Judith Hamilton M.D., F.R.C.P. - Psychiatrist/Psychoanalyst - Freudian and Lacanian Orientation
Hysteria I

TEACHING NOTES

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

Required Reading 
Freud, S. (1905a) Fragment of an analysis of a case of hysteria.  Standard Edition 7: 3-122. 

Supplementary Reading 
Glenn, Jules  (1980) Freud's Adolescent Patients: Katharina, Dora and the "Homosexual woman", in Freud and His Patients.  Edited by Mark Kanzer and Jules Glenn.  Jason Aronson, New York, London.  
 
Notes from Jules Glenn regarding the Dora case
 
Written at the time of the topographic theory: Cs. Precs. Uncs
Prior to the complete articulation of the libido theory in 1905.  Refers to only the oral components, not the anal or phallic.
Aggression was considered to be part of the libido, not a separate drive.
The conflict was seen as occurring between the conscious and the unconscious.  The task of analysis is to make the unconscious conscious.
The ego and self were vaguely defined and were associated with the conscious aspects of mind.
Combines material useful for diagnosis of hysteric neurosis with the construction of dreams and how to analyze them.
Most defensive activity was called repressionConversion was identified as a defense.  Other defenses are clearly present: projection, externalization, reaction formation (reversal of affect), displacement of sensation, regression to infantile (oral) modes of relating, identification, identification with the aggressor, idealization/devaluation, splitting.
Does not take into consideration features specifically linked to her being an adolescent.
 
Fragment of an analysis of a case of hysteria  

From introduction - Freud analyzed Dora for 3 months, from October 1900 to December 1900.  Wrote up the case in January 1901.  Did not have it published until 1905, for reasons of confidentiality.  It was originally called Dreams and Hysteria.             
Real name of patient: Ida Bauer.  She was the daughter of a Marxist philosopher who had consulted Freud.             
Important dates and ages: pp. 5-6.            
Described this as an ordinary case, a case of petite hystérie, in contrast presumably to a grande hystérie.             
Freud said he excluded technique from the report.  However, technique is implied and he said later that his technique likely influenced the premature ending.  He changed his technique after this to less forced interpretation, more attention to the transference as resistance.   

Prefatory Remarks: 1895 and 1896 – pathogenesis of hysterical symptoms and mental processes occurring in hysteria, in Studies on Hysteria (Breuer and Freud, 1895), and The Aetiology of Hysteria (Freud 1896c).  (Also in The Project, 1895) 
Hysterical disorders involve the intimacies of people’s lives – their sexual lives; hysterical symptoms are the expression of their most secret and repressed wishes.  Use frankness; call the organs and functions of sexual life by their proper names. 
A thorough investigation of the problems of dreams is an indispensable prerequisite for any comprehension of the mental process in hysteria and the other psychoneuroses. A single case cannot provide all the answers to this disorder.   

The Clinical Picture  Demonstrate the psychical processes and the organic determinants of hysteria. Particularly in a case of hysteria: 
The history is indistinct, with gaps unfilled, riddles unanswered; connections incoherent, sequence of events uncertain and changeable.  
There is conscious disingenuousness (holding back due to timidity, shame or discretion), unconscious disingenuousness (part of their knowledge disappears at the time of telling), true amnesias, paramnesias formed secondarily to fill in those gaps (e.g. alter the chronological order of events; doubts express the first stage of repression).  Only towards the end of the treatment do we have an intelligible, consistent, and unbroken case history.  We have repaired the damage to the patient’s memory. 
Because of the nature of the facts that form the material of psycho-analysis, we are obliged to pay as much attention in our case histories to the purely human and social, especially family, circumstances of our patients as to the somatic data and the symptoms of the disorder. 

