Sigmund Freud: Famous Cases from Practice
ISBN: 5-89353-219-8
“Sigmund Freud: Famous Cases from Practice”: Cogito Center, 2007.
annotation
The book contains descriptions of the six most famous therapeutic cases to which S. Freud was involved. The presentation of the dramatic circumstances of the life and progress of treatment of patients, commented by the creator of the new science, still serves as an indispensable tool for studying the foundations of psychoanalysis. The book will be of interest to both specialist psychologists and a wide range of readers.
Translation from German by V.I. Nikolaeva, A.M. Bokovikov.
Sigmund Freud:
Famous cases from practice
Preface
Fräulein Anna O. D. Breuer
Fragment of the analysis of hysteria. (Dora's medical history). 1905
Analysis of a phobia of a five-year-old boy (Little Hans). 1909
From the history of a childhood neurosis. (The Case of the Wolf Man). 1914-1915
Notes on a case of obsessional neurosis. (The Case of the Rat Man). 1909
Psychoanalytic notes on an autobiographical description of a case of paranoia. (Schreber case). 1911
Classic Freudian cases. The further fate of the patients Martin Grotjahn
LITERATURE
Preface
Currently, scholars studying Freud's scientific and creative legacy have direct information about 43 patients who were analyzed by Freud. The contribution that the description of these cases made to the development of psychoanalytic theory is, of course, unequal. Thanks to some of them, such phenomena of the therapeutic process as transference and countertransference, negative therapeutic reaction, etc. were discovered, which formed the basis of Freud’s most important theoretical postulates; others are rather visual illustrations of his theoretical positions. Be that as it may, all these cases served as factual material that allowed Freud to defend his theory with all conviction and not be in a state of uncertainty and uncertainty from speculative reasoning.
Among the cases to which Freud was involved in one way or another, six stand out in this volume. As a matter of fact, only three of them relate to the direct therapeutic work of Freud himself - the cases of Dora, Wolfsmann and Rattenmann (“the wolf man” and the “rat man”, as other authors call these patients, without really thinking about how incorrect and offensive and even these names sound absurd). Freud was indirectly related to three other cases - Anna O., “little Hans” and Schreber: Anna O. was treated by Freud’s senior colleague J. Breuer, “little Hans” was treated by the boy’s father, Freud’s student, and the analysis of the Schreber case was carried out on the basis of the patient’s memoirs.
The case of Anna O., which is rightly recognized as the first step taken on the path to the development of psychoanalysis, continues to attract the attention of various authors to this day - both orthodox psychoanalysts and representatives of modern trends in psychoanalysis. The reader can find new and unexpected approaches to the interpretation of this case in Summers (1999), Tolpin (1993), Hirschmuller (1989), and others.
There is probably no need to dwell in detail on the cases described in this book. The reader will find all the necessary information in the preliminary notes to each chapter, as well as in the article by Martin Grotjahn, which tells about the further fate of the patients.
Considering these works from a modern perspective, we see that not everything in Freud’s approach to analysis is correct. We notice that along with absolutely amazing insights there is a tendency to squeeze the received material into prepared diagrams. We are aware that numerous interpretations, which for Freud are beyond doubt, are now outdated and hardly correspond to reality. All this is true. But let's not forget that at that time it was an uncharted path, which often had to be groped. And we can only be grateful to the founder of psychoanalysis for the fact that he dared to follow this path and enriched us with a wealth of knowledge about the driving forces and internal conflicts of the human psyche.
