Ordinary Nervousness

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Ordinary Nervousness

In our last discussion we accomplish a difficult task. Now I shall temporarily leave our subject and address myself to you.

For I know quite well that you are dissatisfied. You thought that an introduction to psychoanalysis would be quite a different matter. You expected to hear vivid illustrations instead of theories. You will tell me that when I gave you the illustration of "on the ground floor in the first story," you had grasped something of the causation of neurosis, only of course this should have been a real observation and not an imaginary story. Or, when in the beginning I described two symptoms (not imaginary also, let us hope) whose analysis revealed a close connection with the life of the patient, you first came to grasp the meaning of the symptoms and you hoped that I would proceed in the same way. Instead I have given you theories—lengthy, difficult to see in perspective and incomplete, to which something new was constantly being added. I worked with conceptions that I had not previously presented to you, abandoned descriptive for dynamic conceptions, and these in turn for economic ones. I made it hard for you to understand how many of the artificial terms I made use of still carry the same meaning and are used interchangeably only for the sake of euphony. Finally, I allowed broad conceptions to pass in review before you: the principles of pleasure and of fact and their phylogenetically inherited possession; and then, instead of introducing you to definite facts, I allowed them to become increasingly vague till they seemed to fade into dim distances.

Why did I not begin my introduction to the theory of neurosis with the facts that you yourselves know about nervousness, with something that has always aroused your interest, with the peculiar temperament of nervous people, their incomprehensible reactions to external influences, to human intercourse, their irritability, their uselessness? Why did I not lead you step by step from the understanding of simple, everyday forms to the problems of mysterious and extreme manifestations of nervousness?

I cannot even say that you are wrong. I am not so infatuated with my art of representation as to see some special attraction in every blemish. I myself believe that I could have proceeded differently, to your better advantage, and this indeed had been my intention. But one cannot always carry out one's sensible intentions. The nature of the subject matter issues its own commands, and easily modifies our plans. Even so usual a performance as the organization of well-known material is not entirely subject to the particular purposes of the author. It forms itself as it will and later one wonders why it turned out so and not otherwise.

Probably one of the reasons is that the title, A General Introduction to Psychoanalysis, no longer applies to this part, which deals with the neuroses. The introduction to psychoanalysis is found in the study of errors and the dream; the theory of neurosis is psychoanalysis itself. I do not think that in so short a time I could have given you a knowledge of the theory of neurosis other than in concentrated form. It was necessary to present to you connectedly the meaning and interpretation of the symptoms, their external and internal conditions and their bearing on the mechanism of symptom formation. This I have attempted to do; it is practically the nucleus of the material that modern psychoanalysis is able to offer. We had to say quite a good deal concerning the libido and its development, and something as well concerning the development of the ego. The introduction had already prepared you for the presuppositions of our technique, for the large aspects of the unconscious and of suppression (resistance). In a subsequent lecture you will learn from what points psychoanalysis proceeds organically. For the present I have not sought to hide from you the fact that all our results are based on the study of a single group of nervous affections, the so-called transference neuroses. Though you have gained no positive knowledge and have not retained every detail, still I hope that you have a fair picture of the methods, the problems and the results of psychoanalysis.

I have assumed that it was your wish for me to begin my presentation of neuroses with a description of nervous behavior, the nature of neurotic suffering, and the way in which the nervous meet the conditions of their illness and adapt themselves to these. Such subject matter is certainly interesting and well worth knowing. It is moreover not very hard to handle, yet it is not wise to begin with its consideration. There is danger of not discovering the unconscious, of overlooking the great significance of the libido, of judging all conditions as they appear to the ego of the nervous person. It is obvious that this ego is neither a reliable nor an impartial authority. For this very ego is the force that denies and suppresses the unconscious; when the unconscious is concerned, how then could we expect justice to be done? The rejected claims of sexuality stand first in the line of these suppressions; it is natural that from the standpoint of the ego we can never learn their extent and significance. As soon as we attain to the point of view of suppression, we are sufficiently warned not to make one of the contending factions, above all not to make the victor judge of the struggle. We are prepared to find that the testimony of the ego may lead us astray. If one is to believe the evidence of the ego, it would appear to have been active all along, all its symptoms would have been actively willed and formed. Yet we know that it has passively allowed a great deal to occur, a fact which it subsequently seeks to conceal and to palliate. To be sure, it does not always attempt this; in the case of the symptoms of compulsion neurosis it must admit that it is being opposed by something alien, which it can resist only with difficulty.

