# Selected Papers on Hysteria and Other Psychoneuroses/Chapter 9

CHAPTER IX.
My Views on the Rôle of Sexuality in the Etiology of the Neuroses.
I am of the opinion that my theory on the etiological significance of the sexual moment in the neuroses can be best appreciated by following its development. I will by no means make any effort to deny that it passed through an evolution during which it underwent a change. My colleagues can find the assurance in this admission that this theory is nothing other than the result of continued and painstaking experiences. In contradistinction to this whatever originates from speculation can certainly appear complete at one go and continue unchanged.
Originally the theory had reference only to the morbid pictures comprehended as "neurasthenia," among which I found two types which occasionally appeared pure, and which I described as "actual neurasthenia" and "anxiety neurosis." For it was always known that sexual moments could play a part in the causation of these forms, but they were found neither regularly effective, nor did one think of conceding to them a precedence over other etiological influences. I was above all surprised at the frequency of coarse disturbances in the vita sexualis of nervous patients. The more I was in quest of such disturbances, during which I remembered that all men conceal the truth in things sexual, and the more skillful I became in continuing the examination despite the incipient negation, the more regularly such disease-forming moments were discovered in the sexual life, until it seemed to me that they were but little short of universal. But one must from the first be prepared for similar frequent occurrences of sexual irregularities under the stress of the social relations of our society, and one could therefore remain in doubt as to what part of the deviation from the normal sexual function is to be considered as a morbid cause. I could therefore only place less value on the regular demonstration of sexual noxas than on other experiences which appeared to me to be less equivocal. ​It was found that the form of the malady, be it neurasthenia or anxiety neurosis, shows a constant relation to the form of the sexual injury. In the typical cases of neurasthenia we could always demonstrate masturbation or accumulated pollutions, while in anxiety neurosis we could find such factors as coitus interruptus, "frustrated excitement," etc. The moment of insufficient discharge of the generated libido seemed to be common to both. Only after this experience, which is easy to gain and very often confirmed, had I the courage to claim for the sexual influences a prominent place in the etiology of the neurosis. It also happened that the mixed forms of neurasthenia and anxiety neurosis occurring so often, showed the admixture of the etiologies accepted for both, and that such a bipartition in the form of the manifestations of the neurosis seemed to accord well with the polar characters of sexuality (male and female).
At the same time, while I assigned to sexuality this significance in the origin of the simple neurosis, I still professed for the psycho-neuroses (hysteria and obsessions) a purely psychological theory in which the sexual moment was no differently considered than any other emotional sources. Together with J. Breuer, and in addition to observations which he has made on his hysterical patients fully a decade before I have studied the mechanism of the origin of hysterical symptoms by the awakening of memories in hypnotic states. We obtained information which permitted us to cross the bridge from Charcot's traumatic hysteria to the common non-traumatic hysteria. We reached the conception that the hysterical symptoms are permanent results of psychic traumas, and that the amount of affect belonging to them was pushed away from conscious elaboration by special determinations, thus forcing an abnormal road into bodily innervation. The terms "strangulated afifect," "conversion," and " ab-reaction," comprise the distinctive characteristics of this conception.
In the close relations of the psychoneuroses to the simple neuroses, which can go so far that the diagnostic distinction is not always easy for the unpracticed, it could happen that the cognition gained from one sphere has also taken effect in the other. Leaving such influences out of the question, the deep study of the psychic traumas also leads to the same results. If by the "analytic" method we continue to trace the psychic ​traumas from which the hysterical symptoms are derived, we finally reach to experiences which belong to the patient's childhood, and concerns his. sexual life. This can be found even in such cases where a banal emotion of a non-sexual nature has occasioned the outburst of the disease. Without taking into account these sexual traumas of childhood we could neither explain the symptoms, find their determination intelligible, nor guard against their recurrence. The incomparable significance of sexual experiences in the etiology of the psychoneuroses seems therefore firmly established, and this fact remains until today one of the main supports of the theory.
If we represent this theory by saying that the course of the life long hysterical neurosis lies in the sexual experiences of early childhood which are usually trivial in themselves, it surely would sound strange enough. But if we take cognizance of the historical development of the theory, and transfer the main content of the same into the sentence: hysteria is the expression of a special behavior of the sexual function of the individual, and that this behavior was already decisively determined by the first effective influences and experiences of childhood, we will perhaps be poorer in a paradox but richer in a motive for directing our attention to a higherto very neglected and most significant after-effect of infantile impressions in general.