The most famous case among psychoanalysts is that of Anna O. The pseudonym Anna O. was given to Bertha Pappenheim (1859-1936), who fell ill while caring for her father, who had cavernous tuberculosis. The patient was “exposed” by E. Jones, the author of the famous three-volume biography of Freud (1953). Freud learned about the patient's treatment from Breuer a few months after its completion (November 1882). Freud was so fascinated by the story of her illness that he could not understand why Breuer did not want to publish it, nor talk about the new treatment method he had created - “cathartic psychotherapy.” And only a year later, Breuer openly admitted to a young colleague that he was so closely involved in the treatment of Anna O. that he aroused his wife’s jealousy. He had to tell the patient that he was stopping treatment forever. In the evening of the same day, he was urgently called to a patient who was lying in “labor pains” from a false pregnancy and shouting: “Dr. Breuer’s child will be born!” Breuer put the patient into a hypnotic state and tried to calm her down, and the next day he and his wife left for Venice. In the same year, a month after the completion of Breuer's treatment, the patient's condition deteriorated so much that she was forced to be admitted for inpatient treatment to the famous Bellevue nervous sanatorium in Kreuzlingen on Lake Constance, where she remained from mid-July to the end of October 1882. There Anna O. was treated for various somatic symptoms (including trigeminal neuralgia), and large doses of morphine were used for this. In the evenings she lost the ability to speak German and switched to English or French. In a letter to Stefan Zweig, Freud wrote: “What actually happened to Breuer’s patient, I was able to unravel only many years after our breakup with him... At the last meeting with the patient, he had in his hands a key with which he could open the door to the mysteries of life, but he let it fall out. Despite all his spiritual talent, Breuer had nothing of Faust in his character. Horrified by what he had done, he fled, leaving the care of the patient to one of his colleagues" (Freud S. Briefe 1873-1939. Frankfurt a M., 1968, S. 427). And this was not the end of the matter, as Jones writes in the first volume of his biography of Freud: “About ten years later, while Freud was treating patients in collaboration with Breuer, the latter invited Freud to see another hysterical patient of his. Before going to see her , Breuer described her symptoms in detail, after which Freud said that this was very typical of an imaginary (false) pregnancy. This repetition of the previous situation was difficult for Breuer to bear. Without saying a word, he took his hat and cane and quickly left Freud" (Jones E. Das Leben und Werk von Sigmund Freud. Bern, 1960. S. 269). For some time, Anna O. abused morphine. Later, without without any medical help, she completely devoted herself to social activities. She was quite famous as a fighter for the emancipation of women, especially Jews. The famous Jewish philosopher Martin Buber (1878-1965) once said: “There are people of spirit, there are people of passion , both of them are not very often to be found, but even more rare are people who combine spirit and passion. This is the kind of person with a passionate spirit that Bertha Pappenheim was" (1939). With her personal savings, she founded the "Shelter for abused girls and illegitimate children." Caring for the unfortunate children completely replaces the absence of her own children. But the memories of the time spent cathartic treatment continues to haunt her later, she strictly prohibits any type of psychoanalytic treatment of people in the institutions she founded. Anna Freud also recalls that Bertha Pappenheim was “hostile to analysis” throughout her life (see . article "Episodes from the life of Bertha Pappenheim (Anna O.)", published by Bernd Nitzschke in the leading German psychoanalytic journal "Psyche". S. 819). Bertha Pappenheim herself says the following about psychoanalysis: "Psychoanalysis in the hands of a doctor is the same that confession is in the hands of a Catholic priest; it will depend only on their personality and skill in mastering their method whether their instrument turns out to be good or a double-edged sword" (see collection edited by D. Edinger, Bertha Pappenheim. Leben u. Schriften. Frankfurt a. M., 1963. S. 12-13). And Anna O. described her general life position as follows: “Everyone, regardless of whether he is a man or a woman, must do what he must do, using either his strength or his weakness.” For Freud the understanding of the power of transference and countertransference revealed in this case history became the starting point for the transition from cathartic therapy to psychoanalysis. In his obituary on the death of Breuer (1925), Freud wrote: "Breuer was confronted with the inevitably existing transference of the patient to the doctor and was unable to understand the extrapersonal nature of this phenomenon." Mistaking the transference feelings for the patient's real feelings, Breuer responded to them with a massive reaction of unconscious countertransference, which, even years later, did not allow him to recognize the sexual nature of Anna O's symptoms. , Breuer, in a letter dated November 21, 1907, writes to the famous psychiatrist August Forel: “I must confess to you that my taste disgusts me to plunge into the field of sexuality, both in theory and in practice. But what does my taste and my feelings have to do with it if it is a matter of truth, of discovering what we are really confronted with. The case of Anna O. proves that a sufficiently severe case of hysteria can arise, persist and be eliminated without sexual elements playing any role in it. My merit lies in Basically, I was able to understand that fate had placed in my hands an unusually instructive case, important for science, which I was able to carefully observe for quite a long time, without disturbing its simple and natural course with any biased approach. I learned a lot, I learned a lot of amazingly valuable things for science. But I also learned what it is necessary to pay priority attention to in practical work. It is impossible for a private practitioner-therapist to treat such cases without completely destroying his work and life way of life I praise myself for the decision I made then not to allow such inhuman tests to happen again. If I had patients who had excellent indications for analytical treatment, whom I myself could not treat, then I referred them to Dr. Freud, who acquired rich practical experience in Paris and the Salpêtrière, to a doctor with whom I was on the most friendly terms. relationships, as well as in fruitful scientific contacts" (1907).
A. Bokovikov
Fräulein Anna O. D. Breuer
Anna O., who was 21 years old at the onset of the disease (1880), was apparently hereditarily burdened with neuropathological diseases, those psychoses that sometimes appear in large families; although her parents are healthy in this regard. Previously, the patient had always been healthy, without any signs of nervousness during the entire period of development; with a very high intelligence, an amazing gift for all kinds of inventions and deep intuition; her amazing logical abilities could process solid spiritual food, they simply needed it, but after finishing school she stopped receiving it. Her rich poetic talent and tendency to fantasize were controlled by her very sharp and critical mind. It was he who made Anna O. completely inaccessible to suggestion; only logical arguments could influence her, and any beliefs were useless. Her will was strong, Anna O. was distinguished by great endurance and endurance, at times even reaching the point of stubbornness. She abandoned her goal only out of a desire to gain the approval of others.
