Judith Hamilton M.D., F.R.C.P. - Psychiatrist/Psychoanalyst - Freudian and Lacanian Orientation
PSYCHOANALYSIS             2 SEMINARS ON HYSTERIA                          Student Outlines

Hysteria I 

Core Concepts:
Conversion
Displacement
Erotogenic zone
Hysterical
Perversion
Phobic
Psychical trauma
Repression
Reproach
Sex, sexuality, sexual excitement
Somatic compliance
Symptom formation
Unconscious phantasy 

Summary of Freud's case of Dora   

Demonstrate the psychical processes and the organic determinants of hysteria.  Typical in a case of hysteria: 
    The history is indistinct, with gaps unfilled, riddles unanswered; disingenuousness, amnesias. 
    Taint of heredity 
    The father, a dominating figure, intelligent 
    The daughter was most tenderly attached to the father.
    The daughter's affection was increased by the father’s many severe illnesses. 
    The mother was described at uncultivated, foolish, by father and daughter. 
    Relations between the girl and her mother had been unfriendly for years. 
    The patient’s brother, 1 1/2 years older, was the model of her early ambitions; he was close to mother.   

Patient’s symptoms
Beginning age 8, subject to chronic dyspnoea  
The first onset – after a short expedition in the mountains; put down to “over-exertion”.  Regarding usual childhood illness, her brother would get it first, slightly, then she would get a
    severe form of it. 
Age 12 – 18 - unilateral migraine headaches, which grew rare, plus attacks of nervous
    coughing, tussis nervosa.  During the attacks, she developed a complete loss of voice.    During many investigations and treatments which had no benefit, she had grown to laugh at the
    efforts of doctors, to resist seeing another doctor.  Only the authority of her father got her
    to see Freud.  
 While 17, although intelligent, with engaging looks, the patient was low in spirits with an
    alteration in her character.  Fatigue, lack of concentration.   One day parents came across 
    a suicide note; then she had a loss of consciousness – subsequently covered by amnesia – and
    father brought her to Freud for treatment. 
 A case of petite hystérie with the commonest of somatic and mental symptoms.  No cutaneous
    sensitivities, no visual field disturbances. 
 In all cases of hysteria, Freud had found the psychological determinants postulated in the   Studies, namely, a psychical trauma, a conflict of affects, and, in 1896, a disturbance in the sphere of sexuality.  In this case too were all the determinants.   


History to Freud of the Presenting Illness 
Their family had formed an intimate relation with a married couple, Herr K and Frau K. 
 Frau K had nursed father during his long illness. (Dora was aged 12) 
 Herr K had been most kind to Dora – going on walks with her, giving her small presents.  
 Dora had taken care of the K’s two little children, being almost a mother to them.  
 
At age 16, Dora and her father traveled to visit the K’s who were spending their summer at a lake in the Alps.   Suddenly Dora insisted on going home with her father.  Some days later she told her mother that Herr K had had the audacity to make her a proposal while they were on a walk after a trip upon the lake.   She slapped his face before he finished and walked away.  The father confronted Herr K on their next meeting, but Herr K denied emphatically having made any advances which could have been open to such a construction.  He threw suspicion on the girl saying that he’d heard from Frau K that Dora took no interest in anything but sexual matters.  

Father considered that this incident, which he did not believe took place, was responsible for Dora’s depression and irritability and suicidal ideas.  She kept pressing him to break off relations with Herr K and more particularly with Frau K, whom she used to worship formerly.  Father could not do this. Father explained to Dora that he "gets nothing" out of his own wife.  Dora had her last attack after one of these conversations pressing him to break off with them.  Father wanted Freud to “bring her to reason”.  Freud noted that at other times, father blamed Dora’s impossible behaviour on mother’s peculiarities.   

Freud's Discussion 
 This experience with Herr K would seem to be the psychical trauma that is the indispensable prerequisite for the production of a hysterical disorder.  However, it does not explain or determine the particular character of the symptoms.  Also, some of the symptoms had appeared in the patient years before the trauma, since age 8.  Hence must look earlier for influences or impressions which might have had an analogous effect. 
 
Dora described an earlier episode with Herr K, when she was 14 - he suddenly clasped her to him and pressed a kiss upon her lips.  Freud thought that this should have called up sexual excitement in Dora, but Dora felt violent disgust, tore herself from Herr K, and hurried out.  She continued to meet him and neither spoke of it again.  Nor did she tell anyone else until Freud.  However, she avoided being alone with Herr K., and refused to go along with the K.’s on an expedition, which was to last for some days. 
Thus, at 14, Dora was already hysterical – Freud considers a person hysterical in whom an occasion for sexual excitement elicited feelings that were preponderantly or exclusively unpleasurable, whether or not the person were capable of producing somatic symptoms.  This he called a reversal of affect -  As well she had a displacement of sensation, from the genital to the mucous membrane of the alimentary tract (disgust).  (She had always been a poor eater and had a disinclination for food.)  She had a sensory hallucination (during the telling of her story) of the pressure on her upper body of Herr K’s embrace. 
 
Another symptom – Dora was unwilling to walk past any man whom she saw engaged in eager or affectionate conversation with a lady.  Freud postulated that during the embrace, she had felt the pressure of the man’s erect member (sic) against her body; this was revolting to her, it was dismissed from her memory, repressed, and replaced by the innocent sensation of pressure upon her thorax – a displacement upward from the lower part of the body.  She avoided any man who she thought was in a state of sexual excitement because she wanted to avoid seeing for a second time the somatic sign which accompanies it. 
 
