Conversion psychology. Dictionary-reference book on psychoanalysis - conversion
Hysterical conversion
The starting point of psychoanalysis and modern psychosomatic medicine is the discovery mental etiology hysterical illnesses. Freud (1983, 1895b) and Breuer found that mental and organic symptoms their patients who could not be substantiated organic lesions, lost their irrationality and incomprehensibility at the moment when it was possible to connect their function with biography and life situation patient. They suggested the "existence of hidden, unconscious" or "secret" motives wherever a "leap" into morbid behavior was recognized.
So Freud (1894) wrote: “In the patients I analyzed, mental health was maintained until the onset of intolerance in the world of their ideas, that is, until some experience, idea or sensation caused such a painful affect in their self that the person preferred to forget about it , because I could not find the strength to resolve the contradiction of this intolerable idea with my I and its mental work.”
He called this “leap” in mental behavior conversion, suggesting a jump “from the psyche to somatic innervation.” He argued: “In hysteria, an idea that is intolerable to the patient is neutralized by translating the growing excitement into somatic processes, for which I would like to propose the term conversion” (Freud, 1894).
Freud did not expect to explain the leap from psyche to somatics with his concept of conversion. He labeled it “mysterious,” believing that “our understanding will never be able to follow this leap” (Freud, 1909). It was more important for him to make conversion recognizable as a specific form of behavior. He understood a somatic symptom, such as hysterical paralysis, as the representation of one or more “incompatible ideas.” Their driving motive was the instinctive desires of infantile sexuality that were later discovered and became unconscious (Freud, 1905a). The “neutralization” of ideas, carried out by converting the sum of their excitation into somatic processes, was presented as a special case of neurotic, that is, incomplete repression.
Freud (1894) suggested that this special form of defense against unconscious instinctual drives is made possible by a special predisposition, the “capacity for conversion.” He later developed this idea into the concepts of “somatic reaction” (Freud, 1905b) and “additional series” (Freud, 1905a). The conversion is carried out by the I, thanks to it becoming free from contradictions, that is, freeing itself from conflict with unconscious instinctive impulses. We can say that Freud's concept of conversion, in a certain sense, became the prototype of the concept of neurotic repression in general, and we will see that the direction in psychoanalytic psychosomatics that emerged from the development of the conversion model largely develops within the framework of the classical psychoanalytic teaching on neuroses.
lat. conversio - change). Separating the affective reaction from the content of mental trauma and directing it in a different direction. According to A. Jakubik, there are three possible options for K.: 1. K. serves as a means of protection against fear, is a mechanism of psychological defense; 2. With K., “psychic energy” (libido) is converted into a somatic syndrome or symptom; 3. K. manifests itself in the symbolization of somatic syndromes or symptoms, reflecting the underlying internal conflict. Considering wide range, as well as the metaphorical nature of psychoanalysts’ understanding of K., A. Jakubik suggests using the concept “hysterical disorders of the sensory-motor sphere” instead of this term, although one might think that the latter term excessively narrows the concept of K.
Syn.: conversion reaction, hysterical conversion, conversion hysteria, hysterical neurosis of the conversion type.
CONVERSION
The process by which rejected mental contents are transformed into bodily phenomena. Symptoms take on a variety of forms, including motor, sensory and visceral reactions: anesthesia, pain, paralysis, tremors, convulsions, gait disturbances, coordination, deafness, blindness, vomiting, hiccups, swallowing disorders.
The first cases of hysteria in Freud's practice were conversion symptoms; hysteria became a model for all psychopathology and for the construction of the theory of neuroses. Freud viewed conversion as a hysterical phenomenon aimed at resolving the conflicts of the Oedipal phase:
“an unacceptable idea is rendered harmless by the transformation of the excitement associated with it into something somatic” (1894, p. 49). Although conversion is still considered exclusively in relation to hysteria, Rangell (1959) and others have insisted on expanding its scope, citing clinical examples conversion symptoms for the most varied psychopathological disorders at all levels of development of the libido and self. The essence of conversion, writes Rengelp, is “a shift or displacement of mental energy from the cathexis of mental processes to the cathexis of somatic innervation, as a result of which the latter expresses in a distorted form derivatives of repressed forbidden impulses” (p. 636). Somatic phenomena have symbolic meaning, are “body language”, expressing in a distorted form both forbidden instinctive impulses and defensive forces. Through analysis, thoughts and fantasies associated with bodily symptoms can be translated back into words.
The early cases on which the ideas of hysteria and conversion were based are now considered much more complex than at first thought. These cases are overdetermined, their dynamic mechanisms arising from multiple points of fixation and regression, including pregenital components along with phallic and oedipal ones. But, according to Freud's observations, for conversion to occur it is necessary favorable conditions, and the range of these conditions is very wide. He admitted that in order to resolve conflict through conversion rather than phobic and obsessive symptoms, a certain “capacity for conversion” or “somatic readiness” is required; however, conversion phenomena are often combined with phobic and obsessive symptoms.
Although Freud's ideas about conversion were economic in nature - psychic energy moved or transformed from the psychic to the somatic sphere - in the same work he laid the foundation for another, now more acceptable explanation. Similar to obsessions can arise when an affect is separated from a rejected idea and replaced with a more acceptable one, in the same way, as a compromise formation, affect can be attributed to a fantasy about a bodily illness and lead to clinical picture conversion (Freud, 1894, p. 52).
The relationship between hysterical conversion symptoms and other psychosomatic manifestations remains not entirely clear. Thus, for example, in orgone neuroses, functional disturbances apparently do not have their own mental meaning, since they are not a translation of specific fantasies and impulses into body language. The same applies to pregenital conversions (Fenichel, 1945), including stuttering, tics and asthma. In order not to classify any shift from the psyche to the soma as conversion, Rangell (1959) proposed limiting cases of conversion disorders to the criteria described above; he suggested excluding cases of inevitable but nonspecific somatic consequences mental stress and undischarged affect. This division, however, often causes clinical difficulties.
CONVERSION
The standard meaning is the transformation of something from one state to another. Therefore: 1. A sharp shift from one set of beliefs to another, especially regarding religious beliefs. 2. Transformation of psychological inconsistency into physical forms (see conversion disorder). 3. Shifting a set of values from one scale to another. 4. Rearrangement of terms in a judgment.
CONVERSION
the process and mechanism for resolving intrapsychic conflict through the formation of somatic symptoms, accompanied by motor, sensory, visual and other disorders.
In a conceptually formalized form, the idea of conversion was expressed by J. Breuer and S. Freud on the basis of their therapeutic activities related to the treatment of patients suffering from hysteria. This idea was reflected in their work “Studies on Hysteria” (1895), although in terminological terms it was S. Freud who had priority in introducing into scientific circulation the term “conversion”, which he used to characterize the “abnormal release of unextinguished excitations”. In the article “Defensive Psychoneuroses” (1894), he considered conversion in terms of the separation of mental energy from a person’s representation, as a result of which there was a shift in mental arousal to the body area, which led to the emergence of somatic symptoms.
As S. Freud tried to build general theory neuroses, he distinguished between “conversion hysteria” and “hysteria of fear.” The first form of hysteria is associated, in his opinion, with the direction of the affect of the mental process from the mental sphere to the bodily area. The second involves repressing traumatic experiences into the unconscious, but preserving them in the human psyche. At first, S. Freud believed that “conversion hysteria” could have an independent meaning, in no way connected with neurotic diseases, the symptoms of which are characterized by mental manifestations. He then hypothesized the presence of mixed neuroses and extremely rare cases of exclusively “conversion hysteria.” However, in his work “Analysis of the Phobia of a Five-Year-Old Boy” (1909), he expressed the point of view according to which there are not only cases of pure “hysteria of fear”, expressed in the manifestation of phobias without an admixture of conversion, but also “pure cases of conversion hysteria without any fear.” .
