phenomena described as hysterical are not caused by ideas alone. Even though some of the phenomena of hysteria are ideogenic, nevertheless it is precisely they that must be described as the specifically hysterical ones, and it is the investigation of them, the discovery of their psychical origins, which constitutes the most important recent step forward in the theory of the disorder. The concept of excitations which flow away or have to be abreacted, is fundamentally important in hysteria and for the theory of neurosis in general.

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Studies on Hysteria (1893-1895).
Chapter III. Theoretical Section (Breuer): 2. Intracerebral tonic excitations-affects.
The 2 extreme conditions of the central nervous system are a clear waking state and dreamless sleep. A transition between these is afforded by conditions of varying degrees of decreasing clarity. When the brain is performing actual work, a greater consumption of energy is no doubt required than when it is merely prepared to perform work. Spontaneous awakening can take place in complete quiet and darkness without any external stimulus, thus demonstrating that the development of energy is based on the vital process of the cerebral elements themselves. Speech, the outcome of the experience of many generations, distinguishes with admirable delicacy between those forms and degrees of heightening of excitation which are still useful for mental activity because they raise the free energy of all cerebral functions uniformly, and those forms and degrees which restrict that activity because they partly increase and partly inhibit these psychical functions in a manner that is not uniform. The first are given the name of incitement, and the second excitement. While incitement only arouses the urge to employ the increased excitation functionally, excitement seeks to discharge itself in more or less violent ways which are almost or even actually pathological. A disturbance of the dynamic equilibrium of the nervous system is what makes up the psychical side of affects. All the disturbances of mental equilibrium which are called acute affects go along with an increase of excitation. Affects that are active, level out the increased excitation by motor discharge. If, how-ever, the affect can find no discharge of excitation of any kind, then the Intracerebral excitation is powerfully increased, but is employed neither in associative nor in motor activity.

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Studies on Hysteria (1893-1895).
Chapter III. Theoretical Section (Breuer): 3. Hysterical conversion.
Resistances in normal people against the passage of cerebral excitation to the vegetative organs correspond to the insulation of electrical conducting lines. At points at which they are abnormally weak they are broken through when the tension of cerebral excitation is high, and this, the affective excitation, passes over to the peripheral organs. There ensues an abnormal expression of emotion with 2 factors responsible for this. The first is a high degree of intracerebral excitation which has failed to be leveled down either by ideational activities or by motor discharge, or which is too great to be dealt with in this way. The second is an abnormal weakness of the resistances in particular paths of conduction. Intracerebral excitation and the excitatory process in peripheral paths are of reciprocal magnitudes: the former increases if and so long as no reflex is released; it diminishes and disappears when it has been transformed into peripheral nervous excitation. Thus it seems understandable that no observable affect is generated if the idea that should have given rise to it immediately releases an abnormal reflex into which the excitation flows away as soon as it is generated. The ‘hysterical conversion’ is then complete. Hysterical phenomena (abnormal reflexes) do not seem to be ideogenic even to intelligent patients who are good observers, because the idea that gave rise to them is no longer colored with affect and no longer marked out among other ideas and memories. The discharge of affect follows the principle of least resistance and takes place along those paths whose resistances have already been weakened by concurrent circumstances. The genesis of hysterical phenomena that are determined by traumas finds a perfect analogy in the hysterical conversion of the psychical excitation which originates, not from external stimuli nor from the inhibition of normal psychical reflexes, but from the inhibition of the course of association. In all cases there must be convergence of several factors before a hysterical symptom can be generated in anyone who has hitherto been normal. Two ways in which affective ideas can be excluded from association were observed: through defense and in situations where the idea cannot be remembered such as in hypnosis or states similar to hypnosis. The latter seem to be of extreme importance for the theory of hysteria.

