Studies in hysteria complete

STUDIES in HYSTERIA.Authors: Dr. Sigmund Freud and Dr. Joseph Breuer.

INTRODUCTION TO THE BOOK,THE PSYCHIC MECHANISM OF HYSTERICAL PHENOMENA,THEORETICAL MATERIAL.- By Ayesha Muneer.

Studies in Hysteria -- First editionThis joint publication of Freud's and Breuer's lays out their theory of hysteria, describing how the hysteric experiences the illness and sometimes overcomes it by gaining insight into how it came about.

Studies in Hysteria is a seminal work on the mind/body connection, and establishes Freud as “the father of psychoanalysis.” Freud theorizes that when the mind is fearful, and overly emotional (i.e. hysterical), a person might imagine experiencing disease symptoms

On April 21, 1896, Sigmund Freud presented a paper titled Aetiology of Hysteria in which he theorized that hysteria in adults was caused by infantile seduction. Freud proposed the seduction theory after listening to the eighteen of his hysterical patients disclose childhood experiences of unwanted sexual contact (Masson, 1984).

Freud's procedure is empirical.His conclusions are drawn from 18 case studies, all of which, he claims, bear out without exception his general thesis. Of these 18 cases 6 are male, 12 are female.

HYSTERIA.Originally "hysteria" designated a link between certain nervous disorders and diseases of the female sexual and reproductive organs. It was thought that there was a direct connection between these physical pathologies localized in the female organs and certain nervous symptoms.

This explains why hysteria has commonly been conceived as a pathology to which women are exclusively susceptible. If it is based in a physiological source that is gender specific (the uterus), then the illness itself could only occur where this prerequisite physiology is present.When it comes to the manifestations of the symptoms Freud argues that neurotic symptoms are substitutes for sexual satisfaction.In this regard an hysterics physical symptoms are in some way a form of sexual satisfaction, or pleasure to the patient. The symptoms of a patent are in effect a form of sexual activity based upon the instinctual forces .

As Freud states:“ … all my experience shows that these psycho-neurotics are based on sexual instinctual forces … the symptoms constitute the sexual activity of the patient.”

Now when it comes to the cause or meaning of the symptoms Freud argued that adult symptoms are regressions back to childhood experiences.Freud states :“ … memories and associations arising during analysis of symptoms [in adults] regularly led back to the early years of childhood.”

SYMPTOMS OF HYSTERIA:Symptoms are described as ostensibly spontaneously idiopathic products and are strictly related to the precipitating trauma.

There can be: Hysterical convulsion (fit).Sensory disturbances-loss of sensitivity.Hypoesthesis (partial loss of sensitivity).Hyperesthesis (excessive loss of sensitivity).Analgesia (loss of sensitivity to pain)Paresthenia (exceptional sensation, such as tingling)Neuralgia ( pain in one or more nerves)

It includes blur of vision, photophobia, double vision, constantly recurring visual hallucinations and night blindness.

The visceral symptoms of this disorder are headache, lumps in the throat, choking sensation, coughing spells, bleaching nausea, sneezing, vomiting, anorexia, even up to the refusal of nourishment difficulty in breathing etc.

Another enigmatic conversion syndrome is pseudociasis (false pregnancy) in women who develop morning sickness, absence of period, fullness of breast, and bulging belly without being pregnant.Thus , the symptom is both a source of sexual satisfaction as well as being the result of sexual repression. In other words the patients symptoms are due to the damming up of their normal sexual life due to repression and resistance to the sexual instinct.

ETIOLOGY:Freud searched in the 18 cases for a single cause that all of them have in common: this would be their uniform basis and would hence point to the general etiology of hysteria. What is this shared element?

A traumatic experience in childhood that is uniformly of a SEXUAL nature !

Psychic Trauma:“Every experience which produces the painful affect of fear, anxiety, shame or of psychic pain may act as trauma.”

CLASSIFICATION OF HYSTERIA ACCORDING TO THE TRAUMA EXPERIENCED:Traumatic Hysteria: An accident (psychic trauma) evokes the syndrome. It is a connection between common hysteria and traumatic neuroses.Ordinary Hysteria: Instead of one large trauma, many partial traumas , grouped cases which can be of traumatic significance only when summarized, and which belong together insofar as they form small fragments of the sorrowful tale.

Conversion hysteria, in which the symptoms are manifested on the body

Anxiety hysteria, in which one feels excessive anxiety because of an external object.

Obsessional neuroses: here a sexual impulse is substituted by obsessive thoughts and compulsive behaviors

THE PSYCHIC MECHANISM OF HYSTERICAL PHENOMENA.(PRELIMINARY COMMUNICATION.)-BY Dr. JOSEPH BREUER AND Dr. SIGMUND FREUD.

Example 1:A very sick child finally fell asleep. The mother exerted all her will power to make no noise to awaken it, because she resolved to do so, she emitted a clicking sound with her tongue. This was later repeated on another occasion when she wished to be absolutely quiet and developed into a tic, which in the form of tongue clicking accompanied every excitement for years.

A very distressed young girl, while anxiously watching at a sick bed, fell into a dreamy state, had terrifying hallucinations and her right arm which was hanging over the back of the chair, became numb. This resulted in paralysis, contracture and anesthesia of that arm. Later on developing grave and most complicated Hysteria, she spoke and wrote only English, whereas her native language was incomprehensible for a year and a half.I. “The hysteric suffers mostly from reminiscences.” Freud acknowledges the difficulty of penetrating through to the origin, the primal cause of the hysteria. Following the patients' trains of association will often lead to other memories that are related to the cause of the hysteria or recount events that are manifestations of the disease itself, but are themselves not the underlying cause.