In S. Freud's understanding, conversion correlated with the economic point of view on hysteria, which took into account the quantitative factor of psychic energy. Expressed in his early studies, this point of view actually predetermined his subsequent metapsychological developments, combining topical (based on the location of unconscious and conscious systems), dynamic (the transition of conscious and unconscious processes from one system to another) and economic (the amount of mental charge) ideas about the nature and causes of neurotic diseases. As S. Freud noted in his “Autobiography” (1925), his theory of hysteria takes into account, along with distinguishing between unconscious and conscious mental acts and a dynamic view of the symptom as a result of counteracting affect, also the economic factor, since it considers the same symptom “as a result of the transformation of a certain amount of energy, usually converted to something else (the so-called conversion).”
Symptoms of conversion can come in a variety of forms, including paralysis, convulsions, incoordination, blindness, deafness, vomiting and other bodily manifestations. From a psychoanalytic point of view, they can be either the result of a transfer of psychic energy or the rejection of psychic content, or a consequence of a person’s fantasies about a particular bodily illness.
In modern psychoanalysis, the questions remain debatable about whether all movements from the psyche to the bodily organization of a person should be considered conversion or whether we can talk about specific forms of the corresponding shift, what are the criteria that allow us to separate conversion symptoms from other psychosomatic manifestations, how and in what way conversion manifestations are combined with phobias, hypochondria and other mental illnesses.
№ 34 Disturbances in physiological functions (sleep, appetite, sexual functions) as a manifestation of mental disorders. The use of psychotherapy and psychotropic drugs to treat these disorders.
Eating disorders may be a manifestation of the most various diseases. A sharp decrease in appetite is characteristic of depressive syndrome, although in some cases overeating is possible. Decreased appetite also occurs in many neuroses. With catatonic syndrome, refusal to eat is often observed.
Syndrome anorexia nervosa It develops more often in girls during puberty and adolescence and is expressed in the conscious refusal of food for the purpose of losing weight.
Sharp loss of body weight , disturbances in electrolyte metabolism and lack of vitamins lead to serious somatic complications - amenorrhea, pallor and dry skin, chilliness, brittle nails, hair loss, tooth decay, intestinal atony, bradycardia, low blood pressure, etc.
Bulimia - uncontrolled and rapid absorption of large quantities of food. It can be combined with both anorexia nervosa and obesity. Women are more often affected. Each bulimic episode is accompanied by feelings of guilt and self-hatred. The patient seeks to empty the stomach by inducing vomiting and takes laxatives and diuretics.
Anorexia nervosa and bulimia in some cases they are an initial manifestation of a progressive mental illness (schizophrenia). In this case, autism, disruption of contacts with close relatives, and an elaborate (sometimes delusional) interpretation of the goals of fasting come to the fore. Another common cause Anorexia nervosa are psychopathic personality traits. Such patients are characterized by sthenicity, stubbornness and perseverance. They persistently strive to achieve the ideal in everything (usually they study diligently).
Treatment of patients with eating disorders should be carried out taking into account the main diagnosis.
Hospital treatment - replenishment of dietary defects, normalization of body weight through organization fractional meals and establishing the activity of the gastrointestinal tract, restorative therapy.
To suppress an overvalued attitude towards reception neuroleptics are used in food. Psychotropic drugs are also used to regulate appetite. Many antipsychotics (frenolone, etaprazine, aminazine) and other drugs that block histamine receptors (pipolfen, cyproheptadine), as well as tricyclic antidepressants (amitriptyline) increase appetite and cause weight gain. To reduce appetite, psychostimulants (fepranon) and antidepressants from the group of serotonin reuptake inhibitors (fluoxetine, sertraline) are used. Properly organized psychotherapy is of great importance for recovery.
Sleep disturbance - one of the most common complaints in a wide variety of mental and somatic diseases.
Insomnia - one of the most common complaints among somatic and mentally ill people.
This symptom manifests itself differently depending on the cause of insomnia.
Thus, sleep disturbances in patients with neurosis primarily associated with a severe psychotraumatic situation. Patients can, lying in bed, think about the facts that bother them for a long time, and look for a way out of the conflict.
For asthenic syndrome , characteristic of neurasthenia And vascular diseases of the brain(atherosclerosis), when irritability and hyperesthesia occur, patients are especially sensitive to any extraneous sounds: the ticking of an alarm clock, the sounds of dripping water, the noise of traffic - everything prevents them from falling asleep.
For those suffering depression characterized not only by difficulty falling asleep, but also by early awakening, as well as a lack of feeling of sleep.
Patients with manic syndrome never complain of sleep disorders, although their total duration may be 2-3 hours. Insomnia is one of the early symptoms anyacute psychosis (acute attack of schizophrenia, alcoholic delirium, etc.). Typically, lack of sleep in psychotic patients is combined with extremely severe anxiety, a feeling of confusion, unsystematized delusional ideas, and individual deceptions of perception (illusions, hypnagogic hallucinations, nightmares). A common cause of insomnia is withdrawal state due to abuse of psychotropic drugs or alcohol.
Treatment. In many cases, the prescription of individually selected sleeping pills is required, but psychotherapy is a more effective and safe method of treatment in this case. For example, behavioral psychotherapy requires adherence to a strict regimen. Gynersomnia May be accompanied by insomnia. Thus, patients who do not get enough sleep at night are characterized by daytime drowsiness.
Narcolepsy - a relatively rare pathology that is hereditary in nature and is not associated with either epilepsy or psychogenic disorders. Characterized by frequent and rapid onset of the REM sleep phase (within 10 minutes after falling asleep), which is clinically manifested by attacks of a sharp drop in muscle tone (cataplexy), vivid hypnagogic hallucinations, episodes of blackouts with automatic behavior or states of “waking paralysis” in the morning after waking up.
Klein-Levin syndrome - An extremely rare disorder in which hypersomnia is accompanied by episodes of narrowing of consciousness. Patients retire and look for a quiet place to nap. Sleep is very long, but the patient can be awakened, although this is often associated with irritation, depression, disorientation, incoherent speech and amnesia.
Sexual dysfunction . The most important criterion for diagnosis is the subjective feeling of dissatisfaction, depression, anxiety, and guilt that an individual experiences in connection with sexual intercourse. Sometimes this feeling occurs during completely physiological sexual relationships.
The following types of disorders are distinguished: decline and extreme rise sexual desire, insufficient sexual arousal (impotence in men, frigidity in women), orgasm disorders (anorgasmia, premature or delayed ejaculation), painful sensations during sexual intercourse (dyspareunia, vaginismus, post-coital headaches) and some others.
Quite often the reason sexual dysfunction are psychological factors - personal predisposition to anxiety and restlessness, forced long breaks in sexual relationships, lack of permanent partner, a feeling of one’s own unattractiveness, unconscious hostility, a significant difference in the expected stereotypes of sexual behavior in a couple, an upbringing that condemns sexual relationships, etc. Often, disorders are associated with fear of starting sexual activity or, conversely, after 40 years - with approaching involution and fear of losing sexual attractiveness.
Significantly less common cause of sexual dysfunction is a severe mental disorder (depression, endocrine and vascular diseases, parkinsonism, epilepsy). Even less often, sexual disorders are caused by general somatic diseases and local pathology of the genital area. Possible disorder of sexual function when prescribed certain medications (tricyclic antidepressants, irreversible MAO inhibitors, neuroleptics, lithium, antihypertensive drugs - clonidine, etc., diuretics - spironolactone, hypothiazide, antiparkinsonian drugs, cardiac glycosides, anaprilin, indomethacin, clofibrate etc.). A fairly common cause of sexual dysfunction is substance abuse (alcohol, barbiturates, opiates, hashish, cocaine, phenamine, etc.).