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Studies on Hysteria (1893-1895).
Chapter III. Theoretical Section (Breuer): 4. Hypnoid states.
The basis of hysteria is the existence of hypnoid states. The importance of these states which resemble hypnosis, lies in the amnesia that accompanies them and in their power to bring about the splitting of the mind. [t must also be pointed out that conversion (the ideogenic production of somatic phenomena) can also come about apart from hypnoid states. True autohypnoses originating spontaneously) are found in a number of [fully developed hysterias, occurring with varying frequency and duration, and often alternating rapidly with normal waking states. What happens during autohypnotic states is subject to more or less total amnesia in waking life. The hysterical conversion takes place more ( easily in autohypnosis than in the waking state, just as suggested ideas are realized physically as hallucinations and movements so much more easily in artificial (non-spontaneous) hypnosis. Neither absence of mind (hypnoid state) during energetic work nor unemotional twilight states are pathogenic; on the other hand, reveries that are filled with emotion and states of fatigue arising from protracted affects are pathogenic. The method by which pathogenic autohypnosis would seem to develop is by affect being introduced into a habitual reverie. It is not known whether reveries may not themselves be able to produce the same pathological effect as auto-hypnosis, and whether the same may not also be true of a protracted affect of anxiety. The term hypnoid points to auto-hypnosis itself, the importance of which in the genesis of hysterical phenomena rests on the fact that it makes conversion easier and protects (by amnesia) the converted ideas from wearing away, a protection which ultimately leads to an increase in the psychical splitting.

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Studies on Hysteria (1893-1895).
Chapter III. Theoretical Section (Breuer): 5. Unconscious ideas and ideas inadmissible to consciousness-Splitting of the mind.
Ideas that we are aware of are called conscious. A great deal of what is described as mood comes from ideas that exist and operate beneath the threshold of consciousness. The whole conduct of our life is constantly influenced by subconscious ideas. All intuitive activity is directed by ideas which are to a large extent subconscious. Only the clearest and most intense ideas are perceived by self-consciousness, while the great mass of current but weaker ideas remains unconscious. There seems to be no theoretical difficulty in recognizing unconscious ideas as causes of pathological phenomena. The existence of ideas that are inadmissible to consciousness is pathological. Janet regards a particular form of congenital mental weakness as the disposition to hysteria. Freud and Breuer say that it is not the case that the splitting of consciousness occurs because the patients are weak minded; they appear to be weakminded because their mental activity is divided and only a part of its capacity is at the disposal of their conscious thought. What underlies dissociation is an excess of efficiency, the habitual coexistence of 2 heterogeneous trains of ideas. In their initial stages, hysterias of a severe degree usually exhibit a syndrome that may be described as acute hysteria. The weakness of mind caused by a splitting of the psyche seems to be a basis of the suggestibility of some hysterical patients. The unconscious split of mind in hysteria is preeminently suggestible on account of the poverty and incompleteness of its ideational content.

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Studies on Hysteria (1893-1895).
Chapter III. Theoretical Section (Breuer): 6. Innate disposition-Development of hysteria.
Most of the hysteria phenomena that Freud and Breuer have been endeavoring to understand can be based on an innate idiosyncracy. The capacity to acquire hysteria is undoubtedly linked with an idiosyncracy of the person concerned. The reflex theory of symptoms (nervous symptoms) should not be completely rejected. The idiosyncracy of the nervous system and of the mind seems to explain some familiar properties of many hysterical patients. The surplus of excitation which is liberated by their nervous system when in a state of rest determines their incapacity to tolerate a monotonous life and boredom and their craving for sensations which drive them to interrupt this monotony with incidents of which the most prominent are pathological phenomena. They are often supported in this by autosuggestion. A surplus of excitation also gives rise to pathological phenomena in the motor sphere, often tic-like movements. Like the stigmata, a number of other nervous symptoms, some pains and vasomotor phenomena and perhaps purely motor convulsive attacks, are not caused by ideas but are direct results of the fundamental abnormality of the nervous system. Closest to them are the ideogenic phenomena, simply conversations of affective excitation. These phenomena are, by repetition, a purely somatic hysterical symptom while the idea that gave rise to it is fended off and therefore repressed. The most numerous and important of the fended-off and converted ideas have a sexual content. The tendency towards fending off what is sexual is intensified by the fact that in young unmarried women sensual excitation has an admixture of anxiety, of fear of what is coming, what is unknown and half-suspected, whereas in normal and healthy young men it is unmixed aggressive instinct. Besides sexual hysteria, there are also hysterias due to fright, traumatic hysteria proper, which constitutes one of the best known and recognized forms of hysteria. Another constitutent of the hysterical disposition is the hypnoid state, the tendency to autohypnosis. The hypnoid element is most clearly manifested in hysterical attacks and in those states which can be described as acute hysteria. The essential change that occurs in hysteria is that the mental state becomes temporarily or permanently similar to that of a hypnotized subject.