Freud calls these peripheral but associatively related recollections screen memories: they "screen" the original causal event, but also point toward it by means of association.To distinguish true causes from screen memories Freud proposes 2 conditions that must be at work for an event to give rise to hysteria:1) Suitability (or appropriateness) of an event to serve as a cause of the symptoms. In other words, the symptom must fit the cause. If a patient suffers from hysterical vomiting, for example, the root cause would likely be something that is associated with disgust. Freud refers to a patient who was forced as a child to stimulate a woman with his foot and whose hysterical symptom was a disorder of the legs, ultimately leading to paralysis. The symptom and the cause must, in short be of the same kind.2) The traumatic force of an event must be powerful enough for it to act as the cause of a hysteria.Hysterical vomiting cannot be caused, for example, by the experience of eating a rotten piece of fruit during one's childhood; this is simply not traumatic enough.

This is the reason why Freud associates hysteria with sexual events: only these, he believes, carry enough traumatic force to stigmatize us to the point of creating a hysterical response.“We found at first to our greatest surprise, that the individual hysterical symptoms immediately disappeared without returning if we succeed in thoroughly awakening the memories of the causal process with its accompanying affect, and if the patient circumstantially discussed the process in the most detailed manner and gave verbal expressions to the affect.”

II. “Repression.”The fading of a memory or the loss of an affect is dependent upon:1. Whether there was an energetic relation to the event that caused the affect. By reaction, it means here a whole serious of voluntary or involuntary reflexes, ranging from crying to an act of revenge, through which according to experience affects are discharged.* If the reaction is suppressed, the affect remains united with the memory.

Example: The reaction of an injured person to a trauma has only then a perfect “cathartic” effect if it is expressed in adequate reaction like revenge.

2. If in somnambulistic states the reaction to traumata is also reduced to nil.3. There appears that general blurring of impressions and the fading of memory (forgetting) and which above all wears out the affective ideas no longer activated.

Hysterical symptoms as a distorted form of expression: if one removes the causes of the distortion (repression) and opens up avenues for understanding the causes, the symptoms disappear.

This explains why Freud's therapy is based, like Breuer's "talking cure," on bringing the original traumatic memory back into the patient's consciousness: once it is freed from repression, the trauma ceases to cause hysterical symptoms and the patient is "cured."“Memories correspond to traumas which were not sufficiently ab-reacted and on closer investigation of the reasons for the hindrances, we can find at least two series of determinants through which the reaction to the trauma was omitted.”

It may therefore be said that the ideas which have become pathological have persisted with such freshness and affective strength because they have been denied the normal wearing- away processes by means of abreaction and reproduction and states of uninhibited associations.“Each individual hysterical symptom immediately and permanently disappeared when we had succeeded in bringing clearly to light the memory of the event by which it was provoked and in arousing its accompanying affect, and when the patient had described that event in the greatest possible detail and put the affect into words. Recollection without affect almost invariably produces no result.”-Sigmund Freud, 1895

III. “Phases of Hysteria.”Charcot’s schematic description of the “major” hysterical attacks, which in complete shows four phases:1. Epileptoid,2. the Major movements,3. Hallucinatory Phase,4. Concluding delirium.

We are now about to witness a convulsion attack. It may be disturbing,Please be brave to watch it.

iii. Hallucinatory phase:iv. Concluding delirium:

The typical course of hysteria is known to be as follows:

To begin with an ideational content is formed in hypnoid states; once this content has grown sufficiently it takes control, during a period of “acute hysteria” of the innervations of the patient’s body and indeed of his entire existence, then creates chronic symptoms and attacks and finally save for a few remaining traces, clears up.If a normal person can regain control, then what survives of the hypnoid ideational content returns in hysterical attacks and periodically draws the person into similar states, which are themselves once more susceptible to influence and receptive to traumas. A kind of equilibrium is established between the psychical groups that are assembled in a person: attack and normal life proceed along side one another, without influencing each other.

The attack then occurs spontaneously as memories tend to occur to us but it can be provoked, just as every memory can be awakened , according to the law of association.The attack is provoked through either through stimulation of the HYSTERIOGENIC ZONE or through a similar experience that is a reminiscent of the pathogenic experience.

HYSTEROGENIC ZONE:Charcot described it as:“more or less circumscribed regions of the body where pressure or simply rubbing brings about the more or less rapid occurrence of the phenomenon of the aura; this may be followed on occasions, if one persists by an hysterical attack. These points or rather these areas have the property of further being the seat of permanent sensitivity. .. Once developed the attack may often be halted by means of a vigorous pressure exerted at these same points.”

Freud reported that in “Studies on Hysteria” , he expanded his meaning by adding:“if the physician pressed or pinched the areas described by hysterical patients as painful he could provoke reactions suggesting that the subject was experiencing a ‘voluptuous tickling sensation’.”An Hysterogenic is thus a part of the body that has become erotogenic .

Freud stresses in the “Three Essays on the Theory of Sexuality” (1950):“Erotogenic zone and hysterogenic zones show the same characteristics.”

Freud delineates 3 groups of hysterics based on the source of this sexual stimulation: 1. Assaults by adults: mostly practiced on women by men (fathers, uncles, brothers, etc.) where there is no consent. That is, rape or other forced sexual activities.2. Love relationships between an adult and a child; these are usually of a longer duration and are the manifestation of deeper emotional and affective bonds. Here genuine feelings of "love" are at work.3. Relationships between 2 children, usually brother and sister, whereby this situation presumes that one of the children has already been initiated into sexual activities by an adult (presumes "seduction" of one of the children previously).

