Studies on Hysteria

The studies on hysteria by Josef Breuer and Sigmund Freud were published in 1895 and are considered the first treatise in classical psychoanalysis . They were finally edited in the 1922 edition. It is a collection of essays which initially deal with the older concept of hysteria according to Paul Julius Möbius (1888), but which quickly introduced new, primarily aetiological, concepts. Freud went on to develop his own concept, which was based on the assumption of unconscious processes as specifically hysterical processes, and later presented a psychotherapeutic treatment method that could do without hypnotic and cathartic elements.

Form of the hysteria according to Breuer and Freud

Regardless of the further limitation of the term, which was still widely used by Möbius (it encompassed everything that is now referred to as neurosis), the studies assume a general form of the hysterical illness. A phase of disposition formation is followed by manifestation through the development of hysterical trauma. The prognosis depends on numerous boundary conditions, but is usually unfavorable without suitable treatment if the patient cannot find suitable means to counteract the progression himself.

Typically, the disease is lived out sooner or later, there are relapses with considerable stress for the patient and the environment, and in the further course of a general breakdown of the personality
Patients with a primarily strong personality could sometimes catch themselves untreated, would come to terms with the disease and reach a state of less severe but permanent symptom burden that could settle in and remain lifelong. A prerequisite for this is a reflection of whatever kind on one's own psychological constitution, without which the patient cannot maintain this state (artistic activity, scientific education). In this case there is also a secondary gain in illness .
The prognosis under treatment is much better. With his cathartic method, Breuer initially did not necessarily require insight into illness, but recognized that an insightful moment about strengthening the healthy parts of the personality significantly influences the further hysterical development.
Freud, on the other hand, said that the cathartic method, while a good tool, could not lead to permanent recovery. An exhaustive treatment can therefore only be carried out with the cooperation of the patient, otherwise one of the other two forms occurs.

The hysteria makes it difficult to understand the disease. In the so-called thrust , the patient is not amenable to reflection and thus psychoanalysis according to Freud, but is accessible to catharsis according to Breuer. Both forms of therapy are therefore still used today in a more developed form.

General characteristics of the development of hysteria according to Breuer and Freud

The consciousness of the hysteric is described as functionally split into at least two states of consciousness ( primary and secondary ). (It is a different split from what is now ascribed to endogenous psychosis .)
These separate states pursue different goals in the patient's behavior , work only with difficulty and show a tendency to be mutually exclusive and to organize (systematize)

This is the basic phenomenon of hysteria, the clinical appearance is very impressive and can be found practically everywhere in the population in many degrees. On this point Breuer and Freud were of one mind, their differences mainly related to the treatment methods indicated.

Disease insight

Based on this concept, it is explained that the patient can only develop insight into the disease if a so-called primary state of consciousness is reached, since the secondary consciousness denies access to otherwise easily available information. The patient himself does not notice the change from one state to the other. This can only

through the eye of an observer or
can be discovered through reflection by the patient who is currently in the primary state of consciousness, as this requires a rational ability to reflect.

Psychodynamically this is explained as follows:

For the insight into disease, the recruitment of associations from the primary state of consciousness is necessary.
The secondary consciousness shows a clear insufficiency here , is therefore less efficient and overall 'torn', albeit very productive.
It is therefore a psychological foreign body .

The exclusion of information accessible in the primary consciousness during the predominance of the secondary consciousness is, according to Freud, topically conditioned and takes place on the basis of permanently running evaluation mechanisms . The secondary consciousness , like every conscious impulse, is administrative and can certainly allow or exclude associations that serve the respective interests. With this concept, Freud justified the approach of psychodynamics , which later was conceptually expanded considerably and is today one of the core concepts of all depth psychology schools. In the clinic, he described secondary consciousness as incapable of useful organization of behavior, but not in terms of self-protection. It produces astonishing dexterity as soon as ideas are raised in everyday life or during treatment that can be 'dangerous' for it. It defends itself against enlightenment - and wherever this defense cannot be reached through affective means, it freely uses every possible source.

