Studies on Hysteria by Sigmund Freud

First published: 1893-1895, in German as Studien über Hysteria

Type of work: Psychological study

Critical Evaluation:

STUDIES ON HYSTERIA is the fascinating account of the invention of the first scientific method for analyzing the human mind. Leaving aside the question of what share of the book should be attributed to each author, we can follow the first steps in the invention of free-association psychoanalysis as the method was developed and as its originators overcame the obstacles that questioned its validity. The five case histories illustrate these obstacles and the manner in which Breuer and Freud developed the tools of psychoanalysis as a way to treat hysteria.

The first part of STUDIES ON HYSTERIA is the essay “on the Psychical Mechanism of Hysterical Phenomena: Preliminary Communication,” which first appeared in 1893. This is a consideration of the nature of hysteria. The authors say that they have sought the cause of the illness and have found that it lies in the subject’s past even though the subject is unable to recollect it unless he is under hypnosis. Each symptom of the illness, however varied, is related to that event in the subject’s life and forms a clearly evident connection to it. Any experience which calls up distressing effects may be the type of psychical trauma that is a cause of later hysteria. The particular type that interests Breuer and Freud is the one that the subject represses; because he has forced it into his unconscious, it persists and, unlike conscious recollections, is a cause of hysteria. The psychologists were greatly surprised when they discovered that the hysterical symptoms immediately and permanently disappeared the moment that the original event and its accompanying affect were recognized by the subject. These psychical events, in other words, no longer cause hysteria when the patient has discharged the affects.

Because such events are completely absent from the subject’s mind when he is in a normal psychical state, the analysts used hypnosis; under the effects of hypnosis the subject can remember things that he has repressed, thereby making reaction possible. Hypnosis can do so because it splits the subject’s consciousness, the basic phenomenon of neurosis. It allows the subject to articulate the strangulated effect and, by introducing it into his consciousness, to remove it by the physician’s suggestion.

The second part of STUDIES ON HYSTERIA is the five case histories in which the remarks of the first part are illustrated. The first case history (Breuer’s patient, Fraulein Anna O.) demonstrated the amnesia characteristic of hysteria and the realization that behind the conscious mind there lay an unconscious mind. The way to get into this unconscious mind was hypnotic suggestion: the analyst got the patient to begin talking and then listened to the patient’s ramblings without interrupting. But the case history of Frau Emmy von N. (Freud’s patient) shows the obstacles in this approach: (1) Freud was not adept at hypnotism, and (2) the patient often resisted treatment. Herein lay the seeds for Freud’s entire career. The third case history, Miss Lucy R., was analyzed in a normal state of consciousness because Freud was unable to hypnotize her; this important case was the beginning of psychoanalysis as Freud was to develop it during the remainder of his career. The fourth case history, Katharina, is little more than a conversation, but through it Freud discovered that in the case of hysteria based on sexual traumas pre-sexual impressions were of utmost importance. The fifth case history, Fraulein Elisabeth von R., concerns what we would now call a psychosomatic condition, paralysis caused by psychical trauma. This was a case of symbolism: the patient had symbolically expressed her painful thoughts in her legs.

The third part of STUDIES ON HYSTERIA, written by Breuer, is a further discussion of the ideas introduced in Part I. Breuer divided this essay into six sections, each of which carries his considerations deeper than the previous one. The first section—“Are All Hysterical Phenomena Ideogenic?”—deals with the origin and determination of hysteria. Breuer and Freud differ from the then current thought that all pathological phenomena are caused by ideas because they feel that some of the phenomena of hysteria are caused by physical mechanism and some are not. In fact, ordinary ideas are not strong enough to cause hysteria; the only idea that can cause a hysteria is one which is accompanied by a special abnormal condition. In this case the hysteria is determined by the abnormal excitability of the nervous system, not by the idea itself. In general, a great number of hysterical phenomena may be ideogenic but all are caused by an abnormal excitability of the nervous system. This conclusion leads to the second question: how do these abnormal excitations arise?