Aside from these qualitative distinctions, Freud also stresses a quantitative factor: the severity of hysterical symptoms is directly proportional to the number of such sexual encounters or acts of sexual abuse that one experiences as a child.

The "trigger" that initiates the latent hysterical symptoms for Freud is usually the sexual encounters one has after puberty. These "permissible" sexual acts recall or re-invoke the "inadmissible" acts, the hysteric's moral "shame," associated with childhood sexual abuse and activate the latent hysteria. The hysterical symptoms, in other words, usually don't occur until long after the initial traumatic experience itself.But if for Freud all psychoneuroses have the same sexual cause, then how can they be distinguished? This is where Freud sneaks nature and gender in through the back door. His answer: The attitude of the patient toward the experience of abuse determines what form the pathology will take:

a. If the sexual encounter is experienced actively, with a sense of pleasure, then the pathology will manifest itself as an obsessional disorder. This occurs most commonly in men because for Freud men are constitutionally the active partners in sexual activities.

b. If experienced passively, with disgust or displeasure, with resistance, the pathology will manifest itself as hysteria. This is more common in women because women are the passive partners in sexual acts (according to Freud).Freud thus returns the theory of hysteria to its origins (the "womb"); he comes full circle and, after denying hysteria's basis in gender and physiology, reintroduces gender as a criterion. But now this gender distinction is based not in physiology, but rather in "constitutionally" defined mental attitudes. Gender, for Freud, is a state of mind, so to speak, that is related to (but not identical with) physiology.

IV. “Splitting of Conscience.”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 memories were the motive for splitting of the psyche (conscience).Breuer stated:“The splitting of the mind is the consummation of hysteria.”

Freud and Breur say:“The existence of hypnoid states is the basis and determination of hysteria.”

V. “Psychotherapeutic techniques.”The psychotherapeutic technique works via bringing to an end the operative forces of the idea, which was not ‘ab-reacted’ in the first place, by allowing the strangulated affect to find its way out via speech.The technique then subjects the affect to associative correction by introducing it into normal consciousness or by removing it through the physician's suggestions.

THEORETICAL MATERIAL-BY Dr. JOSEPH BREUER.

I. Are all Hysterical phenomena ideogenic?IDEOGENIC: Determined by ideas.Breuer says:“… nor do we feel that they are ideogenic i.e. they are all determined by ideas. In this we differ from Moebius who in1888 proposed the following definition; ‘Hysterical are all these morbid manifestations which are caused by ideas.’”

Breur showed disagreement with what Moeibus said about hysteria being caused as a result of some ‘ideas’ only and he said:“…But I profess the opinion that the ‘idea’ of the memory picture alone, without the incitement of the perception-apparatus , despite its great vividness and intensity, would in itself never attain that character of objective existence which constitutes an hallucination.”

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.II. The Intra-cerebral tonic excitements-the affects.The two extreme conditions of the central nervous system are a clearwaking 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.

Incitement and 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 Intra-cerebral excitation is powerfully increased, but is employed neither in associative nor in motor activity.

CONCLUSIONS:Freud's Contributions to the Theory of Hysteria:1) Etiology not based in heredity (Charcot);2) Nurture, not nature, as cause;3) Pubescent experience not cause, but mere "provoking agent" ("trigger");4) Hysteria no longer tied to physiology (to hystera, or "womb" (not "gendered"; but gender re-enters picture on psychological level);5) Hysteria as product of upbringing; it is a social disease;

6) Source of hysterical symptoms as infantile experience7) Nature of these experiences is sexual = the so-called "Seduction Theory";8) Hysteria tied to unconscious memories of this infantile experience (repression);9) Attitude of patient (active or passive) determines nature of the pathology; passive attitude (victim) =Ý hysteria; active (perpetrator) =Ý obsession.

"Unlike Charcot and Breuer, Freud came to the conclusion, based on his clinical experience with female hysterics, that the most insistent source of resisted material was sexual in nature. And even more momentously, he linked the etiology of neurotic symptoms to the same struggle between a sexual feeling or urge and the psychic defenses against it. Being able to bring that conflict to consciousness through free association and then probing its implications was thus a crucial step, he reasoned, on the road to relieving the symptom, which was best understood as an unwitting compromise formation between the wish and the defense" -(Britannica)

THEORETICAL MATERIALIII. HYSTERICAL CONVERSION VI. HYPNOID STATES V. UNCONCIOUS IDEAS AND IDEAS INADMISSIBLE TO CONCIOUSNESS VI.ORIGINAL DISPOSITIONSABA REHMAT

III. HYSTERICAL CONVERSIONExcessive energy gets directed.Sometimes the energy is prevented from equalized distribution.

RESISTANCEResistance to convert energy may be caused by:A high degree of intracerebral excitement which closes the psychic and motor outlet.Or high degree of energy could not be sufficiently discharged

Characteristic of HysteriaExcessively strong excitations may break through the usual coordinated centers and flow off in primitive movements (without one's control over it). and this is said to be characteristic of hysteria.

Conditioned AffectsHysteria appear through objectively Conditioned Affects.If an idea comes to the surface which has been connected with a strong affect, it renews itself with a greater or lesser intensity.

“Affectively Accentuated”This “affectively accentuated” ideas then comes into consciousness clearly and vividly.The force of the affect that a memory can release depends on the time it was exposed to diverse “usurping” influences.Above all, it depends whether or not the affect was reacted upon.ANGER OVER INSULT SILENTLY ENDURED OR RETALIATED

“Abnormal Reflex”Excitement from the affect gets converted into physical phenomena.