Features in the history that are typical of the hysteric
 
The father, who was in his late 40’s when he brought the girl, of this 18-year-old girl was the dominating figure in the circle, owing to his intelligence and his character as much as to the circumstances of his life; unusual activity and talents, a large manufacturer in very comfortable circumstances. 
The daughter was most tenderly attached to the father, and for that reason her critical powers, which developed early, took all the more offence at many of his actions and peculiarities.  This affection was increased by the many severe illnesses which he had been through since her sixth year.  (E.G. tuberculosis, which required a move to a small town in a good climate).  
When the girl was 10, father had to go through a course of treatment in a darkened room on account of a detached retina; his vision was permanently impaired.  His gravest illness was when she was 12 – a confusional attack, followed by symptoms of paralysis and slight mental disturbances.  Herr K brought him to see Freud in Vienna who diagnosed a diffuse vascular infection for which Freud prescribed an anti-luetic treatment.  Father had had a specific infection before his marriage.  Thus, constitutionally, Dora was the daughter of a male parent with syphilis. 
Father brought his daughter to meet Freud first when she was 16; Freud described her as “unmistakably neurotic”.  
Taint of heredity: Father’s older sister – severe form of psychoneurosis, not characteristically hysterical.  Father’s older brother – a hypochondriacal bachelor.  Daughter “took after” and was sympathetic to father’s side of the family. 
Mother was described as uncultivated, foolish, by both father and daughter, with “housewife’s psychosis", concentrating all her interests upon domestic affairs, especially since her husband’s illness and the estrangement to which it led.  Relations between the girl and her mother had been unfriendly for years.  The daughter looked down on her mother and criticized her mercilessly; she had withdrawn completely from mother's influence. 
The patient’s brother, 1 1/2 years older, was the model of her early ambitions, but later their relation became distant.  He was close to mother.   

Patient’s symptoms:  beginning age 8, subject to chronic dyspnoea with occasional episodes in which the symptom was very much aggravated.  
The first onset – after a short expedition in the mountains; put down to “over-exertion”.  Rested and looked after for six months and it left.  Family doctor diagnosed it as “nervous”.  Regarding usual childhood illness, her brother would get it first, slightly, then she would get a severe form of it.             
Age 12 – unilateral migraine headaches plus attacks of nervous coughing, tussis nervosa, likely started originally by a common catarrh.  The headaches became rare but the coughing continued.  By age 18, the attacks lasted from three to five weeks, on one occasion for several months.  During the attack, she developed a complete loss of voice.  All “nervous”.             
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 at 16.  She declined psychological treatment then, since the prolonged attack passed off spontaneously.             
While 17, although intelligent, with engaging looks, the patient was low in spirits with an alteration in her character.  Fatigue, lack of concentration.  Not satisfied with herself nor her family; unfriendly to her father; very bad terms with mother who tried to get her to share housework; avoided social intercourse.  Attended lectures for women and tried to carry on her studies.  One day parents came across a suicide note, saying she could no longer endure her life; 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.   

Family History 
Dora's 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) and had thus earned his undying gratitude.  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.  Dora was to have spent several weeks there while father returned home after a few days.  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.  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, reading a book on the Physiology of Love and others at the lake. Father considered that this incident was responsible for Dora’s depression and irritability and suicidal ideas.  
Dora kept pressing her father to break off relations with Herr K and more particularly with Frau K, whom she used to worship formerly.  Father could not do this.  He believed that Dora’s tale was a phantasy that had forced its way into her mind, and he was bound to Frau K by ties of honourable friendship and he did not wish to cause her pain.  He was Frau K's only support; she was nervous and disappointed in her husband.  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 brought Dora to Freud, wanting him to “bring her to reason”.  Freud noted that at other times, father blamed Dora’s impossible behaviour on mother’s peculiarities.   

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 arranged that the girl should be alone with him at his place of business; he closed the shutters and just as they were to leave, 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 him, 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 considered 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 reversal of affect is one of the most important and at the same time one of the most difficult problems in the psychology of the neuroses.  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 the pressure on her upper body of Herr K’s embrace. 

Another symptom – she 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 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: 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 displacement to the thorax and became fixed there.  She was phobic with respect to seeing a sexually excited man. Freud postulated that disgust arises from the association of the genitals with the site and smell of the excretory functions.  The subject of erection solves some of the most interesting hysterical symptoms, as does the outlines of men’s genitals as seen through their clothing.   