Her character was characterized by kindness and mercy. Her constant concern and care for the poor and sick served her well during her illness. With compassion for the misfortunes of others, Anna O. satisfied one of her greatest needs. - Her moods were always characterized by a certain tendency towards excess, fun and sadness were combined together. And hence the slight capriciousness inherent in her. The complete absence of any sexual interests was striking; the patient, in whose life I was so well versed in a way that was hardly available to anyone else, had never experienced love in her life; in the vast number of her hallucinations, the sexual element of mental life never surfaced.
Fraulein Anna O., despite the spiritual thirst that overwhelmed her, led an unusually monotonous life in the Puritan family of her parents, which the girl managed to brighten up in a special way, apparently generally characteristic of her illness. Anna O. systematically gave herself over to waking dreams, which she called her personal “private theater.” While the people around her thought she was part of the conversation, she was actually living the spirit of her fairytale dream. True, whenever they called out to her, Anna O. always responded easily, so that no one suspected what was happening to her. Along with her household chores, which she always did impeccably, her spiritual activity went on unnoticed and almost continuously in the form of tireless fantasy. A little later I will report on how her usual healthy dreams turned into pathological ones.
The course of the disease falls into several easily distinguishable phases; these will be the following:
A) Latent incubation period, the time of onset of the disease; it took about six months, from mid-1880 until about December 10th. The uniqueness of the presented clinical case provided the opportunity for such a deep consideration of this phase, usually devoid of our understanding, that for this reason alone the case of Anna O. deserves our close attention. A little later I will describe this part of the medical history in detail.
B) The manifested (manifest) disease revealed itself as a special kind of psychosis, paraphasia (paralalia), convergent strabismus (strabismus), severe visual disturbances, contractures-paralysis, completely affecting the right upper and both lower limbs, and partially also the left upper, paresis ( weakening of motor functions) of the occipital muscles. Gradual decrease in contracture of the right limbs. Some improvement, interrupted by severe mental trauma experienced in April as a result of the death of his father. This phase is followed by
C) A period of prolonged somnambulism, which later began to alternate with a normal state of consciousness. Symptoms persisted until December 1881.
D) The gradual disappearance of these pathological conditions and phenomena (the period lasted until June 1882).
In June 1880, the patient's father, whom she loved passionately, fell ill. He could not be cured of a peripleuritic abscess and died in April 1881. During the first months of her father’s illness, Anna O., with all the energy of her young body, devoted herself to caring for the patient. No one was surprised that every day the girl tormented herself more and more. No one, and perhaps even the patient herself, had any idea what was happening inside her. But gradually her state of weakness, anemia, and aversion to food became so painful and noticeable that the patient was forced to be removed from caring for her father. The immediate reason for contacting me was a very severe cough, as a result of complaints about which I examined her for the first time. It was a typical nervous party. Soon the patient developed a strong need to rest in the afternoon, and in the evenings she began to experience a sleep-like state, which was later joined by severe anxiety.
In early December, convergent strabismus occurred. The ophthalmologist explained this (by mistake) as paresis of the abductor muscle. On December 11, the patient went to bed and remained there until April 1.
In quick succession, many severe disorders appeared and disappeared, apparently for the first time in the patient’s life.
Left-sided pain in the back of the head; due to anxiety, convergent strabismus (diplopia - double image) has become much more pronounced; complaints that walls might collapse on her (fear of tilted spaces). Difficult to diagnose visual disorders; paresis of the anterior cervical muscles, so that in the end the head could only be moved by the patient squeezing it between her raised shoulders and then moving the head along with the entire body. Contracture (limited mobility) and anesthesia of the upper right limb, and after some time of the left; there is a feeling that the right limb is stretched, becoming straight and as if chained to the body, turning somewhat inward; later, a similar thing happens with the left lower limb, and then with the left hand, although its fingers still, to some extent, continue to retain mobility. And the shoulder joints were not completely immobilized. The most pronounced contracture was in the muscles of the forearm, and when later we were able to more accurately identify zones of insensitivity, the patient’s elbow area turned out to be the most insensitive. At the beginning of the disease, we were not able to accurately identify areas lacking skin sensitivity. This was due to the patient’s resistance caused by her fears.
It was in this state of the patient that I began treatment. Soon I had to make sure that she had clearly expressed altered mental states. The patient had two completely different states of consciousness, which replaced each other quite often and completely unpredictably; as the disease progressed, these states diverged more and more from each other. In one of them the patient was able to navigate her surroundings quite well, was sad and fearful, in short, remained relatively normal; and in another state she experienced hallucinations, was “ill-mannered,” that is, she swore, threw pillows at people, because and whenever contractures allowed her to do this, with her fingers still able to move, she tore off buttons from linen and bedspreads, and did a lot of other things similar. If during this phase there were any changes in the room, or anyone entering or leaving, she would complain that she had no time, and then lapses of memory would appear in her conscious ideas. Since those around her tried to respond to all her complaints with a calming deception, saying that everything was fine with her, each throwing of pillows and other similar actions was followed by new complaints that she was being deliberately harmed, leaving her in such a confused state, etc. d.