Later, the original affective idea does not evoke the affect, but only the “ABNORMAL REFLEX”

Why just the ONE Abnormal reflex?Conversion of Intracerebral excitement gets converted into a particular path due to:Principle of least resistance- those paths in which the resistance has become weakened through concurrent circumstances.

The path of “Abnormal Reflex”It follows the general Law of Association.A series of associated ideas exist between the affect and it’s reflex, which representsa determination through a symbol.

Symbols and AssociationsUnconscious ideas thrustthemselves, one way or another, into consciousness -- i.e., via images, displaced ideas, etc.

CATHARSISA normal response to such excitations is considered to be speech, i.e., "telling things is a relief; it discharges tension...“ If denied, release by speech it is sometimes converted into somatic phenomena.

CASEA 12 YEAR OLD BOYComplained of pain ofswallowingAnd HeadachesHis physician believed it to be AnginaYet his condition did not improve.

The boy stopped eatingVomited when he urged to doDragged himself in a tired mannerAlways wished to remain in bedIt became evident to Freud that it was psychically causedBoy’s mother persisted in questioningHe revealed the following story…

On the way to home, he had stopped to urinate, and there a man held his penis before the boy with the request that he should take it in his mouth.

The persistence of the disease was due to his silence, which prevented the excitement from normal discharge.From the moment he disclosed the afore-mentioned story, he attained his perfect health.

Exclusion of Affective IdeasTwo forms of exclusion of affective ideas from the association can result in Hypnosis:Defense- the voluntary suppression of painful ideas And those thoughts one cannot recall- Primary Repression

IV. HYPNOID STATESIt is a state in which the emerging ideas is not confronted by any resistances.

IV. HYPNOID STATESIt is a state of AmnesiaHypnoid States include:Auto-hypnosisReveries

Auto hypnosisIn the waking state there is more or less complete Amnesia for the inner processesThe psychic states and associations formed between the abnormal reflex can be kept away by Amnesia from all the corrections in the waking state.

Delusions and HallucinationsAs criticism and control is reduced in auto-hypnoid state, it may give rise to Delusions or Hallucinations.

Auto-suggestionAuto-hypnoid state can give rise to “complicated and irrational symbolic relationship between the causative and the pathological phenomena.”The indiscrimination of the same frequency permits the origin of auto-suggestion.

Reveries Reveries that are filled with emotion and fatigue arising from protracted affects as the concentration on theses can lead to absences of mind.

Absent-mindednessNeither absent-mindedness during energetic work, nor the unemotional lethargic state is pathogenic.But the affectful reveries and exhaustion from protracted affect is Pathogenic!

CONVERSIONThe pathogenic absent mindedness person concentrates on the affective idea.The ideational stream slows up gradually, finally almost to the point of stagnation.But the affective idea with it’s affect remains vivid and also the large quantity of excitement , which was not functionally used up- which creates CONVERSION DISORDERS.

Insightful PatientsIf a physical symptom is caused by an idea and is always released again by the very idea,patients with a good deal of insight must become aware of the connections.Why do even they not realize?The repetitions have been impressed on the body , and now no longer depend on a psychic process but on the changes in the nervous system, which have meanwhile developed.

V. UNCONCIOUS IDEAS & IDEAS INADMISIBLE TO CONCIOUSNESSThe idea we know-consciousnessThe ideas beside what we know- unconscious

Only the clearest and most intensive ideas of self-consciousness are perceived, while the large mass of actual but weaker ideas remain unconsciousThe intensity of an unconscious idea increases as it enters consciousness!

Moods and unconscious Unconscious ideas govern patient's emotional tones or states of feeling.It is possible to trace purely somatic symptoms back to ideas which are not discoverable in the patient's consciousness.

Moodiness, Anxiety, IrritationIdeas which become affectless due to conversion can induce moodiness, anxiety, angry irritation and grief.These symptoms increase until the solution is attained through verbal expression.

AffectsIdeas which are intensive enough to produce not only strong physical symptoms but to awaken their appropriate affect, and to influence the associations by giving preference to related ideas- and yet they themselves remain unconscious.To bring them to consciousness- it requires Hypnosis.

Ideas which are actual but unconscious – incapable of consciousness, not on the account of their relatively weak activity, but despite their great intensity bringPATHOLOGY

VI. Splitting of consciousnessThus, splitting of consciousness occurs via a splitting of the mind, i.e., There is consciousness and unconsciousness and there are ideas that are admissible and inadmissible to the consciousThere is a splitting of psyche into two relatively independent parts.

Splitting of PersonalitySplitting of Personality is based on an original psychic weakness.A normal psychic activity presumes a certain capacity of synthesis or combining different complex ideas into one complex.

THIS CAPACITY TO INTEGRATE DIFFERENT COMPLEX IDEAS INTO ONE IS FOUND TO BE BELOW NORMAL IN HYSTERICS.

Perception of HystericsIf they perceive anything, they are at the time inaccessible to other sense perceptions.Indeed, they are not capable of perceiving altogether the impressions of only one sense.

“Narrowing the field of Consciousness”One idea evokes other ideas into consciousness, which form either a friendly or an antagonistic relationship with the first.Only ideas of the highest activity are so excessively strong as to keep the associations below the level of consciousness.

Disease of the Feeble-minded It develops if other enfeebling influences act on the original weak psyche, or if they put high demands upon it in contrast to which the psychic force seems still more inferior.