The patient consciously felt finished 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.  She was very critical of her father’s falseness, and, when embittered, she used to be 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 her father and his 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.  There is something automatic about this method of defending oneself against a self-reproach by making the same reproach against some one else.  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.  In spite of the affair being pointed out by a governess, Dora remained devoted to Frau K and would hear of nothing that might make her think ill of Frau K's relations with her father.  On the other hand she readily deduced that the governess was in love with her father.  She was amused until the time it occurred to her, because of the governess’s indifference to her, that the governess just used her to get closer to her father.  Dora had been similarly affectionate with Herr K’s children, which had provided a bond between her and Herr 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 cousin (whom Dora thought of as a malingerer, who developed 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.   It cannot occur more than once unless it has a psychical significance, a meaning.  (The capacity for repeating itself is one of the characteristics of a hysterical symptom.)  The hysterical symptom does not carry this meaning; the 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 a hysterical symptom to take place, a conversion.   

Primary gain of illness – falling ill involves a saving of psychical effort; economically the most convenient solution where there is a mental conflict. (flight into illness).  This is the internal primary gain.  There may be a desire for self-punishment because of remorse. 

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.    She had 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 him 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 production of a symptom such as conversion is so difficult, the translation of a purely psychical excitation into physical terms, it depends on the concurrence of so many favourable conditions, that an impulsion towards the discharge of an unconscious excitation will so far as possible make use of any channel for discharge which may already be in existence.             
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. An analyst should be dry and direct when speaking about these things. 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.   
For example 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.  


Hysteria II   
 
Required Reading
Easser, Barbara Ruth and Stanley R. Lesser (1965) Hysterical personality: a re-evaluation.  Psychoanal. Q. 34:390-405.
Halberstadt-Freud, Henrika C. (1996) Studies on hysteria.  Int. J. Psycho-Anal. 77:983-996.
Reich, Wilhelm (1972 [1945])  The hysterical character, in Character Analysis.  Touchstone. Simon and Schuster, New York.  204-209.
 
Supplementary Reading
Bollas, Christopher  (2000) Hysteria.  Routledge, London and New York.
Laplanche, J. (1974) Panel on 'Hysteria Today'.  Int. J. Psycho-Anal. 55:459-469.
Nasio, Juan-David (1998{1990}) Hysteria from Freud to Lacan: The Splendid Child of Psychoanalysis.  Translated by Susan Fairfield.  The Other Press, Llc.  New York.
 
OUTLINE
1. Review what Freud’s conclusions were –
2. Reich’s description and dynamics
3. Important additional points from the assigned papers – Easser and Lesser, Halberstadt-Freud; dream fragment.
(4. Additional points from supplementary or other readings)
(5. Lacan’s understanding of the dynamics – Seminars V and XVII)

SESSION
 
1. Freud’s conclusions about the Dora case:
Freud interpreted her unconscious love attitudes to Herr K.  She rejected this for a time, but finally acquiesced.
But she left the treatment prematurely.
Freud considered it was because he misunderstood the nature of her transference (that she had the same feelings for Freud) and therefore did not take account of it/interpret it.  He thought she must have got angry at what she perceived as his rejection of her.
Later, he came to believe that he had missed the homoerotic aspect of her relation to Frau K, and that she was identifying with the men in this love.  This would be a negative Oedipal configuration.
Later authors have noted that Freud did not understand his complementary counter-transference and his enactment that supported her transference.
Lacan thought that Dora’s interest in Frau K was not as a sexual object but as an object for identification, to learn from her how to be a woman.
 
2. Reich’s description and dynamics
Written in 1933.  No structural theory; psychosexual phases were used, first anxiety theory.  Concept of character armour as formed by defenses against both internal and external stimuli; the external form of this armouring is always historically determined, affected most by the person most responsible for the child’s upbringing.  Also important is the stage of development in which the instinctual apparatus meets its most crucial frustration.

The hysteric (most often women but can be men) has an importunate (pressing, persistent) sexual attitude.

What is apparent: 
   She has a physical agility, with a sexual nuance (This disappears with successful treatment.)    
   She has a light step and gait; is lilting and supple, coquettish, easily excited, with a shyness and anxiousness.  In men it is seen as softness, excessive politeness, with a feminine facial expression, and feminine bearing.