These absences (periods of short-term absence of consciousness) were observed even before she went to bed; At such moments, her speech was interrupted in the middle of a sentence, she repeated the last word she said, so that after a short time she would again continue the speech she had interrupted. Gradually, the patient’s condition began to resemble more and more the picture of her condition described by us. During times of exacerbation of the disease, when the contracture also affected the left side, throughout the day it only became somewhat normal for a short time. But even in these moments of relatively clear consciousness, she was not completely free from frustration; lightning-fast mood swings from one extreme to the other, fleeting cheerfulness, usually difficult to bear states of severe anxiety, stubborn resistance to any therapeutic measures, visions of terrible hallucinations in which black snakes reigned, she saw them in her hair, on shoelaces, etc. etc. And at the same time she still managed to reassure herself that she couldn’t be so stupid, that it was just her hair, etc. During periods of completely clear consciousness, she complained about complete darkness in her head, that she is not able to think that she will soon become blind and deaf, that there are two selves in her soul, the true self and the other, bad self, forcing her to do something evil, etc.
After lunch, she was in somnolence (a pathological state of drowsiness), usually ending only about an hour after sunset, then the patient woke up, complained that something was tormenting her, but most often she simply monotonously repeated the same verb: torment, torment...
Simultaneously with the appearance of contractures, deep, functional disorganization of speech occurred. At first it was noticeable that the patient clearly lacked a vocabulary, but gradually this became more and more obvious. Her speech began to lose its grammatical coherence, syntactic structures were distorted, errors associated with the conjugation of verbs appeared, and in the end Anna O. generally switched to using one single form - the indefinite form of the verb (infinitive), and, naturally, she did this with errors , and it’s not worth talking about articles* [*in German, all nouns are usually used together with an additional function word - an article, denoting their gender (masculine, neuter, feminine) [der, di, das]]. As the disease progressed further, the patient began to almost completely forget words. She tried with great effort to construct a sentence, using four or five different languages to help, so that now she could hardly be understood. And even when she tried to convey her thoughts in writing (if contracture did not prevent this), she used the same indigestible jargon. For two weeks in a row she continued to have mutism* [*from the Latin mutismus, meaning dumbness, numbness. In psychiatry, mutism is commonly understood as a refusal to speak in certain mental illnesses. Apparently, Breuer puts a special meaning into this concept], and no matter how she tried to utter at least one word, not a single sound came from her lips. It was then that the mental mechanism of her disorder first became clear to me. As far as I could find out, she was offended by something and decided to remain silent in retaliation. When I figured this out and managed to get the patient to talk, the obstacle that had previously made it impossible for her to speak was immediately eliminated.
This coincided in time with the return of mobility in the left-sided limbs (March 1881). The paraphasia subsided, but now she spoke only English, apparently not even realizing that she was speaking a foreign language; she scolded the nurse, who, of course, did not understand a word of what the patient was saying; Only after a few months did I manage to convey to her that she spoke English. Although Anna O. herself somehow managed to understand her surroundings, which spoke their native language. And only in moments of intense fear she experienced did speech disappear completely or become completely incomprehensible due to a mixture of completely different idioms. At her most pleasant hours, Anna O. spoke French or Italian. But while in one of these states (when she spoke these languages or English), she could not remember anything from her native language, about which she had complete amnesia. The strabismus, which began to appear only in moments of particularly great excitement, gradually decreased, and the muscles again became obedient to the patient. On April 1, Anna O. left her bed for the first time in a long time.
And then, on April 5, her beloved father, whom she could see only occasionally, and only for short moments, dies during her entire illness. Of all the shocks that exist in the world, the death of her father was the most terrible for Anna O. Initially, frantic excitement gave way to a deep stupor (a state of mental and motor retardation), which lasted about two days; She came out of it a completely different creature. Anna O. looked much calmer than usual, her anxiety had noticeably subsided. The contracture of the right arm and leg did not disappear, nor did the slight loss of sensation in these limbs disappear. The field of view was significantly narrowed. Of the entire spectrum of colors that brought her into an amazingly joyful mood, she was able to perceive only one color at a time. The patient complained that she did not recognize people. Usually she easily remembered faces, for which she did not require any effort. Now she had to resort to very troublesome “recognising work” (translated from English as “recognition work”), telling herself something like this: yes, his nose is like that, his hair is like that, therefore it must be Mr. So-and-so. For her, all people turned into some kind of wax figures that had nothing to do with her. The presence of some close relatives became unusually painful for her, and this “negative instinct” grew more and more. If one of those people whom Anna O. had previously met with great joy appeared in the room, now she shared his company only for a short time, then again plunged into her thoughts, and the person present disappeared for her. And it was only me that she never lost from her field of vision. Whenever I appeared, she invariably showed concern for me, immediately becoming animated when I addressed her. True, when hallucinatory absence seizures appeared completely unexpectedly, this contact was interrupted.