Whoever does not heed these warnings not to mistake the prevarications of the ego for truth, has clear sailing; he avoids all the resistances which oppose the psychoanalytic emphasis upon the unconscious, on sexuality, and on the passiveness of the ego. He will assert with Alfred Adler that the "nervous character" is the cause instead of the result of the neurosis, but he will not be able to explain a single detail of symptom formation or to interpret a single dream.

You will ask: Is it not possible to do justice to the part the ego plays in nervousness and in symptom formation without crudely neglecting the factors revealed by psychoanalysis? I answer you: Surely it must be possible and at some time or other it will take place; but the methods by which we organize the work of psychoanalysis do not favor our beginning with just this task. We can foresee the time when this task will claim the attention of psychoanalysis. There are forms of neuroses, the so-called narcistic neuroses, in which the ego is far more deeply involved than in anything we have studied heretofore. The analytic investigation of these conditions will enable us to judge reliably and impartially the part that the ego plays in neurotic illness.

One of the relations which the ego bears to its neurosis is so obvious that it must be considered at the very outset. In no case does it seem to be absent, and it is most clearly recognizable in the traumatic neuroses, conditions which we do not as yet clearly understand. You must know that in the causation and mechanisms of all possible forms of neurosis, the same factors are active again and again; it is only the emphasis that is shifted from one to the other of these factors in symptom formation. The members of a company of actors each have certain parts to play—hero, villain, confidant, etc.—yet each will select a different drama for his benefit. Thus the phantasies which undergo conversion into symptoms are especially easy to detect in hysteria; compulsion neuroses are essentially dominated by the reactionary formations, or counter-seizures of the ego; what we designate as secondary elaboration in dreams dominates paranoia in the form of delusions, etc.

In traumatic neuroses, particularly if they are caused by the horrors of war, we are especially impressed by a selfish ego-impulse which seeks protection and personal advantage. This in itself is not a sufficient cause for illness, but it can favor its beginning and also feed its needs once it has been established. This motive serves to protect the ego from the dangers whose imminence precipitated the disease, and does not permit convalescence until the recurrence of these dangers seems impossible, or until compensation has been obtained for the danger that has been undergone.

But the ego betrays similar interest in the origin and maintenance of all other neuroses. We have already said that the ego suffers the symptom to exist, because one of its phases gratifies the egoistic tendency toward suppression. Besides, the ending of the conflict by means of symptom development is the path of least resistance, and a most convenient solution for the principle of pleasure. Through symptom formation the ego is undoubtedly spared a severe and unpleasant inner task. There are cases where even the physician must admit that the resolution of the conflict into neurosis is the most harmless outcome and one most easily tolerated by society. Do not be surprised, then, to learn that occasionally even the physician takes the part of the illness he is battling against. He does not have to restrict himself to the role of the fanatic warrior for health in all situations of life. He knows that the world contains not only neurotic misery, but also real, incurable suffering. He knows that necessity may even require a human being to sacrifice his health, and he learns that by this sacrifice on the part of one individual untold wretchedness may be spared for many others. So if we say that the neurotic escapes the conflict by taking refuge in illness, we must admit that in some cases this escape is justifiable, and the physician who has diagnosed the state of affairs will retire silently and tactfully.

But let us not consider these special cases in our further discussion. In average cases the ego, by having recourse to neurosis, obtains a certain inner advantage from the disease. Under certain conditions of life, there may also be derived a tangible external advantage, more or less valuable in reality. Let me direct your attention to the most frequent occurrences of this sort. Women who are brutally treated and mercilessly exploited by their husbands almost always adopt the evasion of the neurosis, provided that their predisposition permits this. This usually follows when the woman is too cowardly or too virtuous to seek secret solace in the arms of another, or when she dare not separate from her husband in the face of all opposition, when she has no prospect of maintaining herself or of finding a better husband and especially when her sexual emotions still bind her to this brutal man. Her illness becomes a weapon in her struggle with him, one that she can use for self-protection and misuse for purposes of vengeance. She probably dare not complain of her marriage, but she can complain of her illness. The doctor becomes her assistant. She forces her inconsiderate husband to spare her, to attend to her wishes, to permit her absence from the house and thus free her from the oppressions of her married life. Wherever such external or accidental gain through illness is considerable and can find no substitute in fact, you can prophesy that the possibility of influencing neurosis through therapy is very slight.