The Splitting of ConsciousnessThe splitting of consciousness does not occur because the patients are weak-minded.But rather the patient seem weak-minded because their psychic activity is divided.Only a part of the functional capacity is at the disposal of conscious thoughts.

We are not “Mechanically Active”!!While a series of thoughts, which have nothing in common with our current activities flow through our consciousness.We are undoubtedly capable of mental functioning while our thoughts are elsewhere.

Ideational Complex It should be understood that hysterical attacks, at least in part, are products of an ideational complex.

The Splitting of PsycheSplitting can be characterized as being similar to a`preoccupation of the mind.`Thus splitting is considered to be a normal mental activity, but what makes it pathological is the amnesia that accompanies it.

VII. ORIGINAL DISPOSITION;THE DEVELOPMENT OF HYSTERIAHysterics are characterized as being intellectual, hyper- active, hate boredom, and crave sensations -- i.e., their body, says Breuer, produces excessive excitations that may cause the splitting via amnesia that begins the hysteria.

I. HORMONAL CHANGESBreuer continues to suggest that a the onset of puberty, excessive hormonal activities add to the already high level of excitement and can send previously normal children into hysterics.

II. SEXUAL NEEDSBreuer states that the sexual needs of hysterical patients are just variable in degree and are no stronger in them than in normal peopleBut hysterics fall ill from them precisely owing to the struggle against them -- that is, because of their Defense against sexuality.

III. HYPNOID STATEThe third constitute of the hysterical disposition is the hypnotic state.

DemographicAnna O was a pseudonym (false name) for Bertha Pappenheim, Born on 26 May 1856, Vienna. Died on May 28, 1936.She was the founding patient of psychoanalysis because Freud developed the first stages of his theory based on her case. She was treated in 1880 and 1881 by Dr. Joseph Breuer of Vienna, a close friend and associate of Sigmund Freud.

Case historyBertha's father, SiegmundPappenheim, was a wealthy Viennese merchant, descended from an old Jewish family from German her mother, Recha gave birth to four children but only two, Bertha and Wilhelm, survived. Bertha learned English as a child and used it exclusively for a time during her illness; she also read French and Italian.

At the time of her illness she was 21 years old.Until the illness struck she had been healthy and intelligent and had shown no sign of neurosis.However her feeling had always been exaggerated and she could be moody and she day dreamed a great deal. Her illness has several phases.

Latent incubationThe early sign of her illness began when her father fell ill and she had to nurse him.Her illness began with a severe cough. She developed a number of other physical symptoms, including paralysis of the extremities of the right side of her body, contractures, disturbance of vision, hearing and language.

Manifest illnessShe began to hallucinate and was abusive, threw things at people and accuses others of doing things to her. At different times these included weakness, inability to turnher head, diplopia, a nervous cough, loss of appetite, hallucinations,agitation, mood swings, abusive and destructive behavior, amnesia, tunnel vision and partial aphasia.

Later in the course of illness she began to speak only in English (she was a native German speaker) but could still understand German.During part of her illness, shewas unable to recognize or accept food from anyone except herphysician, who spent somewhere in the region of a thousand hourswith her between April 1881 and June 1882. She was able to satisfyherself of his identity only by holding his hands.

After her father’s death sleep walking added to other symptoms and she could no longer under stand German and began to refuse food.Freud and Breuer suggested that symptoms were a result of number of events that were buried in her unconscious and were looking for some external expression.

Her symptoms lasted about a year and a half and only went very gradually. Breuer knew that hypnosis sometimes helped hysterical patients get rid of their symptoms, so he decided to hypnotize Bertha. She was an excellent hypnotic subject. Bertha began to improve. After three months she was able to walk across the room .

under hypnosis she battled to hold back tears daily in order not to distress her dying father, her squint and visual disturbance resolved. Her paralyzed arm was related to a dream in which a black snake attacked her father and she was unable to lift a finger to stop it. Similarly, once she recalled the circumstances which led to the paralysis, the symptoms disappeared

One of Bertha's symptoms was a refusal to drink water. While in an hypnotic state, she revealed that she had been disgusted to see her lady-companion's dog lapping water from a drinking glass; then, awakening from her hypnosis, she asked for a glass of water. From this incident emerged a new treatment aim in the discovery of etiological factors through what became known as the "cathartic method."

Her treatment is regarded as marking the beginning of psychoanalysis. Free Association came into being after Anna/Bertha decided (with Breuer's input) to end her hypnosis sessions and merely talk to Breuer, saying anything that came into her mind. She called this method of communication "chimney sweeping", and this served as the beginning of free association.

Anna's case also shed light for the first time on the phenomenon called transference, where the patient's feelings toward a significant figure in her life are redirected onto the therapist. By transference, Anna imagined to be pregnant with the doctor's baby. She experienced nausea and all the pregnancy symptoms.

This was too much for Breuer. His own wife had just delivered a baby and was suffering from depression. Breuer cut off all contacts with Bertha, renounced the "talking cure," and left town on a second honeymoon with his wife.

She was gradually healed and devoted her life and her writing after 1895 to helping young Jewish girls, single mothers, and orphans. She was one of the first "social workers" and her work earned her the admiration of everyone who knew her until her death .

The West German government issued a postage stamp in honour of her contributions to the field of social work.

DEMOGRAPHIC"Katharina," whose real name, AureliaÖhm-Kronichwas uncovered by Peter Swales (1988), born on January 9, 1875, in Viennadied on September 3, 1929, in Reichenau. Her case was the third discussed by Sigmund Freud in the Studies on Hysteria (1895d).