Now Anna O. spoke only English and no longer understood anything that was said to her in her native (German) language. Everyone around her had to speak English, and even the nurses, to some extent, learned to cope with this. But the patient read only French and Italian books, and when she needed to read a passage aloud, she did it with admirable ease and freedom; it was a surprisingly accurate translation of what she read from sight into English.
She began to write again, but she did it in a special manner. She wrote with her left hand, which retained mobility, looking for antique typographic letters in the edition of Shakespeare she had.
If earlier Anna O. still took at least a minimal amount of food, now she completely rejected any food, allowing me to feed herself, so no matter what, she quickly gained weight. And she categorically refused to eat bread. After feeding, Anna O. never forgot to wash her mouth, and she did this even when for some reason she did not eat anything; it was a sign of how indifferent the act of eating was to her.
Doubt after lunch and deep stupor after sunset continued to persist. And when the patient was able to speak out (I will talk more about this later), then her consciousness became clear, she herself became calm and cheerful.
But this relatively tolerable state did not last particularly long. About 10 days after the death of the father, a consultant doctor was invited to see the patient. During my story about the peculiarities of her condition, she completely ignored the presence of the consultant, treating him as she did with all people she did not know. “That's like an examination,” she said laughing, after I asked her to read us the French text in English. The invited doctor also tried to intervene, wanting to attract her attention so that she could finally noticed him, but all our efforts were in vain. This (not noticing the presence of another person) was truly a “negative hallucination”, which could easily be reproduced at any time. Finally, the doctor managed to break the course of events by blowing a whole column of cigar smoke into the patient’s face Suddenly Anna O. saw a stranger in front of her, she rushed to the door to pull out the key and fell unconscious on the floor, and then a small angry outburst followed, which was replaced by an attack of fear, and only with great difficulty did I manage to eliminate her anxiety in the patient. Unfortunately, I had to leave that very evening, and when I returned a few days later, the patient’s condition had become much worse.All this time she was fasting, experiencing constant anxiety. She had many hallucinatory visions with terrifying images of dead men's heads and frightening skeletons. Since, while experiencing this, the patient most often dramatically recreated what she saw and even entered into conversation with the images she saw, the people around her were well aware of the content of her hallucinations. After lunch, at sunset, she plunged into a special state reminiscent of deep hypnosis. For this condition, Anna O. even came up with a special technical term “clouds” (hovering in the clouds). If she managed to talk about the hallucinations she saw during the day, then after that she became surprisingly calm and cheerful, got to work, drew and wrote throughout the night, and she did all this completely rationally; and at about 4 o’clock in the morning I went to bed so that in the morning the old scene would continue anew. The amazing contrast between her two states attracted attention: an insane patient, overwhelmed by frightening hallucinations during the day, and a girl who was lucid at night.
However, despite all the euphoria Anna O. experienced at night, her mental state worsened every day. There was a greater readiness for suicide, which made it inappropriate for the patient to be on the fourth floor. Therefore, the patient, despite her reluctance, was transferred to a country house in the suburbs of Vienna (June 7, 1881). I never threatened the patient with removal from the home environment, a removal that she desperately resisted, quietly expecting and anxious. In this situation of removal from the usual situation, it became clearly visible how strongly Anna O.’s anxiety was expressed. Just as some time after the death of her father, the patient began to calm down, after what the patient feared happened - her removal from her parents' home, Anna O. calmed down. Of course, this did not happen without moving to a new place taking her three days and three nights, during which she tried to come to her senses, completely without sleep and without food, endlessly trying to commit suicide (of course, in conditions dacha, this was completely impossible), breaking glass on windows, etc., experiencing hallucinations without absence seizures, these hallucinations were not at all similar to the previous ones. After 3 days, she calmed down, allowed the nurse to feed her, and in the evening she even took chloral (a sleeping pill).
Before I begin to describe the further course of the disease, I must go back and show the originality of this clinical case, which has so far only been briefly mentioned.