What is hidden: She has a fickleness in attitude, a strong suggestibility leading to compliance, with strong reactions of disappointment leading to devaluation.
    She has the sexual attachment of a childish nature (sweet, innocent), using imagination and pseudologia.
         Her fantasies are experienced and grasped as real experiences.
         Psychic conflicts are expressed in somatic symptoms.

Psychodynamically: she has a fixation at the genital phase and a genital inhibition.  She retains a strong incestuous attachment and although these ideas are repressed, they are in full possession of their cathexis.
         She has strong genital aggression as well as anxiety.
         Other qualities (orality, anality) are allied with the genital, e.g. mouth, anus represent to her the female genital organ.
     She has severe sexual disturbance due to an acute stasis of unabsorbed genital libido.  She is overladen with unabsorbed sexual tension.  Her armouring entails an anxious ego defense against the genital incest striving.
     Her genital sexuality places itself at the service of its own defense; that is, she uses sexuality as a defense.  The more anxiety-ridden her attitude as a whole is, the more urgent the sexual manifestations appear.  She has exceptionally strong, ungratified genital impulses that are inhibited by genital anxiety.   In the transference, she does not recognize the meaning of her sexual behaviour, being shocked by the “insinuation”.
     She always feels at the mercy of dangers that correspond to her infantile fears.  She uses sexuality to explore for the source, magnitude, proximity of the danger, then runs or controls it somehow.  If a hysterical woman displays strong sexuality, it’s wrong to assume she’s expressing genuine sexual willingness.
     During depressive reactions, she regresses easily to oral mechanisms.  The mouth offers stasis because it attracts genital libido in an upward displacement.
     She has little interest in sublimations or intellectual accomplishments (she is so preoccupied with her objects).  Nor does she manifest reaction formations.  Her sexual energy does not mature and become bound, as in the obsessional; rather it is discharged into somatic innervations (e.g. conversions) or in fear and anxiety.  Fully developed genital excitations are ill-suited to purposes other than direct gratification.
 
3. Easser and Lesser in Hysterical personality: a re-evaluation.  Psychoanalytic Q. 1965.
Reasons for the decline of interest in hysteria –
         1.Repeated inconsistency in the ability of the psychoanalytic method to reverse the course of the hysterical symptoms.
         2. Changed presentations of patients.  More study of the obsessive modes of dealing with neurotic conflict.
         3.  Shift of interest from effects of single traumatic event to the complex methods of the psyche to cope with anxiety; has resulted in a shift in emphasis from fantasy (the hysteric’s preferred mode) to defense.
         4. The name is enmeshed with its popular meaning.
         5. Although hysterics are considered to have reached the highest libidinal level for neurotic fixation, the difficulties of treating them has led to their disparagement.
Includes diagnostic groups of conversion hysteria, phobic reaction, fugue states, and hysterical character.  
Easser and Lesser studied 6 female patients with hysteric character.

Differences from Reich's findings:
All showed good to superior performances academically and occupationally.  Buoyant, sprightly, lively and energetic; not flamboyant, dramatic, provocative, seductive, exhibitionistic, highly styled.  They showed concern over sexual behaviour and a  real or imagined sexual object; there had been the shattering of a romantic fantasy.

Findings of Easser and Lesser:
         1. Unconsciously motivated to compete with women, to seduce and conquer men, and to achieve security and power vicariously through the passionate engagement of the man with themselves.  Their fantasies usually involved an irresistible, magnetic body that was to be exhibited to conquer the male and exclude all other women.  Pure wish fulfillment, not masochistic.
         2. Social shyness and apprehensiveness were contrasted with active social involvement.  Long-term good friendships.  However, failed to gain confidence after repeated success.  Severe feelings of humiliation and shame should rejection occur.  Sense of family and friends was strong.  Changed when in the presence of mother, becoming inhibited, juvenile, inefficient, dependent, cute and lovable.

Each was profoundly involved with their father who was dynamic and seductive, but who rejected them at puberty and/or were jealous of their boyfriends.  Their mothers were consistent and responsible and wanted their daughters to live out mother's frustrated romantic fantasies.  Dressed them prettily.

