NEUROSIS

In the ætiology of the obsessional neurosis sexual experiences in early childhood play the same part as in hysteria; it is here, {162} however, no longer a question of sexual passivity, but rather of aggressive acts performed with pleasure and of pleasurable participation in sexual acts---of sexual activity, therefore. This difference in the ætiological conditions explains why the obsessional neurosis appears to favour the male sex.

In all my cases of obsessional neurosis I have, moreover, found a _substratum of hysterical symptoms_ which can be traced back to a scene of sexual passivity of earlier date than the pleasurable activity. I surmise that this coincidence is a regular one and that early sexual aggressivity always implies a previous experience of seduction. Nevertheless, I can as yet give no complete presentation of the ætiology of the obsessional neurosis; I simply have the impression that the decision whether hysteria or obsessional neurosis will arise on the basis of the infantile traumas depends on _temporal_ factors in the development of the libido.

The nature of the obsessional neurosis permits of description in a simple formula:---Obsessions _are always reproaches re-emerging in a transmuted form under repression_---_reproaches which invariably relate to a sexual deed performed with pleasure in childhood_. To illustrate this statement it will be necessary to give a description of the typical course of an obsessional neurosis.

In the first period, that of childish immorality, occur the experiences containing the germ of the neurosis which develops later; first of all in very early childhood the experiences of sexual seduction that make subsequent repression possible, then the deeds of sexual aggression against the opposite sex which appear later as acts to which self-reproach becomes attached. {163}

This period is brought to a close by the onset of sexual 'maturity', often itself premature. No self-reproach becomes connected with the memories of those pleasurable activities, and the relation with the initial passive experience makes it possible to repress them and substitute for them a _primary defence-symptom_---often only after conscious and remembered efforts. Conscientiousness, shame and self-distrust are the kind of symptoms which introduce the third period, that of apparent health, or better, that of _successful defence_.

The next period, that of illness, is distinguished by the _return of the repressed memories_, i.e. by failure of the defence; it is doubtful whether the awakening of these memories usually occurs accidentally or spontaneously or as a kind of by-product in consequence of current sexual disturbances. The re-animated memories and the self-reproach which is built up on them, however, never appear in consciousness unchanged. The obsessional idea and the obsessive affects which appear in consciousness and take the place of the pathogenic memory in conscious life are _compromise-formations_ between the repressed and the repressing ideas.

In order to describe clearly and with probable accuracy the processes of repression, the return of the repressed, and the formation of pathological compromise-ideas, one must resolve upon quite definite concepts in regard to the substratum underlying mental processes and consciousness. So long as one avoids this one must be content with the following rather figurative remarks: There are two forms of the obsessional neurosis, according to whether the memory-content alone of the deed which evokes reproach has forced itself into consciousness, or whether the affect of reproach attaching to it is also present. To {164} the first class belong the typical cases of obsessional ideas, in which the patient's attention is directed to the content, an indefinite affect of discomfort merely being felt, whereas the affect of self-reproach would alone be suited to the content of the obsessional idea. The content of the obsessive act in childhood is changed in a twofold manner before it emerges as an obsessional idea: first, something present is substituted for something past, secondly, something sexual is replaced by something analogous but not sexual. Both these alterations are the effect of the tendency to repression, still in operation---a tendency which we should ascribe to the 'ego'. The influence of the reanimated pathogenic memory is shown by the fact that the content of the obsessional idea is still partly identical with what is repressed, or is derived from it by means of a logical train of thought. If one reconstructs by means of the psycho-analytic method the development of a single obsessional idea one finds that two different trains of thought have been stirred by a recent impression; the one which proceeds _via_ the repressed memory proves to be as correctly and logically formed as the other, although it is incapable of becoming conscious and is insusceptible of correction. If the results of the two psychical operations do not harmonize what happens is not a logical reconciliation of the contradiction between the two, but instead, alongside the normal thought-process, there appears in consciousness, as a compromise between the resistance and the pathological thought-process, an apparently absurd obsessional idea. If both trains of thought point to the same end they reinforce each other, so that we find a normally developed thought-process now behaving psychically like an obsessional idea. _Wherever a neurotic compulsion makes its appearance in {165} psychical life it arises in repression_. Obsessional ideas have, so to say, a forced currency psychically, not on account of their intrinsic value, but on account of the source from which they arise or which has furnished a contribution to their value.

The second form of obsessional neurosis comes about if what has compelled representation for itself in conscious mental life is not the repressed memory-content but the self-reproaches that are likewise repressed. The affect of reproach can with the aid of some psychical reinforcement transmute itself into any other unpleasant affect; when this has happened there is nothing to hinder the substituted affect any longer from becoming conscious. Thus _self-reproach_ (for having performed a sexual deed in childhood) can easily transform itself into _shame_ (lest another person should come to hear about it), into _hypochondriacal anxiety_ (lest some bodily injury should result from the action which evoked the self-reproach), into _dread of the community_ (fear of punishment by the world at large for the lapse), into _religious anxiety_, into _delusions of reference_ (dread of betraying the deed), into _dread of temptation_ (justified mistrust in the personal strength of moral resistance), and so on. Together with this the memory of the deed which evokes reproach may either be represented in consciousness too, or be completely withheld---a fact which renders exact diagnosis much more difficult. Many cases which on superficial examination would be regarded as ordinary (neurasthenic) hypochondria belong to this group of obsessional affects; so-called 'periodic neurasthenia' or 'periodic melancholia' in particular appears to be reducible with unexpected frequency to obsessional affects and obsessional ideas---a recognition that is therapeutically {166} by no means unimportant.