I have already said that during the entire described period of illness, every time after lunch Anna O. fell into doubt, which turned into deep sleep (clouds) at sunset. (This periodicity is apparently best explained by the circumstances of caring for her sick father, to which she devoted herself for months with great zeal. Then at night the patient was awake, carefully listening to her father’s every movement, and full of anxiety for his health lay awake in her bed; after dinner the patient went to rest for a while, as is usual among nurses; this rhythm of night wakefulness and daytime sleep probably had an imperceptible effect on her own illness, continuing to exist even when sleep had long ago been replaced by a hypnotic state). If stupor (deep darkness of consciousness) lasted for almost an hour, then the patient became restless, turned over from side to side, and constantly shouted: “Torment, torment,” always doing this with her eyes closed. On the other hand, it was clearly noticeable that in her daily absence seizures, Anna O. always tried to depict some situation or story, the content of which could be guessed from the individual words that the patient muttered. This happened too. Someone close to her deliberately (the first time it happened completely by accident) shouted out one of these key words during those periods when the patient began to talk about “torment” - and Anna O. immediately included the planted word in the situation that existed in her imagination, at first, stuttering in her paraphasic jargon, but the further she went, the smoother and freer the patient’s speech flowed, until finally the patient began to speak absolutely correct German (in the first period of her illness, even before she was completely captivated by the English language). The stories created by a patient in a deep trance were always beautiful, sometimes even amazing the people who heard them, somewhat reminiscent of Andersen’s fairy tales, and they were probably created in the image and likeness of the books of the famous storyteller; most often the starting point and central point of the whole story was a girl anxiously staying at the bedside of a sick person; but completely opposite motives also appeared, which were skillfully veiled. - Soon after the story she told, Anna O. woke up, apparently calmed by the course of the story she had invented - the patient herself called this state of hers “acceptance” (pleasantness). Later, at night, the patient again became restless, and in the morning, after two hours of sleep, it was clear as day that she was in a completely different circle of ideas. - If Anna O. was not able to tell the entire story she was creating to the end during evening hypnosis, then a peaceful evening mood did not arise, and the next day, in order to improve her condition, she had to tell two stories.
Throughout the entire one and a half year period of observation of the patient, the main manifestations of her illness remained the same: frequent and severe absence seizures in evening autohypnotic states, effective fantasy products as mental stimuli for activity, mitigation, and even temporary elimination of symptoms after using the opportunity to speak out in hypnosis .
Naturally, after the death of her father, the stories told by Anna O. became even more tragic; the deterioration of the patient’s mental state, which followed the powerful invasion of somnambulism into her life, which I just talked about, was sharply striking; the patient’s reports ceased to have more (or) less free poetic character, turning into a series of terrible, frightening hallucinations, the content of which could be guessed even during the day by the patient’s behavior. I have already talked about how skillfully her soul was freed from shocks caused by hallucinations, fear and horror, after Anna O. managed to reproduce all the terrible images she had seen and speak out to the end.
At the dacha, to which I did not have the opportunity to travel every day to visit the patient, events developed as follows: I arrived in the evenings during those periods when, as I knew, she was in an autohypnotic state, and listened to a new series of chimeras (phantasms) ), which she had accumulated since the day of my last visit. To achieve a good effect, the patient had to speak out to the end: then she calmed down, the next day she was kind, obedient, diligent - well, just fun itself. But on the second day everything changed: Anna O. became more capricious, stubborn and uncontrollable, which intensified even more on the third day. When she was in such a state, even in hypnosis, it was not always possible to encourage her to speak out completely. For the last procedure, the patient came up with a well-suited, explanatory name “talking cure” (treatment by permission to speak out), jokingly calling it “chimney-sweeping” (pipe cleaning). Anna O. knew well that after she was able to speak out, she would lose all her obstinacy and “energy.” When the patient, after a long absence of such spontaneous “procedures” of healing, was in a bad mood and refused to speak, then I had to achieve revelations from Anna O. with the help of coercion and requests, as well as some artificial techniques, such as reciting in her presence some standard initial phrases from stories she has already told. But the patient never began to speak without being thoroughly convinced of my presence by carefully feeling my hands. On nights in which the patient did not feel calm, after giving her the opportunity to talk it out, she had to resort to prescribing chloral hydrate (a hypnotic that exerts its effect within 6-8 hours; a single dose is 0.5-1 grams, and the maximum daily intake - 6 grams); but gradually the need for this became less.
Somnambulism, which had lasted for a long time, disappeared, although the alternation of two states of consciousness remained. In the middle of a conversation, Anna O. could have hallucinations, then she would start to run away, try to climb a tree, etc. If she could be detained, then after a short time she would continue the sentence that was broken off in mid-sentence, as if not noticing what had happened in in between. She returned to all these hallucinations later, in hypnosis.
In general, one could say that there were improvements in Anna O.’s condition. She could eat well, without any resistance allowing the nurse to introduce food into her mouth, and only bread, despite the desire to eat, was pushed away by the patient every time it came into contact with her lips; leg contractures and paresis have significantly decreased; the patient was finally able to appreciate and become firmly attached to another doctor who visited her - my friend Doctor B. The Newfoundland dog, which Anna O. received as a gift and passionately fell in love with, also provided considerable assistance in her recovery. Indeed, one should have seen how this weak girl bravely took a whip in her left hand and used it to unfasten a huge beast - her favorite - in order to save his victim, the cat, which he attacked. Somewhat later, the patient began to pay a lot of attention to poor and sick people, which was undoubtedly useful for her.