Correct diagnosis Determining the causes of the disorder allows us to develop the most effective treatment tactics. The psychogenic nature of disorders determines the high effectiveness of psychotherapeutic treatment. The ideal option is to work simultaneously with both partners of 2 collaborating groups of specialists, however, individual psychotherapy also gives positive result. Medicines and biological methods are used in most cases only as additional factors, for example, tranquilizers and antidepressants - to reduce anxiety and fear, cooling the sacrum with chloroethyl and the use of weak neuroleptics - to delay premature ejaculation, nonspecific therapy - in case of severe asthenia (vitamins, nootropics, reflexology, electrosleep, biostimulants such as ginseng).
I hope no one will suspect me of identifying nervous excitement with electricity if I once again cite the example of an electrical installation. When the voltage in the electrical network increases excessively, the insulating layer may melt on the most vulnerable sections of the wiring, where various electrical phenomena, and when two bare wires touch, a “short circuit” occurs. If such damage is not corrected, problems caused by it may occur whenever the voltage increases to a certain level. In this way, incorrect “treading” is produced.
Perhaps it can be argued that in this respect the nervous system is structured like an electrical network. It is a collection of interconnected elements; however, in many of its sections there are some kind of resistors installed that provide significant, although not completely insurmountable resistance, which prevents uniform distribution excitement. When a healthy person is awake, the excitation that arises in the organ responsible for ideas is not transmitted to the organ of perception, which is why we do not experience hallucinations. To ensure the safety and normal functioning of the body, the nervous apparatus, which serves the vital functions of the body, blood circulation and digestion, is separated from the organs responsible for representations by powerful resistors, allowing it to function autonomously; ideas do not directly influence him. But the degree of power of resistors that prevent the entry of intracerebral excitation into the nervous apparatus that serves blood circulation and digestion depends on individual characteristics nervous system; Apart from the “nervous” person and the person who does not show the slightest signs of “nervousness”, whose heart always beats evenly and reacts only to physical stress, the person who maintains his appetite in the most dangerous situations and does not spoil his digestion, there will be many people, mostly or less susceptible to affect.
However, resistors that prevent the flow of excitation to vegetative organs, everyone has normal person. They can be likened to the insulating coating of electrical wiring. In those places where the degree of resistance is reduced, all obstacles are swept away under the pressure of intracerebral excitation, and the flow of excitation associated with affect rushes to the peripheral organ. This is what is called “an abnormal way of expressing emotional impulse.”
We have already described one of the specified conditions for the development of this process in sufficient detail. We are talking about increased intracerebral excitation, which either cannot be eliminated by sequentially building ideas and with the help of motor discharge, or has increased to such an extent that motor discharge alone is not enough to calm it down.
The second condition is created by reducing the degree of resistance of individual conducting paths. In some people, the degree of resistance of the pathways is initially reduced (due to an innate predisposition); a decrease in the degree of resistance can also be caused by a long stay in an excited state, due to which, so to speak, the framework of the nervous system is shaken and resistance weakens everywhere (a predisposition of this kind arises during puberty); it may decrease due to illness, malnutrition and everything that weakens the body (in this case, the predisposition is due to exhaustion). The degree of resistance of individual pathways may decrease due to disease of the corresponding organ, due to which the breakdown occurs nerve pathways leading to and from the brain. A sick heart is more susceptible to the influence of affect than a healthy heart. “It’s like there’s a resonator in my lower abdomen,” a woman suffering from chronic parametritis once told me, “as soon as I do, old pain immediately appears.” (In this case, the predisposition is due to a local disease.)
Motor acts, with the help of which, as a rule, excitation is discharged, are ordered and coordinated actions, although in themselves they are often aimless. But a powerful flow of excitation, bypassing or overcoming the centers of coordination, can push even the simplest movements. All the actions that an infant performs under the influence of passion, when he rests, twists his legs and arms, minus one respiratory act, which is a cry, are just such uncoordinated muscle contractions. With age, a person learns to coordinate muscle contractions and subordinate them to his will. However, opisthotonus, which is the maximum tension of all the muscles of the body, and the convulsive movements that a person made in infancy, when he floundered and kicked, serve throughout his life as a reaction to maximum excitation of the brain; during an epileptic seizure they serve as a reaction to purely mental excitement, and more or less epileptoid convulsions allow for discharge when a strong affect occurs. (They are a purely motor element of a hysterical attack.)
Such violent affective reactions are observed in hysterics, but not only in them; they are signs of more or less pronounced nervousness, but not of hysteria itself. These phenomena can be considered hysterical only if they appear spontaneously, like symptoms of a disease, and do not appear as a result of a strong, but objectively justified affect. Judging by the observations of many doctors, and by our own observations, these phenomena are based on memories that resurrect the original affect or, more precisely, would resurrect it if it had not once already caused exactly such a reaction.
Probably, in moments of peace of mind, any person distinguished by mental alertness slowly floats through his consciousness with thoughts and memories; More often than not, these ideas are so inconspicuous that they disappear without a trace, and then it is impossible to remember where this or that association came from. But when you accidentally stumble upon a representation that was once associated with a strong affect, the latter reasserts itself with more or less force. And then the “emotionally colored” idea reaches consciousness, acquiring its former brightness and liveliness. The degree of expression of the affect that a memory can evoke varies noticeably depending on how much time the affect has been “spent” since it was “reacted” for the first time. In the “Pre-Notice” we pointed out that the strength of the emotion recalled in memory, say, anger caused by an insult, depends on whether the person responded to the insult at the time or endured it without complaint. If in the initial circumstances the irritation was followed by a mental reflex, then the memory of this event excites much less. 77 Otherwise, whenever the corresponding memory arises, the person has swear words on the tip of his tongue, which he then did not dare to utter, although this is precisely what should was to serve as a mental reflex at the moment of irritation.
If the initial affect did not cause a normal reflex and the discharge was produced with the help of an “abnormal reflex,” then the latter is also reproduced when the corresponding memory arises; the excitement caused by the affective idea is transformed through “conversion” (Freud) into a somatic symptom. If this is repeated often and entails the final breakdown of the abnormal reflex, then the potential of the original idea, apparently, dries up, therefore the affect itself that arises at this moment becomes weaker each time or ceases to arise at all, which indicates the completion of the “hysterical conversions." As for the idea, which is no longer capable of influencing the psyche, the individual may simply not notice it or immediately forget about it, just as he forgets about other ideas devoid of affect.
The assumption that instead of the cerebral excitation that should have caused the idea, excitation occurs in the peripheral pathways will seem more plausible if we remember that this process can proceed in the opposite direction in the case when it is not realized conditioned reflex. Let me give you an example of the most common sneezing reflex. If, due to irritation of the nasal mucosa, a person for some reason does not sneeze, then, as is known, he begins to worry and experiences unpleasant tightness. And this is the excitement that cannot be eliminated with the help of motor activity, spreads throughout the brain, causing inhibition that interferes with all other activity. Despite the simplicity of this example, one can judge from it the pattern by which the process develops even in the case when the most complex mental reflexes are not realized. The attraction to revenge excites a person, essentially, for the same reason; signs of the development of this process can be found even in the highest spheres of human activity. The strong impression does not leave Goethe alone until he expresses his feelings in poetry. This is the preformed reflex inherent in it, which must follow the affect, and until this reflex is realized, nothing can calm down the weary excitement.
The amount of intracerebral excitation is inversely proportional to the amount of excitation, the flow of which rushes along the peripheral pathways; the degree of intracerebral excitation increases while the reflex remains unrealized and decreases after intracerebral excitation is converted into peripheral nervous excitation. From this it is clear that a tangible affect cannot arise if the idea itself, which should have been the cause of its appearance, causes an abnormal reflex, due to which the excitement is immediately eliminated. In this way a complete “hysterical conversion” is achieved; the initial intracerebral excitation associated with affect is transformed into excitation, the flow of which rushes along the peripheral pathways; the original affective idea, which previously caused affect, can now only cause an abnormal reflex 78.