In addition to these compromise-symptoms, which signify the return of the repressed and consequently a collapse of the defence originally aimed at, the obsessional neurosis forms a series of further symptoms quite different in origin. The ego seeks to ward off those derivatives of the original repressed memory and in this struggle for defence creates symptoms which may be grouped together as '_secondary defence_' symptoms. These are all '_protective measures_' which had already performed good service in the struggle with the obsessional ideas and affects. If these aids to defence are really successful in once more repressing the symptoms due to the return of the repressed which have been forced upon the ego, then the compulsion is transferred to the protective measures themselves and creates a third form of 'obsessional neurosis'---that of _obsessive actions_. These are never primary, never anything but defensive; they never contain anything of an aggression; psychical analysis of them shows that---in spite of all their oddity---they are to be fully explained by tracing them back to the obsessive memory which they are combating.

To take one example only: an eleven-year-old boy had instituted the following obsessive ceremonial before going to bed. He did not sleep until he had told his mother in the minutest detail all the events of the day; there must be no scraps of paper or other rubbish on the carpet of the bedroom; the bed must be pushed right up to the wall; three chairs must stand by it and the pillows must lie in a particular way. In order to get to sleep he himself must first kick out a certain number of times with both legs and then lie on his side.---This was explained in the following manner: years before a servant-girl who had {167} to put the handsome boy to bed took the opportunity of lying upon him and abusing him sexually. Later on when this memory was awakened by a recent experience, it manifested itself in consciousness in the form of a compulsion to perform the ceremonial described; its meaning was easily guessed and was established point by point by means of psycho-analysis: the chairs by the bedside and pushing the bed against the wall---so that no one could later come near the bed; the pillows arranged in a certain way---so that they should be arranged differently from the way they were on that evening; kicking the legs---pushing away the person lying on him; sleeping on his side---because in the scene he lay on his back; the circumstantial confession to his mother---because he had concealed from her this and other sexual experiences in obedience to his seductress; finally, keeping clean the floor of his bedroom---because this was the principal reproach that he had previously had to endure from his mother.

Secondary defence against obsessional ideas may be brought about by an enforced diversion on to other thoughts, in content as different as possible; therefore when this succeeds _obsessive speculating_ results and the thoughts are regularly occupied with abstract, transcendental topics, because the repressed ideas were always of a sensual kind. Or else the patient tries to master each particular idea by logic and by appeals to his conscious memory; this leads to _obsessive thinking_, the _compulsion to test everything_, and to _folie du doute_. The patient's preference for perception over memory in making these tests first leads him, and later compels him, to amass and preserve all objects with which he comes into contact. Secondary defence against {168} the obsessional affects calls into being a still wider series of protective measures, which may be transformed into obsessive acts. These may be grouped according to their tendencies: _penitential_ measures (burdensome ceremonials, the observation of numbers) _precautionary_ measures (all kinds of phobias, superstitions, pedantry, exaggeration of the primary symptom of conscientiousness), _dread of betrayal_ (collecting paper, misanthropia), _hebetude_ (dipsomania). Among these obsessive actions and impulses the phobias play the greatest part in circumscribing the patient's life.

There are cases in which one can observe the way in which the compulsion transfers itself from the idea or from the affect on to the defensive measure; others in which the compulsion oscillates periodically between the symptom due to the return of the repressed and the symptom of secondary defence; and still other cases in which no obsessional idea is formed at all, but in which the repressed memory is replaced forthwith by the apparently primary defensive measure. The stage which is otherwise attained only after a defensive battle and which concludes the development of an obsessional neurosis is here reached in one leap. Severe cases of this disease end in the obsessive ceremonial becoming firmly established, in a general _folie du doute_, or in an eccentric way of life conditioned by phobias.

That the obsessional idea and all its derivatives find no credence is probably due to the fact that the defence-symptom of _conscientiousness_ is formed at the onset of repression, and that this symptom has a similar obsessional value. The certainty that a moral life has been lived throughout the whole period of successful defence makes it impossible to give credence to the self-reproach involved in the obsessional idea. Only transitorily, upon the {169} appearance of a new obsessional idea or now and then in a condition of melancholic exhaustion of the ego, do the morbid symptoms of the return of the repressed compel belief. The 'compulsion' of the psychical productions here described has in general nothing to do with belief in them and is also not to be confounded with that factor which one designates as the 'strength' or 'intensity' of an idea. Its essential character is rather its insolubility through conscious psychical activity, and this character undergoes no change whether the idea to which the compulsion adheres is strongly or weakly, more or less intensely, 'suffused', 'endowed with cathexis', and so on.

The cause of this invulnerability of the obsessional idea or its derivatives, however, is only its connection with the repressed memory of early childhood; for if it is possible to succeed in making this connection conscious---and psycho-therapeutic methods appear to be already competent to do so---we find that at the same time the compulsion is removed.