The most clear evidence of the pathogenic, exciting influence on absence seizures with their special world of ideas created by alternative consciousness, as well as the elimination of the pathological condition after giving the patient the opportunity to speak out in hypnosis, I received after my return from vacation, when I did not see Anna O. for several weeks There was no “talking cure” during this time, since it was impossible to induce the patient to tell stories to anyone other than me, and Doctor B., to whom in all other respects the girl willingly obeyed, did not succeed either. I found Anna O. in a sad and depressed state, she became lazy, obstinate, capricious and even embittered. In her evening story, it was noticeable that the fantasy-poetic vein, so inherent in her, apparently began to dry up. What the patient said was more like an account of the hallucinations she had and what had angered her over the past days; the elements of fantasy that were encountered in her story were more reminiscent of well-established clichés than anything having anything to do with poetry. The patient became more tolerable only after I allowed her to go to the city for a week and for several evenings forced her to tell me stories (there were 3-5 of them). When this was already over, it turned out that Anna O. and I discussed everything that had accumulated during the weeks of my absence. The old rhythm in the patient’s mood appeared. The next day, after using the opportunity to speak out, Anna O. was kind and cheerful, on the second day she was more irritated and unapproachable, and on the third day, well, simply “disgusting.” Her emotional state was at the mercy of time, which was counting down from the moment she was given the opportunity to speak out. Any pathological formation created by the patient’s fantasy, and any fact snatched by the painful part of her soul, continued to have an effect until Anna O. talked about them in hypnosis, after which she completely got rid of their painful influence.
When the patient returned to the city again in the fall (but to a different apartment, not the one in which she fell ill), her condition was quite tolerable, both physically and mentally; and only a few experiences that captivated her with particular force could turn into pathological mental irritants. I had great hopes for a gradual improvement in Anna O.’s condition as a result of the opportunity given to her to speak out to the end, which was supposed to protect her psyche from heavy overload with new stimuli. But at the very beginning I was disappointed. In December, Anna O.’s mental state sharply deteriorated, she was very excited, she was overcome by pessimism, she would hardly have been able to find at least one tolerable day in her life, although outwardly she tried not to betray her condition in any way. At the end of December, during the Christmas holidays, she experienced especially strong anxiety; I heard nothing new from her all week, except perhaps only a story about the chimeras that she carefully created during the holidays of 1880 under the influence of the strong affects of fear that she experienced. After the patient was able to talk about a whole series of similar images, she felt great relief.
A year has passed since she was removed from caring for her father and she was forced to go to bed herself. It was at this time that Anna O’s condition became clearer and ordered. Both states of consciousness alternating with each other previously existed in such a way that in the morning, as the day began, absence seizures became more frequent, i.e., alternative consciousness dominated, and in the evenings, in general, only it one existed. Now everything was different, if earlier in one state of consciousness she was normal, and in another she had psychopathological syndromes, now the differences took on a completely different character. In the first state, she lived like the rest of us in the winter of 1881-1882, and in the second, she seemed to be reliving the winter of 1880-81, and it seemed that she had completely forgotten everything that happened then during the whole year, when there was a consciousness that the father had died. This time travel in the past year occurred so intensely that while in the new apartment, she recreated her previous room through hallucinations; when I wanted to go to the door, I came across the stove, which was located in exactly the same way in relation to the window as the door in the previous apartment. The transition from one mental state to another occurred spontaneously and with extraordinary ease; one fleeting impression was enough, reminiscent of the living events of the past year. One could simply hold an orange in front of her (her main food during the initial period of the disease) and she was completely transferred from the year 1882 to the year 1881. This movement into the past year did not happen at all by chance, day after day the patient consistently lived through the past winter. I could consider this just a hypothesis if Anna O. herself, during nightly hypnosis, did not go through everything that excited her on this very day exactly a year ago, and if there were no mother’s personal diary for 1881, according to which it is easy ensure the accuracy of the events mentioned by the patient and the time of their occurrence. The renewal of the experiences of the past year continued until complete healing from the illness (June 1882).
It was interesting to notice how psychic events re-experienced in alternative consciousness did not miss the opportunity to influence her normal consciousness.
One morning the patient laughingly told me that she didn’t know why, but she was angry with me; Knowing the contents of my mother's diary, I understood well what she meant. Later in the evening hypnosis, my assumption was indeed confirmed. On the same exact calendar day in the evening in 1881, I made the patient very angry with something. Another time she said that something unusual was happening to her eyes, that she was not perceiving colors correctly. But it turned out that in the color discrimination test she saw everything clearly and correctly; the visual impairment related only to the material of her clothing. The reason was that in those days in 1881 (a year ago), the patient spent a lot of time working with her father’s dressing gown (house dressing gown), which was made of the same material, only in a different, blue color. It was also clearly noticeable that these emerging memories primarily interfered with the functioning of the normal consciousness, and only gradually their influence began to affect the alternative consciousness.