Thus, we have considered the “abnormal way of expressing emotional impulses” and have moved one step further. Even intelligent and observant patients are not inclined to count hysterical symptoms(abnormal reflexes) ideogenic, since the idea that gave rise to their appearance has already lost its emotional coloring and does not stand out among other ideas and memories; A similar phenomenon arises as a purely somatic symptom, and at first it is difficult to notice that it has a mental origin.
What is the reason for such a discharge of excitement caused by affect, why is this particular reflex realized, and not any other abnormal reflex? Judging by our observations, most often such a discharge is also produced according to the “principle of least resistance,” so that excitation is directed along those conductive paths whose resistance level has already been reduced due to accompanying circumstances. As already noted, this occurs in the case when a certain reflex is already worn out due to a somatic disease - for example, in a person suffering from cardialgia, affect also causes pain in the heart area - or due to the fact that with voluntary contraction of certain muscles at the time of the initial affect their innervation increases; for example, Anna O. (described in the first case history), frightened, tried to drive away the snake she had dreamed of with her right hand, which was paralyzed due to compression of the nerve; From then on, her right hand became stiff whenever she saw an object that looked like a snake. Another time, at the moment of the onset of passion, she brought the watch too close to her eyes, trying to distinguish the hand, and since then, as a result of convergence, one of the reflexes accompanying this affect has become convergent squint.
Our ordinary associations are also based on the principle of synchronicity; Any sensation that arises during sensory perception evokes another sensation that once arose simultaneously with it (a classic example of such an association is the appearance of a certain visual image at the moment when you hear the bleating of a sheep).
If in the initial circumstances some strong sensation arose simultaneously with the affect, then when this affect reappears, it arises again, and not in the form of a memory, but in the form of a hallucination, since at this moment a discharge is produced overexcitement. The medical histories of almost all of our patients contain many examples to illustrate the above. For example, due to inflammation of the periosteum, one woman had a toothache at the very moment when she was tormented by a painful affect, and since then the affect itself or simply the memory of it always causes her to have neuralgia of the infraorbital branch of the trigeminal nerve.
This reflex path is based on the universal law of associations. However, sometimes (of course, only when the severity of hysteria is sufficiently high) long strings of interrelated ideas stretch between the affect and the reflex that it causes; This is how determination occurs through symbolism. Often, the connection between affect and the corresponding reflex arises thanks to funny puns and consonances, but this happens only at the moment when a person loses the ability to separate fiction from reality, plunging into a state reminiscent of a dream, and such phenomena already go beyond the scope of the group of phenomena that interests us.
77 The attraction to revenge, so clearly expressed among uncivilized people, and even among civilized people, cleverly disguised rather than suppressed, owes its emergence precisely to the excitement that persists due to the fact that reflex discharge was not produced at the time. The desire to defend honor in a fight with an enemy and strike back at him is a completely adequate predetermined mental reflex. If a person did not react to the insult or his reaction was not strong enough, then the memory of this incident will always evoke the same reflex in him and awaken the “drive for revenge,” a strong-willed impulse that is just as irrational as all drives. It is precisely its irrationality, complete practical unsuitability and inexpediency, and even its ability to prevail over the sense of self-preservation that testify in favor of this assumption. As soon as a reflexive discharge is made, a person realizes the irrationality of his action. “For they are different and not alike in appearance // Hidden anger and bursting anger.” – Approx. author.
78 I wouldn't like to bore to death the comparison with an electrical installation; because, due to fundamental differences between the design of an electrical installation and the structure of the nervous system, this comparison can hardly illustrate and certainly cannot explain what is happening in the nervous system. Still, it is worth recalling one episode. I remember that due to an increase in voltage in the network of our electrical installation, the insulating coating on one section of the wiring was damaged, and a “short circuit” occurred on another section. If various electrical phenomena occur on this section of the wiring (the wire heats up, begins to spark, etc.), then the lamp connected to this wire does not light up; Likewise, affect does not arise if excitement, causing an abnormal reflex, is transformed through conversion into a somatic symptom. – Approx. author.
In many cases, it is impossible to explain what determines the hysterical symptom, since often we can only guess at what the person’s mental state was and what ideas arose in him at the time of the appearance of this hysterical symptom. However, we dare to assume that in such cases the process of determination does not differ too much from any such process of which we have been able to gain a complete understanding through a fortunate combination of circumstances.
We call the experiences that caused the initial affect that caused arousal, which was transformed through conversion into a somatic symptom mental trauma, and the symptoms of the disease themselves are hysterical symptoms of traumatic origin. (The term “traumatic hysteria” is already assigned to symptoms that develop as a result of damage to any part of the body, that is, as a result of trauma in the narrow sense of the word, and belong to “traumatic neurosis.”)
The conversion of excitation, caused by inhibition of the flow of associations, and not by external irritation or inhibition of normal mental reflexes, develops in exactly the same way as hysterical symptoms of traumatic origin.
Let's give the simplest and most obvious example. A person gets into a state of excitement when he cannot remember a word or solve a riddle, but it is enough to suggest the desired word or the correct answer for the excitement to subside, since the hint closes the chain of associations and the same thing happens as when closing the reflex chain. The strength of the excitement caused by the sudden cessation of the sequential movement of associations is proportional to the degree of significance of these associations, that is, depends on how interested the person is in them. Since even an unsuccessful search for the correct answer requires spending a lot of effort, in such cases there is a use for strong arousal, so that the desire for discharge does not arise and the arousal never becomes pathogenic.
But when the inhibition of the flow of associations occurs due to the incompatibility of equivalent ideas, for example, because thoughts come to mind that contradict established ideas, arousal is likely to persist. That is why the religious doubts that plague many people today are so painful, and in the past they were even more prevalent. But even when such doubts arise, excitement, and behind it mental pain, a feeling of displeasure, increases only if the doubts affect the vital interests of a person, if he believes that they threaten his well-being and the salvation of his soul.
This happens whenever a person is tormented by remorse, when a conflict arises between the moral principles instilled in him by upbringing and memories of his own actions or just thoughts that contradict these principles. At this moment, the desire to remain at peace with oneself awakens and the excitement caused by the inhibition of associations increases to the limit. We are constantly convinced that the conflict between incompatible ideas has a disease-causing effect on a person. Most often, the culprits of such conflicts are ideas and incidents related to sexual life: a conscientious young man may suffer from a tendency to masturbate, a lady of strict rules may suffer from love for married man. Often, a single sexual sensation or a randomly flashed frivolous thought that comes into conflict with deep-rooted ideas about virtue is enough to cause a strong arousal in a person 79.
Usually this only affects the person’s mental state, causing dysphoria and what Freud calls anxiety attacks. But in the presence of several conditions favorable to the development of the disease, a somatic symptom may appear, due to which a discharge is produced: such a symptom may be nausea, if the thought of one’s own moral uncleanliness makes a person sick; if remorse causes laryngospasms, a nervous cough may appear, as Anna O. suffered, described in the first case history 80.
Normal, adequate reaction the excitement caused by the appearance of equally vivid, but incompatible ideas is an outpouring of words. Brought to the point of absurdity, the need to pour out one’s soul takes on comic features in the story about the barber Midas, who, unable to keep a secret, shouted out the cherished word into the reeds; but this same need underlies the majestic ancient rite of Catholic secret confession. Confession lightens the soul and relieves tension, even if the confession is not addressed to a priest and does not end with absolution. When it is impossible to give vent to the excitement in this way, it is sometimes transformed by conversion into a somatic symptom, just like the excitement caused by a traumatic affect, so we can, following Freud, call all hysterical symptoms of this origin retention hysterical phenomena.
