This is a summary of my readings on the beginnings of Freud's work with neuroses from 10 years ago. Subsequently I found the historic aspect of thinking about neuroses really useful and hence I am putting this up here. I do not adhere to Freudian explanations, but I find it very instructive to look into history of thinking about mental states. Neuroses as a term at present, if I may, is in something of a Schroedinger's cat state - alive and dead at the same time.
Neuroses is a term that is hardly used in the current language of psychiatry. Modern definitions of neuroses are brief: “Neurotic illnesses are such that the symptoms are distressing to the person, but there are no psychotic symptoms and behaviour is not outside the socially acceptable, and there is no physical cause to the illness.”(Dorland 2007) General medical publications often stress that the term is outdated: “neurosis – a term no longer used medically as a diagnosis for a relatively mild mental or emotional disorder that may involve anxiety or phobias but does not involve losing touch with reality.”(National Institute of Mental Health, USA 2010).
These brief definitions may be more sophisticated in form, but in their spirit they remain similar to the original meaning when the term was first coined by Scottish physician William Cullen (1710 – 90) to include "affections of sense and motion without fever or evidence of local disease". Thus neuroses were considered general and functional affections of the nervous system and the presence of any local lesion would exclude them from the class (Reynolds 1990).
However, soon after coining the term, Cullen added sub-classification that included conditions belonging now to neurology (convulsions, paralysis, etc.) and to psychiatry (mania, melancholia, etc.). His classification contained four main groups and essentially neuroses encompassed all psychiatric disorders:
Comata(e.g. apoplexy, paralysis)
Adynamiae(e.g. syncope, hypochondriasis)
Spasmi(e.g. convulsions, chorea, hysteria, tetany)
Vesaniae(from Latin vesanus ‘mad’; e.g. melancholia, mania, delirium, impaired judgement)
Concept of neuroses was further embraced by the famous French physician Philippe Pinel (1746 – 1825) – regarded by many as the father of modern psychiatry (Sass 2010). Pinel became the chief physician of the Hospice de la Salpêtrière in Paris, and was instrumental in the development of a more humane psychological approach to the custody and care of psychiatric patients. He also translated Cullen's textbook into French (Reynolds 1990).
By the second half of the 19th century there were two main views upon neuroses – both consequence of different application of clinico-anatomical method. The German and Austrian school of neurological science used clinical material for the secondary purpose of demonstrating and confirming existing anatomical and physiological theory – making physiological interpretations of it. In the French school of neurology emphasis fell very much upon the clinical side of the equation and the nosology – to identify, classify and describe the clinical picture. (Kaplan-Solms and Solms 2001) It should be said that not all German and Austrian psychiatrists followed the explanatory model at the time, but Theodor Meynert – a well known neuropathologist, anatomist and an influential teacher of Freud's – certainly did.
Thus French school of neurology would describe the pathognomonic clinical syndromes of
hysteria as “just another topic in neurology”, but for German neurologists the lack of demonstrable lesions in the nervous system on autopsy to account for the clinical symptomatology observed during the life of the patient, presented an insoluble problem. Some German neurologists, Freud's teachers among them, developed elaborate, but completely speculative theories, while others declared that neuroses were not fit subjects for scientific attention; if there was no anatomical lesion, there was no disease. (Kaplan-Solms and Solms 2001).
Some frequently mentioned neuroses
The following are definitions of the main types of neuroses that are encountered in Freud's writings. I think it will be easy to see that they all pertain to what would now be understood as the realm of psychiatric problems.
Hysteria– disease that produces predominantly motor symptoms not explainable from the viewpoint of medical and anatomical sense; “a neurosis in the strictest sense of the word; based wholly and entirely on physiological modifications of the nervous system”(Sigmund Freud 1888). Modern classifications would refer to hysteria as conversion disorder and this use stems from Freud's term conversion of anxiety into physical symptoms) in hysteria. Post-Traumatic Stress Disorder also would likely have belonged in this category as “hysteria brought about by severe general trauma (railway accidents, etc.), known as ‘railway spine’ and ‘railway brain’"(Sigmund Freud 1888).