Freud wrote a letter to Wilhelm Fliess "The etiology of the neurosis pursued me wherever I went, just like the song of Marlborough the Briton while he was traveling. Recently, the daughter of the innkeeper came to see me; it has been a good case for me." Freud wrote this in a letter to Wilhelm Fliess, on Sunday, August 20, 1893, about the improvised consultation he was asked to provide during his vacation for the young daughter of the inn-keeper, who complained of a suffocating feeling, accompanied by the vision of a terrifying face. "Was I to make an attempt at an analysis? I could not venture to transplant hypnosis to these altitudes, but perhaps I might succeed with a simple talk. I should have to try a lucky guess. I had found often enough that in girls anxiety was a consequence of the horror by which a virginal mind is overcome when it is faced for the first time with the world of sexuality" (1895d, p. 127).

Conclusion Of The Case By FreudFreud concluded:At that time she had carried about with her two sets of experiences which she remembered but did not understand, and from which she drew no inferences. When she caught sight of the couple in intercourse, she at once established a connection between the new impression and these two sets of recollections, she began to understand them and at the same time to resist them off. There then followed a short period of working-out, of "incubation", after which the symptoms of conversion set in, the vomiting as a substitute for moral and physical disgust. This solved the riddle. She had not been disgusted by the sight of the two people but by the memory which that sight had stirred up in her (1895d, p. 131).

Sexual etiology of neurosisAt this time Freud was greatly excited by his discovery of the sexual etiology of neurosis, but was unable to convince Josef Breuer of its validity. He also introduced the theory of the "hysterical proton pseudo," a primal sexual scene that has been overlooked and whose memory is reawakened by a recent sensation. As Freud noted, this resembled resembled what "Charcot liked to describe . . . as the 'period of psychical working-out"' (p. 134), which separated the trauma from the appearance of symptoms.

CUREKatharina's cure was similar "not so much to an analyzed case of hysteria as a case solved by guessing" (p. 133) noted Freud, whose work as a hypnotist made him seem more like a magician than a scientist. A note added to the text in 1924 corrects the historical record with the following information: "Katharina was not the niece but the daughter of the landlady. The girl fell ill, therefore, as a result of sexual attempts on the part of her own father" (p. 134)

LUCIE.R"Miss Lucy R." is the second case study presented by Freud in Studies on Hysteria (1895d). Lucy was a British governess whom he treated for nine weeks, beginning in December 1882.

Thirty years old, she was being treated by a colleague of Freud's for chronically recurrent suppurative rhinitis. This young English woman of delicate constitution was a governess for the managing director of a factory in the Vienna suburbs. She had recently lost the ability to smell and suffered from depression accompanied by olfactory hallucinations of the smell of "burnt pudding," which Freud immediately identified as the origin of her hysteria.

FREUD’S SAYING"I therefore decided to make the smell of burnt pudding the starting point of the analysis," Freud wrote (1895d, p. 107). But the treatment, which should have been short, turned out to be more difficult than expected because the patient, who was working, was unable to see him outside his consulting hours. As a result, he could only devote a few moments of time to her, unlike those patients who were able to make appointments in advance. “We used therefore to break our conversation off short and take up the thread at the same place next time. Miss Lucy R. did not fall into a state of somnambulism when I tried to hypnotize her. I therefore did without somnambulism and conducted her whole analysis while she was in a state which may in fact have differed very little from her normal one"

TREATMENTIn his description of Lucy's case, Freud, for the first time, provides a detailed explanation of his new procedure. "When, therefore, my first attempt did not lead either to somnambulism or to a degree of hypnosis involving marked physical changes, I ostensibly dropped hypnosisand asked only for 'concentration';

I ordered the patient to lie down and deliberately shut her eyes as a means of achieving this 'concentration.' . . . I decided to start from the assumption that my patients knew everything that was of any pathogenic significance and that it was only a question of obliging them to communicate it" (pp. 109-10). To force this response, "I placed my hand on the patient's forehead or took her head between my hands and said, 'You will think of it under the pressure of my hand. At the moment at which I relax my pressure you will see something in front of you or something will come into your head. Catch hold of it. It will be what we are looking for.—Well, what have you seen or what has occurred to you?' " (p. 110). This procedure, he added, "has hardly ever left me in the lurch" (p. 111), and all Freud had to do was to tell his patients that it was impossible to fail to extract information from them.

Freud helped Lucy realize that she was in love with the widower whose children she cared for. After his prescribed hydrotherapy treatments failed to have an effect, he was astonished to see her return after the Christmas holidays without any real improvement. Moreover, the smell of burned pudding associated with her hidden love for her employer had been replaced by the smell of cigar smoke.

Freud again applied pressure to her forehead with his hands. Another scene materialized where her employer had scolded her violently for having allowed a female visitor to kiss his children. This scene indicated that she realized he did not love her, and was associated with another scene, this time of the conclusion of a meal and the presence of cigar smoke. This realization resulted in her complete recovery, probably near the end of January 1893.

Freud saw Lucy again in June 1893, when she was in perfect health. He never questioned himself about the cigar smoke. Cigar smoke came up again during Freud's treatment of Dora, for none of his patients was likely to overlook his passion for cigars.Nothing like a transference neurosis can be found in Freud's descriptions of these early treatments, which have little in common with later psychoanalytic therapy. Nonetheless, they are important, aside from the interest in Freud's activity as a therapist, for what they teach us about his theoretical development. With Miss Lucy R., Freud abandoned hypnosis and became certain that his patients possessed an intimate but repressed knowledge of their symptoms. He thus recognized the importance of the means used to overcome patients' resistance to remembering.