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Studies on Hysteria (1893-1895).
Chapter IV. The psychotherapy of hysteria (Freud).
The psychotherapy of hysteria is discussed. Each individual hysterical symptom immediately and permanently disappears when the memory of the event by which it was provoked was brought to light along with its accompanying affect and when the patient had described that event in the greatest possible detail and had put the affect into words. The etiology of the acquisition of neuroses is to be looked for in sexual factors. Different sexual factors produce different pictures of neurotic disorders. The neuroses which commonly occur are mostly to be described as mixed. Pure forms of hysteria and obsessional neurosis are rare; as a rule these 2 neuroses are combined with anxiety neurosis. Not all hysterical symptoms are psychogenic and they all cannot be alleviated by a psychotherapeutic procedure. A number of patients could not be hypnotized, although their diagnosis was one of hysteria and it seemed probable that the psychical mechanism described by Freud and Breuer operated in them. For these patients, Freud by means of psychical work had to overcome a psychical force in the patients which was opposed to the pathogenic ideas becoming conscious. The pathogenic idea is always close at hand and can be reached by associations that are easily accessible, just a question of removing the subjects will. Once a picture has emerged from the patients memory, it becomes fragmentary and obscure in proportion as he proceeds with his description of it. The patient appears to be getting rid of it by turning it into words. It is found from cases in which guessing the way in which things are connected and telling the patient before uncovering it that therapists are not in a position to force anything on the patient about things of which he is ostensibly ignorant or to influence the products of the analysis by arousing an expectation. An external obstacle to successful psychotherapy happens when the patient’s relation to the therapist is disturbed such as if there is personal estrangement, if the patient is seized by a dread of becoming accustomed to the therapist personally or of losing independence in relation to him, or if the patient is frightened at finding she is transferred her distressing ideas onto the therapist.

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Studies on Hysteria (1893-1895).
Appendix A: The chronology of the case- of Frau Emmy von N.
Appendix B: List of writings by Freud dealing principally with conversion hysteria.
The chronology of the case of Frau Emmy von N. is presented. There are serious inconsistencies in the dating of the case history. There is reason to believe that Freud altered the place of Frau Emmy’s residence. It is possible that he also altered the time as an extra precaution against betraying his patient’s identity. A list of writings by Freud dealing principally with conversion hysteria is also presented. They are dated from 1886 to 1910 and include: The Observation of Pronounced Hemi-Anesthesia in a Hysterical Male; Hysteria in Villaret’s Handworterbuch; A Letter to Josef Breuer; On the Theory of Hysterical Attacks; A Case of Successful Treatment by Hypnotism; On the Psychical Mechanism of Hysterical Phenomena; The Neuro-Psychoses of Defense; Studies on Hysteria; Project for a Scientific Psychology; and the Aetiology of Hysteria.

Abstracts of the Standard Edition of 
the Psychological Works of Sigmund Freud

Carrie Lee Rothgeb, Editor

 

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