Actual neurosis– term that Freud distinguished from psychoneurosis in that the origin of actual neurosis lies not within infantile conflicts but in the present – mainly in inadequacy of sexual satisfaction. At first Freud considered that anxiety neurosis and neurasthenia made up the actual neuroses, but he later proposed that hypochondria should be counted among them as well. (Laplanche and Pontalis 1973).
Anxiety neurosis– “I call this syndrome ‘anxiety neurosis’, because all its components can be grouped round the chief symptom of anxiety, because each one of them has a definite relationship to anxiety” (Sigmund Freud 1895a). The syndrome as described by Freud in the referred paper would nowadays correspond to generalised anxiety disorder, panic disorder and phobias.
Obsessional neurosis– compulsive–obsessive ideas, compulsions towards undesirable acts, struggles against these thoughts and tendencies through a mode of thinking which is characterised by rumination, doubt and scruples, and which leads to inhibitions of thought and action. Freud wrote: “I found reason to set alongside of hysteria the obsessional neurosis (Zwangsneurose) as a self-sufficient and independent disorder, although the majority of the authorities place obsessions among the syndromes constituting mental degeneracy or confuse them with neurasthenia”. (Laplanche and Pontalis 1973)
Psychoneurosis– (or neuro-psychosis of defence). This was a term employed by Freud in the years 1894-96 to denote a certain number of conditions such as hysteria, phobia, obsessions, some psychoses – while bringing out the role of defensive conflict, first discovered in hysteria. The symptoms of the psychoneuroses are the symbolic expression of infantile conflicts. (Laplanche and Pontalis 1973)
Transference neurosis– this term first used in writing in 1907 by C.G. Jung – to mean as opposed to psychoses (i.e. neuroses are where capacity for transference exists and therefore they may be treatable by psychoanalysis). It, very likely, was a further development of Freud's term “transference”. In Freud's writing the term transference neurosis appears later and initially it referred to neuroses where capacity to the transference phenomenon existed, thereby contrasting them with narcissistic neuroses (i.e. psychoses, as was thought at the time) and actual neuroses. Later in 1914 in 'Remembering, Repeating and Working-Through' the term was already used in the sense of a therapeutic phenomenon occurring in setting of psychoanalysis. “Provided only that the patient shows compliance enough to respect the necessary conditions of the analysis, we regularly succeed in giving all the symptoms of the illness a new transference meaning and in replacing his ordinary neurosis by a “transference-neurosis” of which he can be cured by the therapeutic work.” (Laplanche and Pontalis 1973).
The term transference, however, is mentioned in theoretical therapeutic context in 1899 in 'The Interpretation of Dreams': “A few days earlier I had explained to the patient that the earliest experiences of childhood were ‘not obtainable any longer as such’, but were replaced in analysis by ‘transferences’ and dreams.” In the same work Freud speaks of “transference of an already formed emotional relation on to a new object”, referring to the emotional relationship in psychoanalysis. A similar, also unconscious, reaction arising in the psychoanalyst towards the patient is termed countertransference – a term that was defined later than 1900.
Neurasthenia– or nervous exhaustion – an entity that is now believed to be hypothetical; described first by the American physician George Beard (1839-83): a clinical picture centred around a physical fatigue of ‘nervous’ origin but embracing symptoms of the most varied kinds.
Freud was among the first to draw attention to the fact that neurasthenia syndrome was being invoked too widely and felt that the category should be broken down and part of its extension be taken over by other nosographical denominations. He nonetheless held, at the time, neurasthenia to be a neurosis in its own right - characterised by feelings of physical tiredness, intra-cranial pressure, dyspepsia, constipation, spinal paraesthesias and the impoverishment of sexual activity. He placed it under the heading of actual neuroses, alongside anxiety neurosis, and sought its aetiology in a type of sexual functioning incapable of adequately discharging libidinal tension (e.g. masturbation). (Laplanche and Pontalis 1973),(Sigmund Freud 1895a).