As I reserve the question whether the etiology of hysteria (and compulsion neurosis) is to be found in the sexual infantile experiences for a later more thorough discussion, I now return to the construction of the theory expressed in some small preliminary publications in the years 1895-1896. The bringing into prominence of the assumed etiological moments permitted us at the time to contrast the common neuroses which are maladies with an actual etiology, with the psychoneuroses which etiology was in the first place to be sought in the sexual experiences of remote times. The theory culminates in the sentence: In a normal vita sexualis no neurosis is possible.
If I still consider today this sentence as correct it is really not surprising that after ten years labor on the knowledge of these relations I passed a good way beyond my former point of ​view, and that I now think myself in a position to correct by detailed experience the imperfections, the displacements, and the misconceptions, from which this theory then suffered. By chance my former rather meagre material furnished me with a great number of cases in which infantile histories, sexual seduction by grown-up persons or older children, played the main role. I over-estimated the frequency of these (otherwise not to be doubted) occurrences, the more so because I was then in no position to distinguish definitely the deceptive memories of hysterical patients concerning their childhood, from the traces of the real processes, whereas, I have since then learned to explain many a seduction fancy as an attempt at defense against the reminiscences of their own sexual activity (infantile masturbation). The emphasis laid on the "traumatic" element of the infantile sexual experience disappeared with this explanation, and it remained obvious that the infantile sexual activities (be they spontaneous or provoked) dictate the course of the later sexual life after maturity. The same explanation which really corrects the most significant of my original errors perforce also changed the conception of the mechanism of the hysterical symptoms. These no longer appeared as direct descendants of repressed memories of sexual infantile experiences, but between the symptoms and the infantile impressions there slipped in the fancies (confabulations of memory) of the patients which were mostly produced during the years of puberty and which on the one hand, are raised from and over the infantile memories, and on the other, are immediately transformed into symptoms. Only after the introduction of the element of hysterical fancies did the structure of the neurosis and its relation to the life of the patient become transparent. It also resulted in a veritable surprising analogy between these unconscious hysterical fancies and the romances which became conscious as delusions in paranoia.
After this correction the "infantile sexual traumas" were in a sense supplanted by the "infantilism of sexuality." A second modification of the original theory was not remote. With the accepted frequency of seduction in childhood there also disappeared the enormous emphasis of the accidental influences of sexuality to which I wished to shift the main role in the causation of the disease without, however, denying constitutional and ​hereditary moments. I even hoped to solve thereby the problem of the selection of the neurosis, that is, to decide by the details of the sexual infantile experience, the form of the psychoneurosis into which the patient may merge. Though with reserve I thought at that time that passive behavior during these scenes results in the specific predisposition for hysteria, while active behavior results in compulsion neurosis. This conception I was later obliged to disclaim completely though some facts of the supposed connection between passivity and hysteria, and activity and compulsion neurosis, can be maintained to some extent. With the disappearance of the accidental influences of experiences, the elements of constitution and heredity had to regain the upper hand, but differing from the view generally in vogue I placed the "sexual constitution" in place of the general neuropathic predisposition. In my recent work, " Three Contributions to the Sexual Theory," I have attempted to discuss the varieties of this sexual constitution, the components of the sexual impulse in general, and its origin from the contributory sources of the organism.
Still in connection with the changed conception of the "sexual infantile traumas," the theory continued to develop in a course which was already indicated in the publications of 1894-1896. Even before sexuality was installed in its proper place in the etiology, I had already stated as a condition for the pathogenic efficaciousness of an experience that the latter must appear to the ego as unbearable and thus evoke an exertion for defense. To this defense I have traced the psychic splitting—or as it was then called the splitting of consciousness—of hysteria. If the defense succeeded, the unbearable experience with its resulting affect was expelled from consciousness and memory; but under certain conditions the thing expelled which was now unconscious, developed its activity, and with the aid of the symptoms and their adhering affect it returned into consciousness, so that the disease corresponded to a failure of the defense. This conception had the merit of entering into the play of the psychic forces, and hence approximate the psychic processes of hysteria to the normal instead of shifting the characteristic of the neurosis into an enigmatic and no further analyzable disturbance.
Further inquiries among persons who remained normal furnished ​the unexpected result, that the sexual histories of their childhood need not differ essentially from the infantile life of neurotics, and that especially the rôle of seduction is the same in the former, so the accidental influences receded still more in comparison to the moments of "repression" (which I began to use instead of "defense"). It really does not depend on the sexual excitements which an individual experiences in his childhood but above all on his reactions towards these experiences, and whether these impressions responded with " repression " or not. It could be shown that spontaneous sexual manifestations of childhood were frequently interrupted in the course of development by an act of repression. The sexual maturity of neurotic individuals thus regularly brings with it a fragment of "sexual repression" from childhood which manifests itself in the requirements of real life. Psychoanalysis of hysterical individuals show that the malady is the result of the conflict between the libido and the sexual repression, and that their symptoms have the value of a compromise between both psychic streams.
