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CLINICAL NOTES
ON SYMPTOMS
Sigmund Freud (1926-27). ‘Inhibitions, Symptoms and Anxiety,’ On Psychopathology,
translated by James Strachey, edited by Angela Richards (London: Penguin Books,
1987), pp. 242-264.
These clinical notes will summarize the main points made by Sigmund Freud about
the structure and function of symptoms in the paper cited above.
Freud defines a symptom as follows:
‘A symptom is a sign of, and a substitute for, an instinctual satisfaction which has
remained in abeyance; it is a consequence of the process of repression.’
This definition builds upon the previous definition which explains that the symptom
constitutes the sex life of the subject.
The term ‘substitute’ in the definition given above has to be understood in that
sense.
The origins of symptoms relate to the process of primal repression in the oedipal
matrix.
If repression is successful in deflecting the thoughts that are incompatible with the
subject and the fantasies that animate the oedipal matrix; then, there will be no need
to produce symptoms.
But, if primal repression is not successful, the subject experiences a return of the
repressed in the form of libidinal substitutes. These then are what Freud refers to as
symptoms in the definition given above.

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It is however not easy for the subject to figure out that the symptoms that he suffers
from are libidinal substitutes for repressed ideas. That is because in addition to
primal repression, there is also repression proper.
This is an attempt on the part of the ego to repress the derivatives of primal
repression and prevent them from coming into consciousness in the original form.
The subject is therefore not in a position to compare the original thoughts that were
subject to repression with those that emerge as substitutes in a distorted form.
Freud also argues that the symptom is akin to a foreign body that has not been
adequately metabolized by the subject.
Each of the psychoneuroses has its typical symptoms, but listing the symptoms is
not enough to infer the mental structure of the patient. That is because all the
neuroses have a hysterical core.
It is therefore possible for a phobic to have hysterical symptoms or for a hysteric to
have obsessional symptoms. The neuroses do not always present themselves in a
pure form.
When a clinician encounters a neurosis in a mixed form, he will find that there is an
overlap of symptoms.
Sometimes, a patient suffering from hysteria will develop an anxiety neurosis during
treatment. It could even be the case that what was thought to be an obsessional
neurosis turns out to be hysteria.
The act of diagnosis then is not reducible to identifying and classifying symptoms
against a given clinical entity. The analyst must be on the lookout for the therapeutic
context in which he makes sense of a particular symptom.
A symptom can also be aimed at the analyst. This is analogous to the situation in
which patients report having dreams for the analyst.
So there is a difference between thinking of symptoms as just libidinal substitutes for
the repressed and thinking of them as that which exists within a transference
neurosis.
Analysts do not treat a neurosis as such. All neuroses are treated in the form of
transference neuroses. So if a patient is not in a state of transference to the analyst, it
is not possible to treat the neurosis.
The structure of the symptom is akin to that of a compromise between the forces of
repression and the forces that resist repression.

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Freud points out that the hysterical symptom represents a compromise between ‘the
need for satisfaction and the need for punishment.’
Even though every symptom starts out as a foreign body, the ego adapts to the
existence of the symptom. It realizes that despite the pain caused by the symptom, it
can be put to work.
There are gains to having a symptom. The phrase, ‘flight into illness,’ is used in
theories of hysteria to describe the unexpected gains from having a symptom.
Patients get so used to their symptoms that it is difficult to get them to drop their
symptoms in analysis.
Each neurosis is constituted by a dominant symptom. So, for instance, anxiety can be
either a symptom or constitute a full-fledged anxiety neurosis in itself.
Likewise, phobia can be either a symptom or a clinical entity in itself. The
characteristic feature in the neurotic symptom is substitution.
Freud points out that in the case of Little Hans, what made it a neurosis is the
substitution of the horse for the father.
Little Hans was not afraid of horses as such, but by the possibility of being ‘bitten’ by
a horse; he has castration anxiety.
That is why Little Hans was afraid of going out in the street. His symptom is a
defence against that anxiety.
So whether Little Hans is described as just having a phobic symptom or whether the
symptom constitutes a clinical entity in itself is what is at stake in defining the scope
and the function of the symptom.
SHIVA KUMAR SRINIVASAN