You will tell me that what I have said about the advantage gained from the disease speaks entirely for the hypothesis I have rejected, namely, that the ego itself wills and creates the neurosis. Just a moment! It probably does not mean more than that the ego passively suffers the neurosis to exist, which it is unable to prevent anyway. It makes the most of the neurosis, if anything can be made of it at all. This is only one side of the question, the advantageous side. The ego is willing to endure the advantages of the neurosis, but there are not only advantages. As a rule it soon appears that the ego has made a poor deal in accepting the neurosis. It has paid too high a price for the mitigation of the conflict; and the sensations of suffering which the symptoms bring with them are perhaps every bit as bad as the agonies of conflict, usually they cause even greater discomfort. The ego wants to rid itself of the pain of the symptoms without relinquishing the gain of illness, and that is impossible. Thus the ego is discovered as by no means so active as it had thought itself to be, and this we want to keep in mind.

If you were to come into contact with neurotics as a physician, you would soon cease to expect that those who complain most woefully of their illness are the ones who will oppose its therapy with the least resistance or who will welcome any help. On the contrary, you would readily understand that everything contributing to the advantage derived from the disease will strengthen the resistance to the suppression and heighten the difficulty of the therapy. We must also add another and later advantage to the gain of illness which is born with the symptom. If a psychic organization, such as this illness, has persisted for a long time, it finally behaves as an independent unit, it expresses something like self-preservation, attains a kind of modus vivendi between itself and other parts of psychic life, even those that are fundamentally hostile to it. And occasions will probably arise where it can prove again to be both useful and valuable, by which it will attain a secondary function, which gives strength to its existence. Instead of an illustration from pathology take a striking example from everyday life. An efficient workman who earns his living is crippled for his occupation by some disaster; his work is over for him. After a while, however, he receives a small accident insurance, and learns to exploit his injury by begging. His new existence, though most undesirable, is based upon the very thing that robbed him of his former maintenance. If you could cure his defect, he would be without a means of subsistence, he would have no livelihood. The question would arise: Is he capable of resuming his former work? That which corresponds to such secondary exploitation of illness in neurosis we may add to the primary benefit derived therefrom and may term it a secondary advantage of disease.

In general I should like to warn you not to underestimate the practical significance of the advantage from illness and yet not to be too much impressed by it theoretically. Aside from the previously recognized exceptions, I am always reminded of Oberländer's pictures on "the intelligence of animals" which appeared in the Fliegende Blätter. An Arab is riding a camel on a narrow path cut through a steep mountain side. At a turn of the trail he is suddenly confronted by a lion who makes ready to spring. He sees no way out, on one side the precipice, on the other the abyss; retreat and flight—both are impossible; he gives himself up as lost. Not so the camel. He leaps into the abyss with his rider—and the lion is left in the lurch. The help of neurosis is as a rule no kinder to the rider. It may be due to the fact that the settlement of the conflict through symptom development is nevertheless an automatic process, not able to meet the demands of life, and for whose sake man renounces the use of his best and loftiest powers. If it were possible to choose, it were indeed best to perish in an honorable struggle with destiny.

I still owe you further explanation as to why, in my presentation of the theory of neurosis, I did not proceed from ordinary nervousness as a starting point. You may assume that, had I done this, the proof of the sexual origin of neurosis would have been more difficult for me, and so I refrained. There you are mistaken. In transference neurosis we must work at interpretations of the symptoms to arrive at this conclusion. In the ordinary forms of the so-called true neuroses, however, the etiological significance of sexual life is a crude fact open to observation. I discovered it twenty years ago when I asked myself one day why we regularly barred out questions concerning sexual activity in examining nervous patients. At that time I sacrificed my popularity among my patients to my investigations, yet after a brief effort I could state that no neurosis, no true neurosis at least, is present with a normal sexual life. Of course, this statement passes too lightly over the individual differences, it is unclear through the vagueness with which it uses the term "normal," but even to-day it retains its value for purposes of rough orientation. At that time I reached the point of drawing comparisons between certain forms of nervousness and sexual abnormalities, and I do not doubt that I could repeat the same observations now, if similar material were at my disposal. I frequently noticed that a man who contented himself with incomplete sexual gratification, with manual ononism, for instance, would suffer from a true neurosis, and that this neurosis would promptly give way to another form, if another sexual regime no less harmful were substituted. From the change in the condition of the patient I was able to guess the change in the mode of his sexual life. At that time I learned to hold obstinately to my conjectures until I had overcome the patient's prevarications and had forced him to confirm my suppositions. To be sure, then he preferred to consult other physicians who did not inquire so insistently into his sexual life.