Mrs. EMMY VON N.SaharSalimHunzai

DemographicMrs. Emmy Von N (a woman of about 40 years.Family came from mid-germany but were living in Russian Baltic Provinces.Brought up carefully by parents but extremely strict motherThey were 14 children, she was 13th, only four living.At age of 23 married a industrialist man.Two daughters 16 and 14 years.

Hereditary predispositions of diseases.Shortly after marriage, her Husband died of sudden heart failure.

EventsAfraid of animals (rats)brothers n sisters threw dead animals on her.Stuttering (pathological manifestations) sickbed for her very sick daughter.Mother was at one time in an insane asylum. Terrible stories told by a servant about patients in asylum.

Mother found dead had stroke (age 15).Age 19 she picked up a stone and saw a toad and lost her speech as she was afraid of animals.Brother sick because of too much morphine had terrible attacks (age 19).Insane relative grabbed her by her arm.strange man staring.

Subject visit to Freud?Nervous disturbances (anxiety, tensed, apprehensive, jumpy, panicky (cause of her disease) Since the death of her husband she remained ill in varying degrees of fluctuating intensity. ( lived psychic isolation, became suspicious of friends)Cold sensation and pain in the right leg, neck cramps.

Suffered speech difficulties, which Freud described as ‘spastic interruptions’ (bursting interruptions) amounting to a stammer’ (hesitate). She was also plagued ‘by frequent convulsive tic-like movements of her face (pathological manifestations) and the muscles of her neck’ and was compulsively given to making repetitive verbal exclamations and clicking sounds.

Hated 2nd daughter because she could take care of her husband when he was suffering through heart problem.Relatives did not accepted the marriage the cause of death was considered to be poisoned by her.She was anorexia eating little because of nursing her brother as he ate the food disgustedly and as not to shame him she accompanied him in eating.

TreatmentWarm baths were given to her twice a day for her bodily pains. She was completely accessible to hypnosis and, in this state, recounted the origin of the delusional fears and visual hallucinations (rats, frogs) from which she suffered, retracing them to her childhood.

"My therapy consists in wiping away these pictures, so that she is no longer able to see them before her. To give support to my suggestion I stroked her several times over the eyes.“Case of Emmy von N. was the first in which he had employed the "cathartic method."

Traumatic incident which gave rise to physical symptoms. the process of analysis was developed called ‘Pressure Technique’ Instructing the patient to report faithfully ‘whatever appeared before their inner eye or passed through their memory at the moment of pressure’.

Time period of hypnosis1889 -1890 two yearsRelapse of her nervous breakdown and physical symptoms.

ResultsThe therapeutic result was considerable but not permanent.Tendency to become sick in same manner from new traumatic events was not removed as she did not concealed about her incidents. Hereditary predispositions, her violent nature, the environment.

The case of Fraulein Elisabeth Von R.AfshaanFatema

Demographics:Fräulein Elisabeth von R. is the pseudonym Freud gave to IlonaWeiss.Was requested by a friendly colleague to examine her in the year 1892. He had diagnosed her as Hysteria but none of the usual symptoms could be found.She was 24 years old when Freud treated her.Freud treated her from 1892 to 1893.

Problem:Elisabeth von R had been suffering from pains in her legs and difficulties walking, sitting, and standing, problems she had been experiencing for two years.Freud confirmed the diagnosis of hysteria that had been made and noted that "if one pressed or pinched the extra sensitive skin and muscles of her legs, her face assumed a peculiar expression, which was one of pleasure rather than pain. She cried out—and I could not help thinking that it was as though she was having a pleasurable tickling sensation—her face flushed, she threw back her head and shut her eyes and her body bent backwards"

Case History:Elisabeth von R was the third daughter in a well-to-do Hungarian family.Last few years had brought much misfortune to the family.Her father died.Mother had a serious eye operation.Married sister died of a chronic heart problem soon after child-birth.Elisabeth von R had taken an active part in all the problems, especially in looking after the sick.

Therapy: After an initial period of four weeks during which he prescribed electrical treatments, he suggested to her the use of a cathartic cure that "turned out, however, to be one of the hardest that I had ever undertaken.“Resistant to hypnosis, the patient stretched out with her eyes closed but was able to move, open her eyes, and sit up.

Through the Cathartic method, Freud found:As the youngest daughter, Elisabeth von R. was devotedly attached to her parents.Her mother’s health was frequently disturbed by an eye problem, thus her attachment became more directed towards her father.Her father used to call her “Cheeky and ill-behaved,” because she was not like an ideal girl.

Events:The father had either concealed or over-looked a heart problem, and was brought home in an unconscious state one day, after the first attack of oedema of the lungs.This was followed by an illness of one and a half years, during which Elisabeth took the most prominent part in nursing him.Her pains, for the first time, came up during the last half year of this care, but she did not worry about them, and they did not return till after two and a half years.

Elisabeth’s father’s death impelled her to concentrate her entire devotion and care on the surviving mother.Her eldest sister married a talented and ambitious man of notable position, who seemed to have been destined for a great future by virtue of his mentality, but he dared to show his disregard for the old lady in the family circle.Elisabeth could not take this, and felt her duty to defend her mother against her brother-in-law.

The marriage of the second sister seemed more promising.The second brother-in-law was a man after the heart of delicate ladies, and was more sensitive towards them.The family stayed near the mother, and they even had a child.

The same year the child was born, her mother’s eye problems required treatment in a dark room, followed by an operation, which was successful.Elisabeth participated throughout in nursing her mother.