Concepts to explain the origin of the secondary state of consciousness

Here Breuer and Freud distinguished the following levels:

During the early anamnesis, a hysterical disposition developed under the influence of traumas and partial traumas , without which no psychopathological picture could arise. (The 'hysterical process' itself, however, was seen as widespread in the population.)

In later stages of life, numerous smaller ideas develop which, in terms of actual genetics, transfer parts of the consciousness into a state that is similar to artificial hypnosis . (hypnoid state)

Since these ideas can be easily associated with one another, but are logically incompatible with the rest of the associative environment, they tend to be demarcated and organize themselves in a way that does not depend on logic and realism.

Over time, they melt into one another and form a more or less uniform hypnoid state on which the secondary consciousness develops and can reach considerable complexity.

Condition seconde

The person could sometimes be in this, sometimes in that state of consciousness . The predominance of the secondary state of consciousness was called the condition seconde . The hysteric is said to have limited productivity here, but at times very productive.

These include:

Phases of severe symptom burden
Absences
Freaking out, tantrums

diagnosis

In Freud's view, psychoanalysis blurs the lines between diagnosis and therapy . Every effort made on the patient is diagnostic and therapeutic at the same time. However, since the decision about a certain form of therapy is only possible with the diagnosis, but this cannot be reliably made without therapy, Freud began his further work on the respective patient first with the cathartic method according to Breuer , in order to be able to collect information in the respective case . It struck him that the cathartic treatment method was by no means successful for every symptom of every patient who, according to conventional understanding, would have been diagnosed as a hysteric. Freud then began to deal with the clinical pictures of neuroses in general , starting with hysteria , and to differentiate them further. He said that the neurotic diseases with which the patients appeared in the practice were mostly mixed neuroses in which the signs of different classes of neuroses were combined. The success of a therapeutic measure taken would depend to a large extent on which neurosis component the targeted symptom was.

Historical classification of the neuroses

In the hysteria studies, Sigmund Freud presented for the first time a classification of psychogenic neuroses based on the conceptual content involved , which introduced the psychiatric concept of the mixed form of mental illness into psychotherapy for the first time. As a starting point , he took the classification used at the time, which was very simple and looked like this:

Explanation	Mold inventory
neurasthenia
monotonous clinical picture without " psychological mechanism " Weakness or exhaustion of the function of the - in itself healthy - nervous system caused by overwork or other external influences ( infection , intoxication , stress, etc.) Collective term for organically not quite comprehensible complaints According to Freud, this group later constitutes one of the three actual neuroses on the basis of inadequate drive removal	Pure forms were also distinguished from this neurosis, which would occur particularly in adolescents . Mixed forms would also occur.
Obsessive-compulsive disorder
Neurosis of real obsessions with a complex psychological mechanism (comparable to that of hysteria); can be successfully treated psychoanalytically	Mixed forms are rare; this neurosis is usually combined with an anxiety neurosis.
Anxiety neurosis
Neurosis with symptoms that correspond to equivalents or rudiments of expressions of fear comparable in terms of form to neurasthenia, but sharply demarcated from them. Anxiety neuroses include phobic, hyperesthetic, hypochondriac and fearful expressions.	Pure forms were also distinguished from this neurosis, which would occur particularly in adolescents. Mixed forms would also occur.
hysteria
Neurosis based on one of the postulated psychological mechanisms of hysteria, the so-called hysterical mechanism .	Mixed forms are rare; this neurosis is usually combined with an anxiety neurosis.

Freud believed that a large part of the causes of neurotic diseases - as far as he could speak of causes - can be traced back to sexual moments. With the classification based on sexual moments, sharply demarcated lines were soon separated, which separate individual forms of neurosis and are characteristic of the respective severity of the disease. The distinction between pure and mixed hysterical diseases also brought a decisive advance in the understanding of the neuroses.