At that time it did not escape my notice that the origin of the disease could not always be traced back to sexual life; sexual abnormality would cause the illness in one person, while another would fall ill because he had lost his fortune or had suffered an exhausting organic disease. We gained insight into this variation by means of the interrelations between the ego and the libido, and the more profound our insight became, the more satisfactory were the results. A person begins to suffer from neurosis when his ego has lost the capacity of accommodating the libido. The stronger the ego, the easier the solution of the problem; a weakening of the ego from any cause whatsoever has the same effect as a superlative increase of the claims of the libido. There are other and more intimate relations between the ego and the libido which I shall not discuss, as we are not concerned with them here. To us it is of enlightening significance that in every case, regardless of the way in which the illness was caused, the symptoms of neurosis were opposed by the libido and thus gave evidence for its abnormal use.

Now, however, I want to draw your attention to the difference between the symptoms of the true neuroses and the psychoneuroses, the first group of which, the transference neurosis, has occupied us considerably. In both cases the symptoms proceed from the libido. They are accordingly abnormal uses of it, substitutes for gratification. But the symptoms of the true neurosis—such as pressure in the head, sensations of pain, irritability of an organ, weakening or inhibition of a function—these have no meaning, no psychic significance. They are manifested not only in the body, as for instance hysteric symptoms, but are in themselves physical processes whose creation is devoid of all the complicated psychic mechanism with which we have become acquainted. They really embody the character that has so long been attributed to the psychoneurotic symptom. But how can they then correspond to uses of the libido, which we have come to know as a psychological force? That is quite simple. Let me recall one of the very first objections that was made to psychoanalysis. It was stated that psychoanalysis was concerned with a purely psychological theory of neurotic manifestations; that this was a hopeless outlook since psychological theories could never explain illness. The objectors chose to forget that the sexual function is neither purely psychic nor merely somatic. It influences physical as well as psychic life. In the symptoms of the psychoneuroses we have recognized the expression of a disturbance in psychic processes. And so we shall not be surprised to discover that the true neuroses are the direct somatic consequences of sexual disturbances.

The medical clinic gives us a valuable suggestion (observed by many research workers) for the comprehension of the true neuroses. In all the details of their symptomatology, and as well in their characteristic power to influence all organic systems and all functions, the true neuroses reveal a marked similarity to the conditions of those diseases which originate through the chronic influence of foreign poisons and as well through their acute diminution; with conditions prevalent in intoxication and abstinence. The two groups of conditions are brought still closer together by the relation of intermediate conditions, which, following M. Basedowi, we have learned to attribute to the influence of toxic substances, but of toxins, however, which are not introduced into the body from without, but arise in its own metabolism. These analogies, I think, lead us directly to the consideration of these neuroses as disturbances in sexual metabolism. It may be that more sexual toxins are produced than the individual can dispose of, or that inner, even psychic conditions, stand in the way of the proper elaboration of these substances. The language of the people has always favored such assumptions as to the nature of sexual desires. It calls love an "intoxication"; it will have love-madness aroused through potions, and thus sees the motive force removed, as it were, to the outer world. For the rest, the phrase "sexual metabolism" or "chemism of sexuality" is a chapter-head without content. We know nothing about it and cannot even decide whether we are to assume two sexual substances, the male and the female, or, if there is only one sexual toxin, which to consider the carrier of all the stimulating power of the libido. The structure of psychoanalysis that we have erected is really only a superstructure which at some future time must be placed upon its organic foundation; but what this is we do not know as yet.