Elisabeth’s pains returned after her mother’s operation, but they were attributed to “fatigue and cold.”She was advised to rest in a spa called “Bad Gastein,” and while she was there, her second sister also succumbed to heart trouble, which was aggravated by pregnancy, and died.

Elisabeth again saw everything go to pieces that she had planned for her mother.The widowed brother-in-law was inconsolable and withdrew from his wife’s family.Her sadness grew with the knowledge that the two brothers-in-law had a disagreement between them.

These events had coincided with the two years of the development of her illness. “Resentful of her fate, embittered over the failure of her little plans to restore the family luster; of those dear to her, some were dead, some away, and some estranged—she lived thus for a year and a half away from almost all social relations nursing her mother and her pains.”

This confession of the patient was disappointing for Freud, because her history neither explained the causation of hysteria nor its determination.It was assumed that the patient had formed an “association between her psychically painful impressions and bodily pains, which she accidently perceived simultaneously, and that now she utilized in her memory the physical sensation as a symbol for the psychic.”

During the first part of the treatment, she repeated to Freud that she was not doing better in spite of her confession and Freud remarked that "when she looked at me as she said this with a sly look of satisfaction at my discomfiture, I could not help being reminded of old Herr von R.'s judgment about his favorite daughter—that she was often 'cheeky' and 'ill-behaved'"

Freud then applied his "concentration technique,“ a trick of pressing the head.This was done by “requesting the patient to inform of whatever appeared before her mind’s eye or flashed through her memory at the moment of the pressure.”

The “Concentration technique” revealed:Memories of a young man who had accompanied her home from some social affair, of the conversation that passed between them, and of her feelings on returning home to nurse her father.Apart from him being a mutual friend, no one knew about Elisabeth’s relationship and her hopes connected with him.This young man was the son of an old family friend, who, being an orphan had attached himself with great devotion to her father, and this regard for the father had extended to the ladies too.

Event:At the urging of the family, Elisabeth consented to leave the sick bed one evening and attended the social affair, where she was to meet that young man.She wished to hasten home early, but she was forced to remain, and only yielded on his promising to accompany her home.“At no time had she entertained such a tender regard for him as during this walk, but after returning home at a late hour in this blissful state and finding the condition of her father aggravated, she bitterly reproached herself for having sacrificed so much for her own amusement.”

That was the last time that she left her sick father for a whole evening, and thereafter she saw her friend only rarely.After the death of her father he seemed to hold himself aloof out of respect for her sorrow, and business affairs later took him to other regions.Gradually, she came to the realization that his interest in her was suppressed by other feelings and that he was lost to her.This failure of her first love pained her as often as she thought of it.

Conversion for the purpose of Defense:A conflict, or a state of incompatibility arose through the contrast between the happiness which she had not at that time denied herself, and the sad condition in which she found her father upon her arrival home.As a result of this conflict , the erotic ideas were repressed from the associations and the simultaneously existing physical pain.It was thus, the mechanism of a conversion for the purpose of defense.

An improvement occurred when she herself provided the source of her hysterical conversion: Her pains began at the spot on her thigh where, every morning, her father placed his inflamed leg so she could change his bandages. She, thus, gave the desired explanation for the origin of an atypical hysterogenic zone.

The patient was free from pain when Freud began his work, but as soon as he evoked some recollection, she at first reported some pain and then winced and placed her hand on the painful area.This awakened pain remained constant as long as the patient was dominated by the recollection, reaching its height when she was about to utter the essential and critical part and disappeared with the last words of the statement.

Freud’s Discoveries:It was found that the spontaneous fluctuations never occurred unless provoked associatively by the events of the day.As she never reproduced the same pain motives twice, it was expected that the stock would in time become exhausted, and thus, she was not prevented from getting into situations conducive to evoking memories, which had not yet come to the surface.

Functions associated with painful zones:Among the most prominent scenes, that had made walking painful was this;It referred to a walk that she had taken in large company at the watering place.She had been in a good mood and her second brother-in-law had also joined them for the walk for her sake, leaving her sick sister at home.Elisabeth reported that the contrast between her solitude and the married happiness of her sick sister, of which she was constantly reminded by the behaviour of her brother-in-law, was painful to her.

The scene closely related to her pains on sitting was;A few days after the last mentioned scene, she found herself in a longing mood.She went to a top of a hill, where she used to sit and spend time with her family (including her brother-in-law), and gave free play to her thoughts.There, she thought about her lonesomeness, the fate of her family, and her wish to become as happy as her sister.After this morning’s meditation, she returned home with severe pains.

Elisabeth’s pain related to standing was associated with her feeling of helplessness, the sensation that she “could make no headway.”Freud assumed that she directly sought a symbolic expression for her painfully important thoughts and had found it in the aggravation of her pains.

In the spring of 1893 a sharp pain reoccurred when she heard, in a room adjacent to Freud's office, her brother-in-law who had come to pick her up. This enabled Freud to track down her "secret"—she had fallen in love with her brother-in-law. She had grown closer to him as a result of her sister's illness, and upon her death was unable to repress the thought that, “Now he is free again, and I can become his wife.”She entertained an affectionate regard for her brother-in-law, which was against her morals.

In spite of his patient's denials, Freud insists on, and goes so far as to solicit the testimony of the young woman's mother, who confirmed that she had suspected as much. The treatment concluded in July 1893 with the appeal to the mother for assistance. This was to have repercussions later on, since the daughter rebelled and refused to see Freud again because he had betrayed her secret.

Studies in hysteria complete

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