Freud redefined hysteria. He no longer referred to all neuroses in which individual hysterical symptoms could be discovered as hysteria, but separated the clinical picture and symptoms from one another. He said that the hysterical symptom could also appear in healthy people, but also in many other clinical pictures, for which they, however, are not causally responsible. In individual cases, mental illnesses are made up of a large number of symptoms and psychological mechanisms, some of which were previously assigned to one clinical picture, others to another.

Before Freud, for example, a doctor who discovered a hysterical symptom immediately diagnosed “hysteria”, on whose account the perverse , degenerative, neurasthenic , etc. components that were often added were then also taken into account . The previously so enormously inflated concept of disease, hysteria, came about, according to Freud, precisely because one did not know its mechanism and did not know what exactly it could and what not. The hysterical mechanism is very widespread and can be observed to a lesser extent in almost all people, which does not mean that they all suffer from hysteria.

Classification of hysteria according to Freud

In the course of his work, Freud classified four forms:

Topics of the hysterical consciousness

In his work, Freud presented a comprehensive concept on the topic of hysterical consciousness, which he himself changed in later works and which is no longer represented in its original form today. However, it was historically significant and shows important features that today's models also have. The graphs shown were not used by Freud, but similar drawings, in which representations and their associative connections are shown, still occur routinely in session transcripts of psychoanalysts.

In his contributions to the hysteria studies, Freud imagined the psyche as a multi-dimensional structure with multiple layers . It starts from a hysterical core in consciousness , which represents an associative combination of partial traumatic representations, which are unconscious to the patient and which underlie the neurosis and its symptoms. According to Freud, this core works like a foreign body in the surrounding, healthy psychological substrate . Freud compared the symptoms to "inflammation" that occurs when mechanical foreign bodies are in the tissue and cause inflammation symptoms (for example a splinter ).

Freud describes chains of associations as “themes” that spread out from this core. The representations that are close to the core would tend to be integrated into the core and also become part of the symptoms; associations that are further away form the substrate of the remaining, primary consciousness .

features

Freud states that the themes are:

strict linear-chronological arrangement of the representative offices within a topic
are always connected to the core
end in representations generated by current genetics (e.g. new ideas entered by the analyst)
they are layered concentrically
their outer end leads to the symptom (specified later)

Freud assumes a concentric layering of the issues around the core. Several of the association chains shown above wrap around, but have no noteworthy connections between them. The ends of the chains on the periphery correspond to the recently added representative offices.

While the hysterical core, as a foreign body, does not enter into any connection with the surrounding healthy psychic material, the topics would represent connections that more or less mediate between the core and the environment. Starting from normal consciousness, the topics become more and more alienated from it as soon as they are pursued towards the core. Its pathological character gradually increases until it is soon clearly recognizable. The whole neurotic structure thus resembles an infiltrate with a solid core. According to Freud, psychotherapy aims to neutralize the separating effect of resistance and to make the ideas so far conscious that they allow a view of the core.

Freud noticed that individual associations of a topic can get in touch with the core even if they are further away from it. He saw in this a pathological effect, which would consist in the endeavor of the neurosis to expand the core and acquire further representations.

Another aspect of the stratification of the topics is resistance . Associations within a topic that have a similar or comparable resistance can be described as "equidistant" from the core idea. Freud is of the opinion that the issues are subject to less resistance outside, but increasing resistance inside. The closer you get to the explosive core, the more the patient tries to withhold information ( psychological defense ).

The further away such a ring is, the less is the resistance of the topic in it, and the less is the extent of irrational attachments and changes in consciousness.

Freud describes an amazing observation with this model: If a layer boundary (somewhere) has been broken during therapy, the patient will deliver large amounts of memories of his own accord, which are also located in this layer. This can happen like a dam burst, with the patient sometimes speaking quickly and productively, which is associated with great psychological relief. He could then not only provide further information about the topic just dealt with (in which the layer was broken), but also about all ideas of other topics that are on the same layer. It is as if the resistance of this layer has completely disappeared, whereupon all the reminiscences located there are "released".