The states of waking and of sleeping are two extreme conditions of the central nervous system. Separating these extremes is the amount of energy being consumed, the waking state consuming more energy to do its work than the sleeping one. The brain uses a limited amount of energy, but it varies in its application of this energy. For example, if we are exercising, we cannot engage in continuous thought. Thus in the waking brain the “intracerebral tonic excitation” is varied. In the mind, however, there is a tendency to keep the intracerebral excitation constant (Freud’s “principle of constancy”); therefore, we tend to convert an overstimulation into something else. If we are overstimulated, for example, we may convert this excitation into aimless pacing up and down. If, however, there is no discharge of excitation, the mind is powerfully stimulated but has no immediate release as in the cases of anger, fright, or anxiety. There are two ways by which the brain can return to its ordinary level of excitation: gradually leveling off (normal process) or hysterical conversion.

Breuer extensively analyzes hysterical conversion in the third section of this essay. An abnormal affective reaction is not hysteria if it has an immediate objective basis. If the idea releases its affect as it emerges, then the mind has undergone a normal reaction; but if the affect is transformed into another channel, the affective idea now produces an abnormal reflex. Such a discharge is determined through symbolism; associations are made along fresh lines that have a symbolic relation to the pathogenic idea. Because the idea has been disguised, the subject no longer feels threatened by it and can be happy. In other words, the origin of hysteria is an idea that the subject represses into his unconscious. Through hypnosis and the hypnoid states, Breuer was led to the conclusions that unconscious ideas exist and that they are operative. Conscious ideas he defines as ideas that the subject is aware of; all other ideas are unconscious.

Only the clearest ideas remain conscious; the greater number of ideas remain unconscious. The pathogenic idea is one which the conscious mind is unable to admit without strenuous help from a physician. This idea is pushed into the unconscious, where it disturbs the intracerebral excitation constancy and through symbolism causes hysteria. Thus while the patient has not split his consciousness, he has split his mind, the degree of the split determining the seriousness of the hysteria. The unconscious idea can affect the conscious mind, but the conscious mind has no control over the unconscious idea. But all hysterical phenomena form an almost unbroken chain passing from the symptom to the pathogenic idea. Thus the physician can follow the chain to its source.

In the last section of his essay Breuer asks why one person represses an idea and gets a particular kind of hysteria while another person, who has the same idea, has no pathological reaction. His answer is that any explanation that generalizes is wrong, the capacity for hysteria being a part of the subject’s innate disposition. When he wrote, the field of psychological investigation had already advanced far enough for Breuer to recognize sexuality as one of the major causes of hysteria, but the great work in this area was still to be done by Freud.

The final essay in STUDIES ON HYSTERIA is Freud’s “The Psychotherapy of Hysteria.” Breuer discussed the theoretical nature of hysteria; Freud discusses the method or instrument that he and Breuer had invented for treating hysteria. Breuer’s method (as described in the case history of Fraulein Anna O.) was to hypnotize his patients and then allow them to follow the chain of associations back to the pathogenic idea. Freud, however, found that not everyone could be hypnotized. This discovery led him to distinguish between hysteria and neuroses, and he found that Breuer’s method worked perfectly well with the cases of neurosis that had no symptoms of hysteria. This finding led him to the conclusion that hysteria was not unique, a significant discovery in the early history of psychology.

Because hypnosis would not work for all patients, even though they had symptoms of hysteria, Freud sought to by-pass it and still obtain the pathogenic idea by means of a continuous chain of symbolism. Freud found that by using association, the patient could remain conscious but still follow certain key themes back toward their cause. Still, however, there was the barrier, the resistance of the conscious mind to the undesired idea or to the undesired complex of ideas. Freud found that it did no good for him to tell the patient what the cause of his hysteria was; the patient had to recognize it himself. Thus when the patient had followed his free association to the point where he reached the barrier, Freud applied the pressure to the patient’s head, and the pathogenic idea that had ostensibly been forgotten was quite often remembered. (Freud later abandoned this pressure technique, but in 1895 it seemed extremely important to him.) This psycho-therapeutic method works only if and when the patient faces the idea that had been pushed into his unconscious. If he refuses to recognize it, nothing the physician can do or say will help him. Freud recognized that there was a possibility of the pressure technique failing, but he also saw that he and Breuer had made a significant break-through in the study of the human mind.

While Freud would later repudiate certain parts of this book and greatly enlarge others, STUDIES ON HYSTERIA is a landmark in his career as well as in the early history of psychology. It records the birth of the method of psychoanalysis, the method that Freud would perfect in THE INTERPRETATION OF DREAMS, and it introduces the studies that were to occupy Freud for the next forty years.