The given description of the mental mechanism of the occurrence of hysterical phenomena may seem too schematic and simplified. In fact, in order for a real hysterical symptom to arise in a healthy person who has no predisposition to neuropathy, which in appearance is in no way connected with the mental state and may seem purely somatic, several conditions must almost always be present simultaneously that favor the development of this process.
Perhaps, using the example of the practical case described below, we can show how complex such a process is. The twelve year old son is very nervous man, who suffered from bedwetting in previous years, fell ill one day after returning from school. He complained of a headache and difficulty swallowing. The family doctor thought that a common sore throat was to blame. But several days passed, and the boy did not feel better. He refused to eat, and when forced to eat, he vomited. He tiredly and indifferently wandered around the house, every now and then trying to lie down on the bed due to severe physical exhaustion. When I examined him five weeks later, he immediately seemed to me to be a timid, withdrawn child, and I did not doubt for a minute that his illness was of mental origin. In response to persistent questioning, he said that he fell ill because his father had given him a severe reprimand, but this unremarkable incident could in no way be the cause of the illness. According to him, nothing happened to him at school that day either. I promised to extract the truth from him later under hypnosis. But nothing happened without that. As soon as his mother, an intelligent and energetic woman, put a lot of pressure on him, he burst into tears and told everything. It turns out that while returning from school that day, he went into a public restroom, where a man held up his penis to him and demanded that he take it into his mouth. The frightened boy ran away. Nothing else happened to him that day. But it was after this that he fell ill. Having confessed everything, he quickly began to recover. In order for a child to develop symptoms of anorexia, a sore throat when swallowing and gagging, it took the influence of several factors: these included congenital nervousness, fear, the influence of sexual harassment in its most gross manifestation on the vulnerable child’s soul and the feeling of disgust that appeared key factor in the disorder. The illness became protracted due to the fact that the boy kept silent about this incident and therefore was unable to overcome his excitement naturally.
In order for a hitherto healthy person to develop a hysterical symptom, the influence of several factors is always necessary; the hysterical symptom, in Freud's words, is always “overdetermined.”
Overdetermination also occurs when the same affect repeatedly arises for different reasons. The patient himself and his relatives believe that the hysterical symptom arose due to a recent incident, whereas such an incident often only serves as an immediate cause for the manifestation of a symptom that had previously almost completely developed as a result of other traumas.
79 Interesting notes on this subject can be found in an article by Benedict, published in 1889 and reprinted in 1894 in the treatise “Hypnotism and Suggestion” [Benedikt. Hypnotismus und Suggestion, 1894. S. 51]. – Approx. author.
80 In Mach’s Kinesthesia, I found one passage that is worth quoting in full: “In the course of the experiments described (related to the study of the state of dizziness), it was repeatedly noted that the feeling of nausea arose mainly in those cases when it was difficult to bring motor sensations into accordance with visual impressions. It seemed that some of the impulses emanating from the labyrinth, bypassing the visual paths already occupied by other impulses, were forced to pave a completely different path for themselves... When trying to combine stereoscopic images with a large gap, I also repeatedly noted the appearance of a feeling of nausea.” It is perhaps impossible to more accurately describe in the language of physiology the process of the emergence of pathological, hysterical phenomena due to the coexistence of equally vivid, but incompatible ideas. – Approx. author.
First hysterical attack, followed by a series of similar seizures, occurred in one young girl 81 at the moment when a cat jumped on her shoulders in the dark. It would seem that ordinary fear was to blame. But having questioned the patient in more detail, the doctor found out that the surprisingly pretty seventeen-year-old girl, due to the negligence of those who were supposed to look after her, had recently more than once become a victim of more or less gross harassment, from which she herself experienced sexual arousal (i.e. she developed a predisposition). A few days before the seizure, on the same dark staircase, she was attacked by a young man, from whom she managed to fight off. This caused her real mental trauma, the consequences of which became evident at the moment when the cat attacked her. But how often does such a cat serve as a completely sufficient causa efficiens? 82
The conversion of excitation, caused by the repeated appearance of the same affect, should not always be preceded by a long series of events that push it from the outside; Often it is enough to constantly remember the affect immediately after the trauma, when the feelings have not yet had time to fade. For conversion, memories of affect are sufficient if the affect itself was very strong, as happens with traumatic hysteria in the narrow sense of the word.
For example, a person who survived a train crash, for several days in his dreams and in reality, recalls the terrible scenes of the disaster, each time experiencing the same fear that gripped him then. And this continues until, after the incubation period, which Charcot calls the period of “psychic development,” the excitement is transformed by conversion into a somatic symptom. (However, there is another factor at work here, which we will talk about a little later.)
However, an affective idea, as a rule, is suppressed immediately after its appearance and little by little loses its affect under the influence of all those factors that we mentioned in the “Pre-Notice”. The excitation that it causes becomes weaker each time, the memory of it can no longer contribute to the development of a somatic symptom, the abnormal reflex disappears, and thus the status quo ante 83 is fully restored.
In order to maintain an affective idea, it is necessary to establish appropriate associative connections, reflect on it and make amendments to it, taking into account other ideas. If an affective representation is removed from “associative circulation”, it is impossible to expend it, and in this case the magnitude of the affect associated with it remains unchanged. Releasing at the moment of its next appearance the total excitation caused by the initial affect, it allows the continuation of the abnormal reflex that began in the initial circumstances or the preservation and strengthening of the abnormal reflex in the form in which it then arose. Under these conditions, hysterical conversion can occur constantly.
During our observations, we studied two ways of removing an affective representation from association.
The first method, called “defense,” involves the arbitrary suppression of unpleasant ideas that can poison a person’s life or shake a person’s self-esteem. In an article entitled "Defensive Neuroses", published in the tenth issue of the "Neurological Bulletin" for 1894, and in the case histories presented here, Freud described this process, undoubtedly having great importance for the development of the disease.
It is perhaps difficult at first to understand how a certain idea can be arbitrarily repressed from consciousness; however, we know no more about how we can focus attention on a specific idea, although we know for certain that a person is capable of this.
Since a person stops thinking about ideas from which consciousness has turned away, it is not possible to stop them, so the magnitude of the affect associated with them remains unchanged.
In addition, we have established that ideas of a different kind cannot be stopped by thinking, not because a person does not want to remember them, but because he simply cannot remember them, since they first arose against the background of a hypnotic or hypnoid state and were endowed with affect, which is completely forgotten at the moment when a person is awake. In the light of the theory of hysteria, the hypnoid state appears to be a very significant phenomenon and therefore deserves more detailed discussion84.
IV. Hypnoid states
Arguing in the “Pre-Notice” that the basis and condition of hysteria is the existence of hypnoid states, we lost sight of the fact that Moebius expressed exactly the same idea back in 1890: “The prerequisite for the pathogenic influence of ideas is, on the one hand, an innate predisposition to hysteria , and on the other hand – a special state of mind. It is impossible to say anything definite about this state of mind. It should resemble a hypnotic trance, when immersed in which an emptiness appears in the consciousness, so at this moment any idea can appear without encountering resistance from another idea, and, as they say, the first one that comes along rules the show here. We know that a person can plunge into such a state not only under the influence of hypnosis, but also as a result of mental shock (from fear, from rage, etc.) and physical exhaustion (from insomnia, hunger, etc.).”
First, Mobius tried to find a more or less intelligible answer to the question, which can be formulated in the following way: how somatic symptoms arise based on ideas. Recalling that under the influence of hypnosis this happens with amazing ease, he concludes that affects act in a similar way. We have already outlined in some detail our considerations regarding the influence of affects, which differ somewhat from the views of Mobius. Therefore, now I will not go into detail and point out all the inconsistencies associated with M.’s assumption that from rage “an emptiness appears in the mind” 85 (although from fear and during a long stay in a state of anxiety it indeed arises) , not to mention the fact that comparing the excitement caused by affect with a calm hypnotic sleep is only a very big stretch. However, we will return to Mobius’s assumptions, since, in my opinion, there is a grain of truth in them.