Overdetermination of psychopathological symptoms

The overdetermination of psychopathological symptoms, which is now generally known, was also described for the first time by Freud using this model. Topics close to the core can unite with one another and jointly lead to the outside in order to generate the symptom there. When the two topics merged, there would be clearly irrational attachments by which this process can be recognized.

It should be noted that the analysis moves from the symptom (outside) towards the core. (So it begins at the periphery.) It could turn out that a symptom that initially appears to be monolithic is overdetermined, i.e. more than one topic is covered. The topics come from different origins, but were later integrated into one another in the course of the biography .

Complications in the analysis would arise if there was more than one hysterical nucleus. This could be the case, for example, if two different neurotic events are to be analyzed, one of which expired years ago and subsided automatically, but the other was acutely added later. Often the two cores are connected, but are clearly separated and different.

Since people are constantly evolving, one would encounter artifacts from attempts to heal themselves and other efforts by the patient to deal with his or her idiosyncrasy.

First psychotherapeutic concept by Sigmund Freud

" There is nothing left but to stick to the periphery of the pathogenic psychic structure. One begins with letting the patient tell what he knows and remembers, directing his attention and using the pressure procedure to overcome slight resistance. Every time one has opened a new path by pressing, one can expect that the patient will continue it a little way without resistance.
Sigmund Freud, 1895 "

Based on the early topical model of hysteria (neurosis), Sigmund Freud presented the first method with which one could move therapeutically through the topical . This was the first birth version of psychoanalysis as a form of therapy . It also contains some features that many forms of therapy that are represented today have.

General procedure:

Association on different topics ( horizontal direction)
If resistance occurs on various topics, it is overcome on one topic by means of therapeutic pressure build-up. As a result, the resistance in the other topics also falls to a new, lower level. ( vertical direction)
This new level will be processed according to (1) associatively (again horizontal direction)
After repeating steps (1) and (2) one finally arrives (step by step) at the core that is the cause of the hysteria (neurosis). If you finally become aware of this, the symptoms would disappear.

Freud's conception of the horizontal and vertical directions

Remaining on a layer of equal resistance was described by Freud as moving horizontally through the topic . Resistance does not break through here , but only the processing of those offshoots of the issues that lie in this layer. However, since the issues would lead to a resistance limit in the direction of the core, the horizontal movement alone does not lead to coming to terms with the disease.

Freud described breaking through a resistance as the vertical direction. While the analysand is reproducing, the analyst is picking up on a piece of logical thread that he suspects leads a layer deeper inside. The patient, however, carefully conceals these threads, which lead deeper. It is not easy to discover them. But you would be betrayed by an illogical or irrational move. In the descriptions of " gaps " and " damage ", you discover interruptions in the context, etc. Such interruptions would preferably be bridged by different, characteristic behaviors.

Idioms
insufficient information
makeshift additions
apparently superfluous references to your own motivations (!)

Above all, the patient does not want to acknowledge these loopholes if he is made aware of them. If you tell him that there is a logical contradiction here and that there is probably something else behind it that now needs to be uncovered, his reaction to this will provide information about the type and strength of the impending resistance.

All later psychoanalytic models show features of this model, including the staggered resistances of different strengths, the breaking through of the resistances and the chains of associations . One can imagine that there are two topics (chains of associations) on a layer a, which merge shortly before the transition in a layer b. If the resistance is overcome, they split up again on layer b and are subject to different fates. While one part can be exhausted horizontally , the other part has another breakthrough on a layer c.

Freud explicitly pointed out that the contents of the associations of a layer that has not yet been processed are unknown in every concrete case. Only the patient can illuminate them. Today, in different terminology, this represents one of the basic requirements that classical psychoanalysis provides. Any assumption about the content of the patient's unconscious is dubious.

Freud found that the patient prefers to work horizontally , but the analyst works vertically to the layers . The patient is probably pushing in the opposite direction, since he himself has an interest in not letting the associations drift to the bottom of the layer, to the limit of resistance. The analyst, on the other hand, tries to bring the associations just over this limit.