Without a comprehensive discussion of my conception of repression I could not explain any further this part of the theory. It suffices to refer here to my "Three Contributions to the Sexual Theory," where I have made an attempt to throw some light on the somatic processes in which the essence of sexuality is to be sought. I have stated there that the constitutional sexual predisposition of the child is more irregularly multifarious than one would expect, that it deserves to be called "polymorphous-perverse," and that from this predisposition the so called normal behavior of the sexual functions results through a repression of certain components. By referring to the infantile character of sexuality, I could form a simple connection among normal, perversions, and neurosis. The normal resulted through the repression of certain partial impulses and components of the infantile predisposition, and through the subordination of the rest under the primacy of the genital zones for the service of the function of procreation. The perversions corresponded to disturbances of this connection due to a superior compulsive-like development of some of the partial impulses, while the neurosis could be traced to a marked repression of the libidinous strivings. As almost all perversive impulses of the infantile predisposition are ​strable as forces of symptom formation in the neurosis, in which, however, they exist in a state of repression, I could designate the neurosis as the "negative" of the perversion.
I think it worth emphasizing that with all changes my ideas on the etiology of the psychoneuroses still never disavowed or abandoned two points of view, to wit, the estimation of sexuality and infantilism. In other respects we have in place of the accidental influences the constitutional moments, and instead of the pure psychologically intended defense we have the organic "sexual repression." Should anybody ask where a cogent proof can be found for the asserted etiological significance of sexual factors in the psychoneuroses, and argue that since an outburst of these diseases can result from the most banal emotions, and even from somatic causes, a specific etiology in the form of special experiences of childhood must therefore be disavowed; I mention as an answer for all these arguments the psychoanalytic investigation of neurotics as the source from which the disputed conviction emanates. If one only makes use of this method of investigation he will discover that the symptoms represent the whole or a partial sexual manifestation of the patient from the sources of the normal or perverse partial impulses of sexuality. Not only does a good part of the hysterical symptomatology originate directly from the manifestations of the sexual excitement, not only are a series of erogenous zones in strengthening infantile attributes raised in the neurosis to the importance of genitals, but even the most complicated symptoms become revealed as the converted representations of fancies having a sexual situation as a content. He who can interpret the language of hysteria can understand that the neurosis only deals with the repressed sexuality. One should, however, understand the sexual function in its proper sphere as circumscribed by the infantile predisposition. Where a banal emotion has to be added to the causation of the disease, the analysis regularly shows that the sexual components of the traumatic experience, which are never missing, have exercised the pathogenic effect.
We have unexpectedly advanced from the question of the causation of the psychoneuroses to the problem of its essence. If we wish to take cognizance of what we discovered by psychoanalysis we can only say that the essence of these maladies lies in ​disturbances of the sexual processes, in those processes in the organism which determine the formation and utilization of the sexual libido. We can hardly avoid perceiving these processes in the last place as chemical, so that we can recognize in the so-called actual neuroses the somatic effects of disturbances in the sexual metabolism, while in the psychoneuroses we recognize besides the psychic effects of the same disturbances. The resemblance of the neuroses to the manifestations of intoxication and abstinence following certain alkaloids, and to Basedow's and Addison's diseases, obtrudes itself clinically without any further ado, and just as these two diseases should no more be described as "nervous diseases," so will the genuine "neuroses" soon have to be removed from this class despite their nomenclature.
Everything that can exert harmful influences in the processes serving the sexual function therefore belongs to the etiology of the neurosis. In the first place we have the noxas directly affecting the sexual functions insofar as they are accepted as injuries by the sexual constitution which is changeable through culture and breeding. In the second place, we have all the different noxas and traumas which may also injure the sexual processes by injuring the organism as a whole. But we must not forget that the etiological problem in the neuroses is at least as complicated as in the causation of any other disease. One single pathogenic influence almost never suffices, it mostly requires a multiplicity of etiological moments reinforcing one another, and which can not be brought in contrast to one another. It is for that reason that the state of neurotic illness is not sharply separated from the normal. The disease is the result of a summation, and the measure of the etiological determinations can be completed from any one part. To seek the etiology of the neurosis exclusively in heredity or in the constitution would be no less one sided than to attempt to raise to the etiology the accidental influences of sexuality alone, even though the explanations show that the essence of this malady lies only in a disturbance of the sexual processes of the organism.
* ↑ From Löwenfeld, " Sexualleben und Nervenleiden," IV ed., 1906.
* ↑ See Chapter VII, and Zur Aetiologie der Hysterie, Wiener, Klinische Rundschau, 1896.
* ↑ Trans, by A. A. Brill, Journal of Nervous & Mental Disease Monograph Series.