Freud and neurosis
Freud began his medical studies at the University of Vienna in 1973 aged 18. When he was 20 he became an assistant at the Institute of Physiology of Vienna under Prof. E. Brücke. He graduated as Doctor of Medicine at the age of 25 in 1881. His teachers saw him as a very capable and industrious young man who tended to procrastinate with his studies - constantly being sidetracked by his interest in histological and physiological research. His research, despite his own rather obsessive dissatisfaction with it, was acknowledged and twice he was awarded grants to enable him to complete histological studies in reproductive and nervous systems of primitive animals. (Ernst Freud, Lucie Freud, and Grubrich-Simiths 1985)
Following graduation he could have continued with a brilliant research career at the Physiological Institute, however he gave up the possibility of this work as he fell in love and became engaged to Martha Bernays in 1882. Freud needed to achieve financial independence and to prepare for that he spent the following 3 years in apprenticeship at the Vienna General Hospital, preparing for opening his medical practice.
In January of 1885 Freud applied for a lectureship (Dozentur) granted only to young doctors of exceptional achievement at the University of Vienna.Six months later his appointment was confirmed and Freud's further career as a classical neuropathologist appeared set. However his life took a different turn when in the same year he was awarded University Jubilee Travel Scholarship. Freud used this money to stay in Paris at the Salpêtrière hospital to study from Jean-Martin Charcot. (Ernst Freud, Lucie Freud, and Grubrich-Simiths 1985)
Influence of his studies with Charcot was very significant. We can read in Freud's 'Report' on his studies that he went to went to Salpêtrière do further studies in neuropathology expecting to find “a large assemblage of clinical material such as only exists in Vienna dispersed in various departments”. However in the same report Freud also says that he was very keen to evaluate himself whether French neurologists tended to lack critical judgement and to dramatize their findings, as was often believed in the medical circles of Vienna at the time.
Freud was extremely impressed by Charcot and writes in the 'Report': “I had an opportunity of seeing a long series of patients, of examining them myself and of hearing Charcot's opinion on them. But what seems to me to have been of greater value than this positive gain in experience was the stimulus which I received during the five months I spent in Paris from my constant scientific and personal contact with Professor Charcot.” He later continues with relaying Charcot's idea that in neurology the work of anatomy was finished and what had next to be dealt with were the neuroses and Charcot's remarks on the aetiological connection between trauma and neurosis. (Sigmund Freud 1886)
It seems that seeing Charcot's work with neuroses, very likely in combination with Freud's exposure to the “cathartic method” through communication with his friend Dr joseph Breuer became the turning point in Freud's career that redirected his scientific interest from histological and anatomical research to work with neuroses.
Freud, admired the French neurologist's broad mindedness that included hypnosis in scientific study. It should be noted though that Freud's own experience with hypnosis was not successful and, even though he mentions hypnosis as an important method of treatment of hysterias, in his later paper on the subject he says that treatment is even more successful if we employ the method first practised by Joseph Breuer “and lead the patient under hypnosis back to the psychical prehistory of the ailment and compel him to acknowledge the psychical occasion on which the disorder in question originated” (Sigmund Freud 1888).
Account of Freud's relationship with neuroses would be incomplete without mentioning his friendship with Joseph Breuer – a well respected doctor of general practice in Vienna. Freud met Breuer during his medical studies and greatly valued his friendship and his mentor's advice. He learned from Breuer about the “cathartic method” that was employed in treating Anna O – a 21 years old woman with hysteria between 1880 and 1882. This treatment was only intermittently successful, at times promising full improvement, at times sliding backwards and developing new symptoms. Breuer, apparently torn by erotic transference and counter-transference (phenomena not recognised in his day), decided not to employ the method ever again and lost all interest in hysteria. It was not until some ten years later that Freud persuaded Breuer to publish a joint report on hysteria. Perhaps it is appropriate to mention as a side note – Martha Bernays was a friend of Anna O and warned Freud in her letters that she would disapprove if Freud's patients fell in love with him.