We have always attached great importance to "hypnoid" states, that is, states similar to hypnotic sleep, since they cause amnesia and create the conditions for the splitting of the psyche, which we will talk about a little later and which underlies "intense hysteria." We can repeat this now, but with one significant caveat. Conversion, the transformation of excitement associated with ideas into a somatic symptom, occurs not only against the background of a hypnoid state. Freud established that the basis for the formation of a complex of ideas withdrawn from associative circulation is also created by voluntary amnesia, caused by protection, and not by a hypnoid state. But, despite this reservation, I still believe that hypnoid states are often the basis and condition of hysteria, especially in cases where the severity of the hysteria is high and the disease causes many complications.
Of course, the hypnoid state is, first of all, true self-hypnosis, which differs from artificial hypnotic sleep only in that a person plunges into this state spontaneously. Some patients who exhibit sufficiently developed hysteria exhibit a tendency toward self-hypnosis, although the frequency and duration of stay in this state may vary. Often short-term self-hypnosis alternates with normal wakefulness. The ideas that arise in a person who is under the influence of self-hypnosis often resemble dreams, so this state can be called delirium hystericum 86. While awake, a person does not remember or barely remembers what happened to him while he was in a hypnoid state, but, plunging into artificial sleep under hypnosis, he remembers everything. It is precisely because of amnesia that it is impossible to think through and correct associations that arose against the background of a hypnoid state while awake. And since, under the influence of self-hypnosis, the ability to critically evaluate emerging ideas and control the process of their emergence, comparing them with other ideas, sometimes decreases, and most often disappears altogether, self-hypnosis can give rise to completely crazy ideas that remain safe and sound for a long time. For example, the more complex “symbolic relationship between the triggering incident and the pathological phenomenon,” often based on hilarious verbal associations and consonances, occurs almost exclusively in this state. Due to a decrease in critical abilities against the background of this condition, self-hypnosis is very often performed, therefore, for example, after a hysterical attack, paralysis occurs. However, in the course of analyzing our patients, we were never able to detect a single hysterical symptom that arose in this way. Perhaps we were just unlucky, but all the symptoms we studied, including those that arose due to self-hypnosis, were due to the conversion of arousal caused by affect.
81 I owe information about this case to Mr. Assistant Dr. Paul Karplus. – Approx. author.
82 Causa efficiens (lat.) – motivating reason.
83 Status quo ante (lat.) – previous state.
84 When we mention here and below about ideas that influence a person while remaining unconscious, with rare exceptions (which is, for example, a hallucination associated with the image of a huge snake, which caused contracture in Anna O.), we are not talking about individual ideas, but about complexes of interrelated ideas, which include memories of events and one’s own thoughts. The individual ideas that collectively make up this complex are realized from time to time. Only when they are an integral part of certain complexes are these ideas expelled from consciousness. – Approx. author.
85 Perhaps M. calls emptiness nothing more than inhibition of the flow of ideas, which indeed occurs at the moment of the onset of affect, although inhibition in this state and inhibition under hypnosis occur for different reasons. – Approx. author.
86 Delirium hystericum (lat.) – hysterical insanity.
Be that as it may, it is easier to produce a “hysterical conversion” against the background of self-hypnosis than during wakefulness, and to induce hallucinations in the patient, accompanied by corresponding movements, instilling in him certain ideas, which is much easier during artificial sleep under hypnosis. But even in this case, the process of excitation conversion essentially develops according to the scheme that we described above. If once a conversion has been made, then a somatic symptom begins to arise whenever affect appears against the background of self-hypnosis. And apparently, subsequently the affect itself can put a person into a hypnotic state. At first, while hypnosis alternates with wakefulness, the symptom arises only against the background of a hypnotic state and each time becomes more and more ingrained; however, it is impossible to realize, evaluate and correct the incentive idea itself, since just at the moment when a person is awake, it does not arise at all.
For example, Anna O., described in the first case history, has contracture right hand, which, under the influence of self-hypnosis, was associated with a feeling of fear and the image of a snake, for four months arose only against the background of a hypnotic (say, hypnoid, if the first definition seems inappropriate to someone when describing a very short-term clouding of consciousness) state, although this happened quite often . In a similar way, other phenomena arose due to the conversion carried out in the hypnoid state, so that gradually the patient developed a complex of hysterical symptoms, which appeared at the moment when the duration of stay in the hypnoid state increased.
During wakefulness, these phenomena can arise only after the splitting of the psyche, as a result of which the alternation of wakefulness and the hypnoid state ceases and conditions are created for the coexistence of a complex of normal ideas and a complex of hypnoid ideas.
Do such hypnoid states occur long before the onset of the disease, and how does this happen? It is difficult for me to answer this question, since we can judge this only on the basis of observations of one and only patient, Anna O. In this case, the ground for self-hypnosis was undoubtedly prepared by the patient’s habit of daydreaming, and then with the assistance of affect, a persistent feeling of anxiety , the tendency to self-hypnosis has finally developed, because this affect alone is enough to put a person into a hypnoid state. It can be assumed that such a process always develops according to this pattern.
“Detachment” can be caused by a variety of conditions, but only some of them cause a tendency towards self-hypnosis or lead directly to it. The feelings of a scientist whose attention is focused on one issue atrophy to some extent, so he cannot consciously perceive many sensory sensations, just like a person who paints bizarre pictures in his imagination (just remember “my theater” by Anna O.). Nevertheless, a person in such a state spends the released nervous excitement by vigorously performing mental work. But when all thoughts scatter and a person falls into semi-oblivion, intracerebral excitement, on the contrary, causes drowsiness; a person plunges into a state bordering on drowsiness and turning into sleep. If, at the moment of such “prostration,” when the general flow of ideas is inhibited, consciousness is taken over by a certain group of bright, emotionally charged ideas, then there is an increase in intracerebral excitation, which can be used for conversion, since it is not used to perform mental work.
Therefore, “detachment” accompanied by energetic activity and semi-oblivion in the absence of affects are not pathogenic, in contrast to immersion in dreams imbued with affect, and fatigue caused by prolonged affect. Such conditions include melancholy, anxiety that engulfs someone who spends days and nights near the bedside of a loved one suffering dangerous disease, dreams and reveries of lovers. By focusing attention on a group of affective ideas, a person initially becomes “detached.” The flow of ideas moves more and more slowly and finally stops; however, the affective idea and the affect associated with it remain in force and cause an increase in excitation, which is not used to perform any functions. The described state undoubtedly resembles a hypnotic trance. If a person is to be put into a state of hypnosis, he should not fall asleep, in other words, the excitement in his brain should not decrease to the level at which sleep occurs, but it is necessary to cause him to inhibit the flow of ideas. Then the entire mass of excitation will be under the control of the suggested idea.
Most likely, some dreamy people can spontaneously plunge into a hypnotic state, when affect arises against the background of habitual dreams. Perhaps, including for this reason, the history of hysteria so often reveals two pathogenic factors that have crucial: falling in love and caring for the sick. Yearning for an unattainable lover, a person “withdraws into himself,” loses his sense of reality, his consciousness is taken over by passion, and all his thoughts freeze; the need to remain silent while caring for a patient, concentrating attention on one object, the need to listen to the patient’s breathing - all this creates almost the same atmosphere in which many methods of hypnosis are usually used, and causes a strong affect and a feeling of anxiety in the oblivious nurse. Perhaps such a state is inferior to self-hypnosis only in terms of the power of influence, but, in essence, it is no different from it and passes into it.
Having once plunged into a hypnoid state, a person begins to plunge into it every time he finds himself in a similar environment, as a result of which two natural mental states, wakefulness and sleep, are supplemented by a third hypnoid state, which is also observed if a person is often immersed in an artificial state. sleep under hypnosis.