Predictions about the places where the chains of association meet resistance are possible. If the analyst is correct in a prediction, this will accelerate the course of the analysis, but if he is wrong, he would force the patient to take sides, which the patient would reject. This could be tried as a trick in order to sound out the strength of the rejection . From it the analyst would be able to see how much better the patient knows the truth ! Freud later largely confirmed this observation by introducing his concept of the system ubw , which is based on an unconscious but functioning world of ideas.

The I of the (later) three-instance model

The cooperation of the patient plays a major role here; after a while the patient will develop his own interest in further analysis and will be eagerly ready to cooperate. Freud speaks of the strengthening ego seizing an opening up opportunity to clear up the unconscious foreign body. The patient automatically brings in larger amounts of associative material - within the layer on which he has already overcome the resistance. He feels this is a great relief. While working horizontally, it makes sense to let the patient reproduce for a while without being influenced. He then automatically erases the memories and consequently makes numerous connections and finds his way back to his logical performance.

If it were not produced, it could lead to something remaining buried, which would later have to be dug up again with the same effort that has already been made once. On the other hand, the analyst must reckon with the fact that as soon as the patient approaches the next layer of resistance, he will use the opportunity of independent direction to prepare himself and lure the analyst on the wrong track. If one can discover this, it becomes clear in which direction the resistance can be expected.

Breakthrough to the core

Only after the method has led to the discovery of the core does the symptoms disappear, the patient begins (depending on intellect and mental ability ) independently to organize a large number of his ideas and to reproduce further material. He tidied up, had won over his hysterical idea and was aware of the reasons for his suffering.

The analytical work is not yet over, since now 'from below' as much as possible unconscious ideas have to be caught up and a lot of material processed. The subsequent sessions can now penetrate straight to the core and continue working from there. It is only at this stage that it is useful for the analyst to uncover guessed connections and communicate them to the patient. But even then it is only certain that what the patient can confirm himself and develop independently.

Assessment of success according to Freud

The analysis seldom brings a topic to a close straight away. Most of the time you follow a thread until it ends in a layer of greater resistance, but without reaching the core point. Then you let the thread drop in order to pick it up again later when the associative environment has been lit up enough to allow the breakthrough into the relevant, deeper layer. The analyst needs a sensibly structured record so that nothing is lost. With a practiced eye, the analyst can recognize at which point the conversation is taking place from the patient's facial expressions, gestures and phonics.

The illogic of hysterical (neurotic) thinking

Freud argued that a neurotic hysteria could never fall so low that they logic as fundamental property of thinking zer interfere. The reasoning will only ge interfere. This is another difference to psychosis.

The only thing that occurs in the patient is:

illogical thinking due to a refusal to provide information or
the formation of its own logic , which, however, always remains lawful.

In the first case, a lot of effort will operated by the patient to the information not having to install in his conscious view. But this means that he must have unconsciously drawn the logically correct conclusions, otherwise he would not be able to decide which information to refuse. Regardless of the point in time at which this took place - the respective result is guaranteed to be available, because the consequences are avoided. A psychological structure, however, which is alogical in nature, i.e. is in deep disintegration, would not appear so quickly in a hysteria (neurosis).

Patients are also amenable to logical arguments, as long as they are ready in the respective situation to take in information that they consider harmless with regard to the resistance. This gives rise to the possibility of numerous conversation techniques that were developed later, of initially offering the patient and allowing them to receive information that is so cleverly hidden that the patient's connection with the resistance is initially not apparent. He is then only confronted with it afterwards. (see also interview techniques ; paradoxical intervention )

swell

Wikisource: Studies on Hysteria, Original 1895 Treatise - Sources and Full Texts

Sigmund Freud / Josef Breuer: Studies on Hysteria. Franz Deuticke, Leipzig + Vienna 1895. Reprint: 6th edition. Fischer, Frankfurt a. M. 1991. ISBN 3-596-10446-7