Three symptoms and their theorized causes: Disgust is the symptom of repression in the erotogenic oral zone which had been over-indulged in Dora’s infancy by the habit of sensual sucking.  The excitement of the second erotogenic zone, her clitoris, was referred by a process of displacementto the thorax and became fixed there.  She was phobic with respect to seeing a sexually excited man.   
The patient consciously felt done with Herr K, but she was angry at her father for what she took to be his love-affair with Frau K.  She had detailed memories of many occasions, ever since she was 12, that confirmed this view.   Overcome by the idea that she had been handed over to Herr K by her father as the price of Herr K's tolerating the relations between Dora's father and Herr K's wife.  Her father would have been horrified at any such suggestion, but he was one of those men who know how to evade a dilemma by falsifying their judgement upon one of the conflicting alternatives.  Father would have denied that anything untoward was happening between Herr K and his daughter.  Thus it was possible for Herr K to send Dora flowers every day for a whole year while he was in the neighbourhood, to take every opportunity of giving her valuable presents, and to spend all his spare time in her company, without her parents noticing anything in his behaviour that was characteristic of love-making.   

A string of reproaches against other people leads one to suspect the existence of a string of self-reproaches with the same content. For example, while Dora was very critical of her father’s not wanting to look too closely into Herr K’s behaviour to his daughter, for fear of being disturbed in his own love-affair with Frau K, Dora had done the same thing for years – giving every possible assistance to her father’s relations with Frau K. Dora did not at first or completely assent to Freud’s interpretation that she had for all these years been in love with Herr K.        
Dora’s second reproach against her father was that he exploited his illness for his own purposes, but she did the same, for example regarding developing gastric pains in identification with her female cousin (whom Dora thought of as a malingerer, who had gastric pains to be able to leave home where she felt envious of her younger sister’s engagement).  She knew that Frau K used illness whenever her husband returned home to be able to escape the conjugal duties which she detested.  And Dora herself had developed periods of “aphonia” when Herr K was away from home.   
 
Hysterical symptoms involve the participation of both somatic and psychical functions.  There must be a degree of somatic compliance offered by some normal or pathological process in or connected with one of the bodily organs. The hysterical symptom does not carry meaning; meaning is lent to it, soldered to it, as it were; and in every instance the meaning can be a different one, according to the nature of the suppressed (unconscious) thoughts, which are struggling for expression.   
The clearing up of a symptom is achieved by looking for its psychical significance; but also it is useful to indicate the organic factor that was the source of the “somatic compliance” that enables the meaning to be expressed.  This factor is essential for the hysterical symptom of conversion to take place.   
 
Primary gain of illness – falling ill involves a saving of psychical effort.
Secondary motives of illness  (or external primary gain) – serves as a resistance to recovery. Question of malingering – a reproach which Dora brought against her father.  Freud told her that she had a motive similar to that of Frau K – to detach her father from Frau K – either out of fear (her suicide note), or out of pity (her fainting fits) or, if all this failed, get her revenge on him. 
Reproach against father for not believing her story about Herr K; what is the corresponding self-reproach?  Also, why did she respond so negatively after having given Herr K many signs of affection over the years?  

The reproach and her cough continued. A symptom signifies the representation – the realization – of a phantasy with a sexual content; it signifies a sexual situation; that is, at least one of its meanings, because it will have many unconscious meanings.  It is not necessary for the various meanings of a symptom to be compatible with one another.  A symptom may also be used to express successive meanings over a number of years.            
The cough represented her unconscious picturing to herself the nature of the sexual act between her father (whom she knew to be impotent) and Frau K. It is typical of a hysteric that they know a lot about sexuality without knowing that they know it (i.e. unconsciously) or how they came to know it.  It is necessary to speak of sexual things with a hysteric: ‘pour faire une omelette il faut casser des œufs.’  There is never a danger of corrupting an inexperienced girl, for where there is no knowledge of sexual processes even in the unconscious, no hysterical symptom will arise, and where hysteria is found there can no longer be any question of ‘innocence of mind’ regarding sexual matters.
 
All psychoneurotics are persons with strongly marked perverse tendencies which have been repressed in the course of their development and have become unconscious.  Consequently their unconscious phantasies show precisely the same content as the documentarily recorded actions of perverts.  Psychoneuroses are, so to speak, the negative of perversions.  They continue in their unconscious the undifferentiated sexual disposition of every child.   
 
Example of symptom formation:  Dora could remember a scene from her early childhood in which she was sitting on the floor in a corner sucking her left thumb and at the same time tugging with her right hand at the lobe of her brother’s ear as he sat quietly beside her.  The mucous membrane of the lips and mouth is to be regarded as a primary “erotogenic zone”, which is preserved in the act of kissing.  An intense activity of this erotogenic zone at an early age thus determines the subsequent presence of a somatic compliance on the part of the tract of mucous membrane which begins at the lips.  At a time when the sexual object proper, the male organ, has become known, circumstances may arise which once more increase the excitation of the oral zone, whose erotogenic character has been retained.  Substitute the sexual object of the moment (the penis) for the original object (the nipple) or for the finger which does duty for it, and you place the current sexual object in the situation in which gratification was originally obtained.  In most instances a cow’s udder has aptly played the part of an image intermediate between a nipple and a penis.   



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