There is major conflict when the gratification of physical sexuality is inhibited and repressed.  Romance then preoccupies and invades every area of functioning.  Remain fixated to their fathers; mother seems uninteresting and ridiculous.  Unable to acknowledge their envy of mother’s feminine abilities.  Also envious of father’s purported physical attributes which substitutes for the forbidden sexuality.

Labile emotionality – the predominant use of feelings rather than thought in crises and conflicts.

Direct and active engagement with the human world.  Hypersensitive to others; afraid of any sign of rejection (e.g. criticism), affectionately interested in their self (love analysis); egocentric need to test love results in emotional upheavals.

Responds badly to frustration but also to over-excitability.  As tension mounts, she responds with anxiety and flight.

A close relationship between excitability and its derivative fantasy; romantic.

Suggestibility – these have a defense against suggestibility.  Rather, suggestibility occurs more often in the object toward whom the emotionality of the hysteric is directed.  The hysteric receives the suggestion she has already planted in the other, confirming her preference all along.

Dislike of the exact, the rote, and the mundane.  Thought of as flighty, irresponsible, self-indulgent, rebellious. However she is capable of proficiency when the project captures her interest and allows her to express herself.  In this group superior performance was the rule.
Maintains the self-presentation as a child-woman.  Denies the unpleasant, the distasteful, the forbidden, the actual or fantasied transgression through insouciance, naiveté and inexperience.
Substitutes one emotion for another more painful emotion.  Uses emotional reconnaissance; shielding the core affect, the primary underlying desire.  Participates vicariously or fictitiously.
 
Other patients have hysterical symptoms but are lower level characters (more oral); call these hysteroid.
Hysterical patients in treatment.
Dreams of hysterical and hysteroid patients.
 
Halberstadt-Freud – Studies on hysteria one hundred years on –
 
Discussion of trauma as etiology.
Series of traumas and the associated fantasies.
Chain always led back to sexuality.
Rejection of seduction theory as the only or main cause.
Etiology in Dora case remains unclear; no subsequent case studies by Freud featuring the female Oedipus complex.  Used her case to confirm his theories; angry when she made him powerless; did not consider the role of the mother.
Freud never developed a coherent theory of hysteria capable of replacing the account given in the Studies.  Replaced his early idea of splitting of the ego with the later model of the drives and fantasies. He was previously more right: hysteria is based on seduction in the sense of prematurely aroused desires that have more to do with the adult’s than with the child’s need.  “Seduction by the mother was only raised towards the end of his life, in the context of female sexuality."
Hysteria now seen as pre-oedipal, pregenital, specifically oral in origin.
Seen also in men.

Hysteria today: Brenman – four aspects – disavowal of the reality of the internal and external worlds; the tendency to convince the other that one is in the right; identification with a fantasy object; possessive but sterile dependence.  Based on wishful thinking.  Manipulation, penetration into the other’s thinking and feeling to make the other reality credible.  A catastrophe is feared, expressed in restrictive anxiety, phobia or conversion, while the subject denies that anything is the matter.  A hypomanic mood defends against depression.  Violence hides a sense of emptiness.  Not aware of his anxiety about being unattractive and sexually inadequate.  Both frigidity and hypersexuality serve the purpose of denial of the sexual.  Dramatic victimhood is intended to mask and disavow aggression.
         Feelings of inadequacy on the part of eroticizing patients reflect the original interaction with a seducing parent, whose desires it was impossible for the child to satisfy.  The mother is anxious and fears catastrophe; she suggests that there are panaceas and thus does not present herself to the child as a realistic object for identification.  Mother encourages disavowal of psychic reality, of what is true and what is untrue; and she supplies idealizing love and sensuous stimulation, thereby promoting both hypersexuality and dependence.
Nowadays it is generally assumed that hysteria is a matter more of defending against depression, abandonment anxiety and narcissistic dangers than of genital sexuality.  Subtle phobic mechanisms serve for avoiding the development of anxiety.  Narcissistic problems are circumvented by compromise formations and displacement to the field of sexuality.
         Also homosexual conflict and fixation to bisexuality, disavowal of the difference between the sexes, between the generations, and between subject and object.  Fixation at the phallic level and castration anxiety still deemed important. Fantasy performs a symbolic function rather than that of wish-fulfilment; it leads to plans that miscarry and do not lead to satisfaction.  The drives are inhibited, leading only to ideas divorced from action or to muscular tension and pain.  Out of anxiety at the possibility of repetition of traumas, object loss is actively courted.  Possessiveness and intrusiveness are projected and then feared by identification.  Analyst may be faced with artificial transference and irresolvable resentment and irreparable deficiencies, resulting in intense countertransference feelings.  Hysteric conceals his wish to make an impression behind his fascination and identification with the spectator (in his stories).