Elaboration on neuroses in Vienna
Freud's admiration of Charcot and attempts to introduce Charcot's work to Viennese colleagues by translating Charcot's lectures in German were met with reservation. Unfortunately, Charcot himself also did not show any enthusiasm when Freud relayed the merits of the cathartic method to him. Nevertheless Freud continued to advance Charcot's ideas also demonstrating a case of male hysteria in Vienna. This demonstration highlighted an important issue of the time as it defeated the widely believed association of hysteria to female reproductive system (hysteros – womb in Greek). Unfortunately Freud's enthusiasm caused some of his eminent teachers to distance themselves from him.
After Freud's visit to Salpêtrière further defining and differentiation of neuroses would have seemed important to him as he wrote that thanks to Charcot “hysteria was lifted out of the chaos of the neuroses” (Sigmund Freud 1886) and further reduction of the “chaos” would be in order. Freud had started his private neurological practice in Vienna and saw many patients with neurological afflictions including some hysteric patients.
Freud's neurological symptom based approach is evident. In his letter to Wilhelm Fliess about a year later Freud writes: “Mrs. A. has consulted me and caused me some agonizing in coming to a decision. I have finally arrived at the conclusion that her case is not a neurosis; not so much because of the foot clonus + - (which at present is not in evidence) as because I do not find in her what I consider to be the most important characteristics of neurasthenia ... In the distinction, often so difficult to make, between incipient organic and neurasthenic affections I have been guided by one particular characteristic: in neurasthenia the hypochondriacal alteration, the anxiety psychosis, is never missing and, whether denied or admitted, betrays itself by a profusion of newly emerging sensations, that is, by paresthesias [altered sensation: RK]. Our case is almost devoid of such symptoms.”(Sigmund Freud 1897c)
In his later paper "On The Grounds for Detaching a Particular Syndrome From Neurasthenia Under The Description ‘Anxiety Neurosis’" (1895) Freud gave a very detailed description of anxiety neurosis, including both psychological symptoms such as anxious expectation, general irritability and physical symptoms – palpitations, respiratory disturbances, night sweats, ravenous hunger attacks, diarrhoea, locomotor vertigo e.t.c. Freud was a meticulous thinker preferring precision and detail in his thought.
Even though in the above paper Freud presents the disease in primarily physical terms his mindset appears grounded in his therapeutic work, as he states when differentiating phobias belonging to anxiety neurosis from other phobias: “... relation of these phobias to the phobias of obsessional neurosis, ... is of the following kind. What they have in common is that in both an idea becomes obsessional as a result of being attached to an available affect. The mechanism of transposition of affect thus holds good for both kinds of phobia. But in the phobias of anxiety neurosis (1) this affect always has the same colour, which is that of anxiety; and (2) the affect does not originate in a repressed idea, but turns out to be not further reducible by psychological analysis, nor amenable to psychotherapy. The mechanism of substitution, therefore, does not hold good for the phobias of anxiety neurosis. (Sigmund Freud 1895a)”.
In the same paper Freud equates hysteria with a traumatic neurosis and says that anxiety neurosis never could occur as a result of a single fright, but rather “in a deflection of somatic sexual excitation from the psychical sphere, and in a consequent abnormal employment of that excitation” that occurs through sexual practices not allowing for full sexual satisfaction (e.g. masturbation), or in Freud's terms – "for discharge of psychical state of libidinal tension"; the tension being achieved through physical mechanisms, e.g. “somatic excitation manifested as a pressure on the walls of the seminal vesicles” and needing a discharge through a specific or adequate action – consisting “for the male sexual instinct, in a complicated spinal reflex act which brings about the unloading of the nerve-endings, and in all the psychical preparations which have to be made in order to set off that reflex. Anything other than the adequate action would be fruitless, for once the somatic sexual excitation has reached threshold value it is turned continuously into psychical excitation, and something must positively take place which will free the nerve-endings from the load of pressure on them — which will, accordingly, remove the whole of the existing somatic excitation and allow the subcortical path of conduction to re-establish its resistance.” (Sigmund Freud 1895a)
This frequent use of psychological and biological terms alongside was not a coincidence but reflected Freud's worldview. We should remember the Project for Scientific Psychology Freud drafted at the end of 1895 . The Project remained unpublished throughout Freud's lifetime; his attitude to the work oscillating between fondness and frustrated disregard (Solms 1990). Freud referred to it as Psychology for Neurologists (Sigmund Freud 1895b) in his communication to Fliess. I think we can say The Project is important to understand Freud's approach to psychology.