Psychoanalysis is characterized as a science, not by reason of the subject matter it handles but by the technique it employs. This can be employed in dealing with the history of civilization, the science of religion or mythology, as well as with the theory of neurosis, without altering its character. The revealing of the unconscious in psychic life is all it aims to accomplish. The problems of the true neuroses, whose symptoms probably originate in direct toxic damage, yield no point of attack to psychoanalysis. Psychoanalysis can do little for their elucidation, and must leave the task to biological-medical research. Perhaps you understand now why I did not choose to organize my material differently. If I had given to you an Introduction to the Theory of the Neuroses as you wished, it would unquestionably have been correct to proceed from the simple forms of the true neuroses to those complex illnesses caused by a disturbance of the libido. In discussing the true neuroses I would have had to bring together the facts we have gleaned from various quarters and present what we think we know of them. Only later, under the psychoneuroses, would psychoanalysis have been discussed as the most important technical aid for insight into these conditions. I had, however, intended and announced A General Introduction to Psychoanalysis, and it seemed to me more important to give you an idea of psychoanalysis than to present certain positive facts about neuroses; and so I could not place the true neuroses into the foreground, for they prove sterile for the purposes of psychoanalysis. I believe that I have made the wiser choice for you, since psychoanalysis deserves the interest of every educated person because of its profound hypotheses and far-reaching connections. The theory of neurosis, on the other hand, is a chapter of medicine like any other.

You are, however, justified in expecting some interest on our part in the true neuroses. Because of their intimate connection with psychoneuroses we find this decidedly necessary. I shall tell you then that we distinguish three pure forms of true neuroses: neurasthenia, anxiety neurosis and hypochondria. Even this classification has not remained uncontradicted. The terms are all widely used, but their connotation is vague and uncertain. Besides, there are in this world of confusion physicians who object to any distinctions between manifestations, any emphasis of clinical detail, who do not even recognize the separation of true neuroses and psychoneuroses. I think they have gone too far and have not chosen the road which leads to progress. The types of neuroses we have mentioned occur occasionally in pure form; more often they are blended with one another or with a psychoneurotic condition. This need not discourage us to the extent of abandoning the task of distinction. Think of the difference between the study of minerals and that of ores in mineralogy. Minerals are described as individuals; frequently of course they occur as crystals, separated sharply from their surroundings. Ores consist of an aggregate of minerals which have coalesced not accidentally, but as a result of the conditions of their origin. We understand too little of the process of development of neuroses, to create anything similar to the study of ores. But we are surely working in the right direction when we isolate the known clinical factors, comparable to the separate minerals, from the great mass.

A noteworthy connection between the symptoms of the true neuroses and the psychoneuroses adds a valuable contribution to our knowledge of symptom formation in the latter. The symptom in the true neuroses is frequently the nucleus and incipient stage of development of the psychoneurotic symptom. Such a connection is most easily observed between neurasthenia and the transference neuroses, which are termed conversion hysteria, between anxiety neurosis and anxiety hysteria, but also between hypochondria and paraphrenia (dementia praecox and paranoia), forms of neuroses of which we shall speak subsequently. Let us take as an illustration the hysteric headache or backache. Analysis shows that through elaboration and displacement this pain has become the gratification substitute for a whole series of libidinous phantasies or reminiscences. But once upon a time this pain was real, a direct sexual toxic symptom, the physical expression of libidinous excitation. We do not wish to assert, by any means, that all hysteric symptoms can be traced to such a nucleus, but it is true that this is frequently the case, and that all influences upon the body through libidinous excitation, whether normal or pathological, are especially significant for the symptom development in hysteria. They play the part of the grain of sand which the mollusc has enveloped in mother-of-pearl. In the same way passing signs of sexual excitation, which accompany the sexual act, are used by psychoneurosis as the most convenient and appropriate material for symptom formation.

A similar procedure is of diagnostic and therapeutic interest especially. Persons who are disposed to be neurotic, without suffering from a flourishing neurosis, frequently set in motion the work of symptom development as the result of an abnormal physical change—often an inflammation or an injury. This development rapidly makes the symptom given by reality the representative of the unconscious phantasies that had been lurking for an opportunity to seize upon a means of expression. In such a case the physician will try different ways of therapy. Either he will try to do away with the organic basis without bothering about its noisy neurotic elaboration, or he will struggle with the neurosis brought out by the occasion, and ignore its organic cause. The result will justify now one, now the other method of procedure; no general laws can be laid down for such mixed cases.

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