I don’t know whether a person is capable of spontaneously plunging into a hypnoid state not only under the influence of passion, but also due to an innate tendency towards self-hypnosis, but I believe that this is quite possible. After all, the abilities of the sick and healthy people in this respect are so different and some of them are so easily amenable to artificial hypnosis that the assumption naturally arises that the latter are capable of immersing themselves in hypnosis spontaneously. Perhaps immersion in dreams cannot turn into self-hypnosis if a person does not have a predisposition to it. So, I do not at all intend to assert that the mechanism of the emergence of the hypnoid state, studied in the example of Anna O., operates in all hysterics.
I am talking about hypnoid states, and not about hypnosis itself, since it is extremely difficult to distinguish between these states, which have such a tangible impact on the development of hysteria. Perhaps immersion in dreams, which we called above the preliminary stage of self-hypnosis, and lingering affect in themselves can have the same pathogenic effect as self-hypnosis. At least it is known that fear has a similar effect. Inhibition of the flow of ideas, in which the consciousness is taken over by a vivid affective idea (of danger), makes the state caused by fear related to immersion in dreams imbued with affect; constantly remembering this event, a person again and again plunges himself into the previous state, as a result of which a “hypnoid state due to fear” arises, which allows for the conversion to be carried out or strengthened; This is sens, strict, 87 the incubation period of “traumatic hysteria.”
By calling “hypnoid” such seemingly different states that are equated to self-hypnosis on the basis of the similarity of their most significant features, we can identify their internal similarity and generalize the considerations outlined by Mobius in the article, excerpts from which were given above.
87 Sens, strict, (lat., abbr.) – in the literal sense.
However, this definition applies primarily to self-hypnosis, which contributes to the development of hysterical symptoms, since it favors conversion, does not allow the conversion of converted ideas, causing amnesia, and prepares the ground for the splitting of the psyche.
Since a certain somatic symptom is conditioned by an idea and occurs whenever the corresponding idea appears, intelligent patients capable of introspection would presumably pay attention to this relationship, knowing from experience that they only need to remember some incident when this somatic symptom immediately arises. Of course, the deep connection between cause and effect remains incomprehensible to them; however, any person knows what ideas make him cry, laugh or blush, even if he has no idea about nervous mechanism the emergence of these ideogenic phenomena. Sometimes patients really pay attention to such coincidences and realize that such a connection exists; for example, according to one woman, a mild hysterical attack (accompanied by tremors and rapid heartbeat) happened to her for the first time due to strong emotional excitement, and since then she has had tremors whenever some event reminds her of those experiences. But this does not happen with all hysterical symptoms. Most often, even reasonable patients do not notice that this or that phenomenon occurs after the idea, and take it for an independent somatic symptom. If things were different, psychic theory hysteria would have been created a long time ago.
Perhaps the symptoms that interest us are initially ideogenic, but repeated relapses, as Romberg puts it, “impose” them on the body, and from now on they no longer depend on the mental process, but on the changes that the nervous system has undergone during this time; in this way they gain independence and become real somatic symptoms. I would not dismiss this assumption out of hand, although, in my opinion, the results of our observations allow us to update the theory of hysteria precisely because they indicate that, at least very often, this assumption does not correspond to reality. We were convinced that all kinds of hysterical symptoms, which did not disappear for years, “disappeared once and for all when it was possible to clearly recall the motivating event in memory, thereby causing the affect that accompanied it, and when the patient described this event in detail as much as possible and expressed emotion in words." This statement is supported by some episodes from the case histories presented here. “To paraphrase the saying cessante causa cessat effectus, we may well conclude from these observations that the inciting incident (i.e., the memory of it) somehow continues to have an effect for many years, but not indirectly, not through intermediate links in the cause-and-effect chain, but directly, as the causative agent of the disease, like heartache, the memory of which in a state of waking consciousness causes tears for a long time: hysterics suffer for the most part from memories.”
But if the memory of the trauma really reminds foreign body, which, after penetrating inside, remains an active factor for a long time, although the patient himself is not aware and does not notice this memory at the moment of its appearance, then the fact of the existence of unconscious ideas and their influence on the human condition should be recognized. However, during the analysis of hysterical phenomena, we were unable to detect isolated unconscious ideas and were convinced of the correctness of the well-known and praiseworthy French researchers, who proved that large complexes of ideas and complex mental processes, which have great consequences, remain completely unconscious in many patients, although they coexist with conscious mental activity; In addition, we were convinced that patients experience a splitting of the psyche, the study of which is crucial for understanding the essence of hysteria and the complications it causes. Let us take a short excursion into this unexplored and difficult region; Since we need to clarify the meaning of the definitions expressed here, we hope that this circumstance will to some extent justify our abstract reasoning.
Notes
“For they are different and not alike in appearance // Hidden anger and bursting anger” - a quote from the tragedy “The Bride of Messina” by Schiller.
In the story about the barber Midas, who... shouted out the cherished word into the reeds... - according to one of the many myths about King Midas, Apollo ordered that Midas grow donkey ears as punishment for the fact that Midas, being a judge at a musical duel between the gods, gave preference to Pan. Since then, Midas always appeared in public wearing a special headdress that hid his donkey ears. This feature of the king became known to his barber, who swore to remain silent, but, pining with the desire to tell about what he saw, he dug a hole on the river bank and whispered into it: “King Midas has donkey ears!” Soon the secret of King Midas became known to everyone, since reeds grew in this place, in the rustling of which one could hear the words of the barber (SP.).
In Benedict's article, published in 1889 and reprinted in 1894 in the treatise “Hypnotism and Suggestion” ... - see note. 7.
In Mach's Kinesthesia... – Mach, Ernst (1838 – 1916) – an outstanding Austrian physicist, philosopher and psychologist. Mach's work entitled “Fundamentals of the Doctrine of Kinesthesia” was published in 1875 (Mach, Ernst. Grundlinien der Lehre von den Bewegungsempfindungen. Leipzig: Engelmann, 1875). Max, who headed the department of history and theory of inductive sciences at the University of Vienna in 1895, supported friendly relations with Breuer, who took part in his research on the functions vestibular apparatus. While studying experimental studies visual, auditory and motor perception, Mach designed a device for studying motor illusions (“Mach’s drum”) and developed a method for analyzing perceived motion, based on the fact that the subject’s eyelids were fixed with soft putty. Mach’s book, first published in 1886 and containing a description of these experiments, was also in Freud’s personal library (Mach, E.: Die Analyse der Empfindungen und das Verhaltnis des Physischen zum Psychischen. Jena: Gustav Fischer 1919; in Russian translation “Analysis of Sensations and the relationship of the physical to the mental,” 2nd ed., M., 1908). In 1886, Mach put forward the thesis according to which physical and mental phenomena have a single substrate - “neutral experience”, consisting of “elements of experience” (SP.).
Retention hysteria is a term from Freud and Breuer, the appropriateness of which Freud doubts already in “Studies on Hysteria”. Retention (lat. retentio - retention) in the psychotherapeutic sense involves retention of suggestion (V.M.).
The symptom... “overdetermined”... Here for the first time the concept “overdetermined” appears, which Freud actively uses in this book and further. Moreover, overdetermination in “Studies of Hysteria” is used both as a combination of various deterministic factors generating unconscious contents, and as a heterogeneity of unconscious elements arranged in various associative chains (V.M.).
I am obliged to Mr. Assistant Dr. Paul Karplus... - Karplus, Paul is Breuer’s colleague, Krafft-Ebbing’s assistant, since 1893 Anna von Lieben’s attending physician and the husband of her daughter Valeria (SI).