Cognitive style – tend to forget and to mystify.  Poor observers.  Stories are lacunary and clothed in feelings that give an exaggerated and artificial impression.
Identifications are used as a way of relating to others.  Identifies superficially with non-existent fantasy-objects.  He experiences through others what he cannot experience in himself; his capacity to empathize with the other as other inevitably suffers because of repression.
Projective identification is often used to combat uncertainty and feelings of inadequacy; often rapidly reversible pseudo-identifications.  Attempts to get rid of anxieties by projecting them into the object and then identifying with it at a distance – by making the other powerless, thereby shifting the uncertainty from the subject to the object.  The practitioner is first approached with an attitude of idealization, but then disappoints and is reviled.
 
Hysteria and women
Both male and female hysteria a partly a matter of the absence of a representation of the female sex, as a result of which sexuality takes on a powerful phallic coloration.  In hysteria, the phallic mode is a substitute for and a defense against the dreaded femininity in both men and women.  Repudiation of an excessively strong identification with the problematic mother figure plays a part in both sexes.

Hysteria and French psychoanalysis
The French psychoanalysts lay considerable emphasis on the anal-sadistic elements that are banished from the hysterical universe, both aggression and guilt being repressed and projected into the other.

Hysteria in practice
Hysteria meets the expectations of the social environment or the therapist.
In practice hysteria is frequently misleading, tending to make the other powerless by seduction and blockage of any meaningful dialogue.  Disavowal of depression and of mourning for lost love is converted into excitement.  It is more fruitful to connect depression with narcissistic deficiency than with erotic elements in the transference and countertransference.

Three examples –
Making the therapist reflect her own feeling of powerlessness, her self-image as lacking talent, worthless and a failure. Mourning for what is lost is lacking in hysteria.  Mourning for what has not been attained, whether it be the love of the object or the high ego ideal, is a condition for success in the treatment.
Peter had a seductive mother who could not accept her life as it really was.  He always had to please and excite her by being her dream prince, more intelligent and more successful than his father.
 
The insight concerning the importance of the technical capacity to utilize the analysand’s message creatively in order to arrive at an interpretation of the unique interaction seems to me to be the biggest change in treatment in the last hundred years.
         The Studies are closer to our own time than Freud’s later work.  They do not yet make assertions that lay claim to absolute validity; various doctrines had not yet emerged (psychosexual phases, theory of the Oedipus complex).  The search was still on, just as it is in our own day, when many axioms of psychoanalysis, as well as its theoretical structure, have lost their stability, whereas the clinical facts remain.

FRAGMENT OF A DREAM OF AN HYSTERIC WOMAN  I had somehow got married to Peter, Susan’s husband.  (Susan was her good “listening”, advice-giving friend who died 2 years ago.)  It was strange, the feeling of being married to him, but I didn’t really know what that meant.  Were we going to sleep in the same bed, and were we going to have sex?  Peter was pretty business-like.  I thought, Well if you get married, you have sex; so I did.  Peter said it was serious, real, not pretend, not as if…Noone asked me.  It was not as if I wanted to.  It felt outside of me.  I didn’t know how I’d gotten into this.  It was like an arranged marriage.  I’d been brought in to be the wife.  There were some art objects around.  A vase – what is my relation to this vase?  Should I be cleaning the room; is that what a wife does?  Someone said, No, that is not what you should do.  We have cleaners.  In a bedroom; the next room was brightly lit…  
 
 
 
   


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