Some salient points from The Project.
- Freud attempted to create a theory linking neuronal events to the phenomena he observed in clinical work.
- At the centre of the theory there were
three different types of neuronswith differing capabilities to transfer or to store energy through contact barriers separating them [synapses had not yet been discovered then: RK]
Nerve energywas thought to originate mainly through
perceptionsfrom outside world or from internal organs of the human organism.
- The differences between neuronal permeability and their connections accounted for the ability of psychic apparatus to
store memories(mnemic traces) and to attach or detach affects (emotional states) to memories.
- The term
cathexis(besetzung) referred to neurones storing energy (becoming cathected; besetzt) and this accounted for mental states or stimuli activating linked memories and leading to preferential activation of a discharge pathway that could lead to an ordinary action or to an action that would be a symptom in neurosis.
In Freud's further work where he was firmly in the field of metapsychology we also find frequent use of cathexis (besetzung) and other ideas stemming back to this period in his life. In my view that would indicate Freud's thinking being grounded in the neurological ideas of the time - such as of transfer of energy between neurons through contact barriers. Freud's views on neuroses and psychoanalytical theory in general remained very influenced by his advances as a thinker of neurology of his time.
-- Dorland. 2007. Dorland's Illustrated Medical Dictionary . 31st ed. Saunders, July 10.
-- Freud, Ernst, Lucie Freud, and Ilse Grubrich-Simiths. 1985. Sigmund Freud: His Life in Pictures and Words. New edition. Penguin Books Ltd, August 29.
-- Freud, Sigmund. 1886. Report on my Studies in Paris and Berlin (1886) Carried out with the Assistance of a Travelling Bursary Granted from the University Jubilee Fund (October, 1885—end of March, 1886).
———. 1888. Hysteria.
———. 1895a. On The Grounds for Detaching a Particular Syndrome From Neurasthenia Under The Description ‘Anxiety Neurosis’. January 15.
———. 1895b. Letter from Freud to Fliess, April 27, 1895. April 27.
———. 1895c. Project for a Scientific Psychology. November.
———. 1896. The Aetiology of Hysteria. Standard Edition (Freuds) 3: 187-221.
———. 1897a. Letter from Freud to Fliess, September 21, 1897. September 21.
———. 1897b. Letter from Freud to Fliess, October 15, 1897. October 15.
———. 1897c. Letter from Freud to Fliess, November 24, 1887. November 24.
———. 1900. The Interpretation of Dreams. Standard Edition (Freuds) 4.
———. 1924. The Dissolution of the Oedipus Complex.
-- Kaplan-Solms, Karen, and Mark Solms. 2001. Clinical Studies in Neuro-psychoanalysis: Introduction to a Depth Neuropsychology . 2nd ed. Karnac Books, November 1.
-- Laplanche, J., and J. Pontalis. 1973. The Language of Psycho-Analysis: Translated by Donald Nicholson-Smith. The International Psycho-Analytical Library.
-- National Institute of Mental Health, USA. 2010. Mental Illness—Glossary [NIMH]. US government research agency. National Institute of Mental Health . February 5.
-- Reynolds, EH. 1990. Structure and function in neurology and psychiatry. The British Journal of Psychiatry 157, no. 4 (October 1): 481-490. doi:10.1192/bjp.157.4.481.
-- Sass, Henning. 2010. Role of Psychopathology in Psychiatry and Psychiatric Training. June 2.
-- Solms, Mark. 1990. A Moment of Transition: Two Neuroscientific Articles by Sigmund Freud . Karnac Books, January 1.