As Romberg puts it, they are “imposed” on the body... - Romberg, Heinrich Moritz (1795–1873) - an outstanding German neurologist, director of the hospital at the University of Berlin, author of the first systematic three-volume “Textbook of Human Nervous Diseases”, to which Breuer refers ( Lehrbuch der Nervenkrankheiten des Menschen. Berlin, Alexander Duncker, 1840–1846. S. 192). Two volumes of this textbook, which was recognized as a classic, were available in Freud's personal library (Romberg, Moritz Heinrich: Lehrbuch der Nervenkrankheiten des Menschen, Bd. 1–2, Berlin: Alexander Duncker 1840–46) (SP.).
At the end of the nineteenth century, the famous French neurologist Jean-Martin Charcot published the results of his experiments with a group of extremely interesting patients from a medical point of view and thereby gave new life concept of the interconnectedness of mind and body.
These people, called hysterics, showed severe neurological symptoms (for example, paralysis of an arm or leg) in the absence of neurological diseases. Imagine what an impression the demonstration of a hypnosis session made on a medical audience, during which a person’s paralysis disappeared!
Among the many doctors who visited the famous Charcot clinic was the Viennese neurologist Sigmund Freud. Now his name is known throughout the world thanks to his theory of the unconscious (or subconscious, if you prefer), which made it possible to deeply understand the motives of human behavior.
Alas, despite the fact that Freud began to write...
on this topic about a hundred years ago, most psychologists and psychiatrists still have little idea what subconscious emotional activity is and how it affects people’s behavior and feelings. This is sad, because the source of disorders such as muscle tension syndrome, stomach ulcers and colitis is the subconscious - their appearance is associated with suppressed emotions driven into it.
Freud became extremely interested in patients with hysteria and began working with them. He tried to find an answer to the question: why hypnosis temporarily relieves symptoms, but essentially does not cure. Freud eventually came to the conclusion that the pseudo-symptoms exhibited by hysterical patients, which he called symptoms of hysterical conversion, were the result of a highly complex subconscious process in which emotions were repressed and then released as physical symptoms. He believed that these symptoms carry a symbolic meaning and play the role of psychological relief.
Freud put forward the following idea: the process of suppressing painful emotions is a defense mechanism. However, he believed that the symptoms resulting from the action of such defense mechanism, there is nothing to do with violations affecting internal organs, such as the stomach and intestines. Be that as it may, Freud discovered that he could help many patients suffering from hysterical conversion using the psychotherapeutic method he invented - psychoanalysis.
The first psychosomatic theories are associated with psychoanalysis. Freud first of all argued that the mental and physical are interconnected. In addition, a mental pathogenic “agent” was indicated - affect, affective conflict, and a model of hysterical conversion was developed, which attributed to bodily disorders the function of symbolic expression of suppressed intrapsychic conflicts. Many psychoanalysts believed that all bodily symptoms (as well as neurotic ones) are a compromise way of discharging sexual energy, but this interpretation of hysterical conversion did not dominate psychosomatics for long.
Conversion theories have been criticized for absolutizing the role of symbolism. It is also noted that expressive symbolic functions can only be performed by those body systems that are under the control of the voluntary nervous system (primarily the sense organs). The concept of vegetative neurosis arose, however, and today a group of so-called conversion diseases is distinguished. The significance of this theory lies in the fact that for the first time, when explaining the mechanisms of development of somatic diseases, they turned to “intangible” psychological factors.
Alexander and Dunbar, whose names are associated with two fairly popular psychosomatic theories, opposed giving symptoms exclusively symbolic meaning. Doctor and psychoanalyst Alexander identified a group of psychogenic disorders in vegetative systems organism and called them autonomic neuroses. He believed that a symptom is not a symbolic replacement for a suppressed conflict, but a normal physiological accompaniment of chronic emotional states. Any emotional reaction that has not found a way out at the moment has its relatively clearly defined somatic equivalent. The specificity of the disease, in his opinion, should be sought in conflict situation. His model is therefore often called the "illness-specific psychodynamic conflict theory" or the "specific emotional conflict concept"
Alexander identifies three main forms psychogenic diseases: hysterical conversions, autonomic neuroses and psychosomatic diseases. Conflict resolution occurs only through vegetative pathways, and this causes the development of diseases such as hypertonic disease, ischemic disease heart disease, bronchial asthma, peptic ulcer, diabetes mellitus, thyrotoxicosis, rheumatoid arthritis, ulcerative colitis. Each disease is characterized by its own intrapsychic conflict, which corresponds to certain emotional experiences with their physiological correlates. For example, a patient with neurodermatitis suppresses the desire for physical intimacy, patients with peptic ulcer experience a conflict between the need for dependence, care and the desire for autonomy and independence.
All these diseases, according to Alexander, are multi-causal, that is, in their origin and development they have important many factors: birth injuries, illnesses infancy and physical injuries, emotional climate in the family, personal traits of parents, etc. He is absolutely right when he emphasizes that psychosomatics only adds some factors to those traditionally considered in medicine. But in reality he only considered psychological factors. Alexander’s theory did not have an answer to a number of questions: how is suppression related to regression? Why does a certain disease not occur in all people involved in an addiction conflict? etc. However, Alexander's ideas influenced psychosomatic medicine for several decades and even withstood some experimental tests.
A must for everyone!!!Dissociative (conversion) disorders
The clinical picture of dissociative and conversion disorders is manifested by somatic and mental symptoms. Somatic symptoms (often resembling a neurological disease) are characterized by a sudden and temporary change or loss of some bodily function as a result of psychological conflict (eg, psychogenic paralysis). Psychiatric symptoms are also closely associated with psychological conflict and are characterized by sudden onset and reversibility.
Conversion in this case means the replacement (conversion) of anxiety with somatic symptoms, which often resemble a neurological disease (for example, psychogenic paralysis).
Dissociation means the origin of symptoms from insufficient interaction between different mental functions and is manifested by symptoms of mental disorders (for example, psychogenic amnesia).
Alternative title This group of neurotic disorders is hysteria. The term “hysteria” is excluded from the American classification and ICD-10 as “compromising” and replaced by dissociation, conversion, histrionic personality disorder. Nevertheless, this term is widely used by domestic psychiatrists. In the American DSM-IV classification, the terms dissociative and conversion have different meanings: the concept of “conversion disorder” is used to define those psychologically determined disorders that are manifested by somatic symptoms; while dissociative disorders refer to disorders that involve psychological symptoms (eg, amnesia). In ICD-10, the terms “dissociative” and “conversion” disorders are identical.
Clinical picture
Dissociative (conversion) disorders are manifested primarily by symptoms of somatic and mental disorders caused by unconscious psychological mechanisms. The physical symptoms of this disorder are often similar to those of neurological diseases. Mental symptoms can easily be mistaken for other symptoms mental disorder, for example, dissociative stupor, which is also observed in depression and schizophrenia. Dissociative (conversion) disorders are not caused by somatic, neurological diseases, exposure to psychoactive substance, is not part of another mental disorder. The exclusion of somatic illness and other mental disorders is the main condition for diagnosing dissociative (conversion) disorders. There are two main problems in diagnosing these disorders.
1 .On initial stage disease, it is almost impossible to completely exclude somatic pathology that can cause dissociative (conversion) symptoms. Long-term observation of the patient and numerous diagnostic procedures (for example, MRI to rule out a brain tumor) are often necessary to make this diagnosis. In all doubtful cases, it is better to make a preliminary diagnosis of dissociative (conversion) disorder so as not to miss a serious somatic illness.
2 In many cases, it is difficult to determine whether the symptoms of a disorder are unconscious or conscious and intentional (deliberate reproduction of symptoms is called malingering in psychiatry). In most cases, simulation is observed in those under investigation, prison inmates, soldiers conscript service, as well as during conscription into the army. Patients with dissociative (conversion) disorder often consciously and deliberately exaggerate the unconscious symptoms of their illness. However, the diagnosis of this disorder assumes the existence of an unconscious component in the origin of symptoms.