Evening hypnosis was quite burdensome for the patient in that she had to talk not only about newly created chimeras, but also about experiences and “mysticism” dating back to 1881 (fortunately, the chimeras of 1881 had already been eliminated at that time). This work carried out by the patient and the doctor was unusually large due to the presence of a special kind of disorder that also had to be eliminated, I mean here the psychopathological manifestations of the very initial period of the illness from July to December 1880, those phenomena that led to the appearance of hysterical phenomena. After the patient was given the opportunity to speak out, the symptoms disappeared.
I was simply amazed when, after an unintentional story from a patient who was in evening hypnosis about a symptom that was tormenting her, it suddenly disappeared, despite the fact that it had existed for quite a long time. She talked about the summer, it was unusually hot, the patient suffered terribly from thirst, and all because, for no apparent reason, problems suddenly arose with quenching her thirst. As soon as her lips touched the glass of water she so desired, she sharply pushed it away from her, as if she suffered from hydrophobia. Obviously at these seconds she was in absence seizure. To some extent, it was possible to quench the thirst that tormented her only with fruits, watermelons, etc. This lasted about 6 weeks. Somehow, in hypnosis, she began to talk about her English companion, whom she clearly did not like. With a clear expression of disgust, the patient told how she entered her room and saw her companion’s small dog, a most disgusting dog, drinking from a glass. She didn't say anything then because she didn't want to seem impolite. For some time after the story she told, the patient still indulged in the manifestation of the anger raging in her, then she asked for a drink, without any obstacles she drank several glasses of water and came out of hypnosis, holding the glass to her lips. This is how her symptom disappeared forever. In the same way, her other inveterate quirks disappeared; it was enough just to tell about the event that really served as the reason for them. But the greatest achievement was the disappearance under the influence of such a procedure of the first stable symptom - contracture of the right leg, although it had already significantly decreased. The patient’s hysterical symptoms immediately disappeared, as soon as the event that provoked the appearance of the symptom for the first time was reproduced under hypnosis. It was from such observations that a therapeutic technique was created, impeccable in terms of logic, consistency and systematicity. Attention was paid to every single symptom of this rather complicated disease, to all the reasons that could provoke their appearance. The story about them began in reverse time order, starting from the days when the patient went to bed and back to the events that served as the reason for their first occurrence. If Anna O. managed to talk about them, then the symptom disappeared without a trace and forever.
Thus, contractures-paresis were “dissuaded” (wegerzahlt) and skin sensitivity was restored, a variety of visual and hearing disorders, neuralgia, nervous coughs and tremors, etc. were eliminated, and finally speech disorders. For example, the following visual disorders consistently disappeared: convergent strabismus with double vision; squinting of both eyes to the right, so that the grasping hand always ended up to the left of the object; narrowing of the field of view; central amblyopia (decreased visual acuity without detectable objective changes in the visual apparatus); macropsia; a vision of a dead man's head instead of his father; inability to read. And only to some phenomena that appeared already in the bed period, it was not possible to apply this approach, for example, to the spread of contracture-paresis to the left side; Apparently, it did not have any direct psychological reasons.
All attempts to speed up the matter by attempting to directly awaken in the patient's memories the first reason for the appearance of the symptom were completely unsuccessful. She could not find him, fell into confusion, and the treatment proceeded even slower than in the case when the patient was allowed to calmly and safely unwind the thread of memories she had picked up to the end. Treatment through evening hypnosis proceeded too slowly due to the fact that during the process of “reprimanding” the patient was forced to be distracted by two other series of mental phenomena disturbing her. And the memories themselves apparently needed a certain amount of time in order to have time to appear in their original brightness. Therefore, the following treatment procedure was formed. I visited the patient in the morning, hypnotized her (very simple hypnotic techniques were found experimentally), and when she managed to concentrate sufficiently on thoughts about the next symptom, I asked her about the life circumstances in which it first appeared. When quickly presented with a sequence of small key phrases, the patient listed external reasons, which I immediately wrote down. And during evening hypnosis, with the support of the notes I made, the patient described in some detail the specific circumstances of the appearance of the symptom. How much the patient immersed herself in herself can be judged by the following example. It often happened that the patient did not hear when she was addressed. This temporary “deafness” can be divided into the following groups:
A) not noticing that someone has entered the room; here I have recorded 108 cases in detail; Anna O. named circumstances, persons, and often dates; the father is mentioned first on the list;
B) inability to understand words when several people speak at the same time; 27 cases; the first on the list is again the father and one of the patient’s acquaintances;
C) Anna O. was so withdrawn into herself that she did not notice that they were addressing her directly; 50 times; the very first memory that relates to this is her father asking her to bring wine;
D) deafness occurring due to shaking (in a carriage, etc.); 15 times; the first case on the list - having tracked down the patient,
when she listened at night at the door to the patient’s room, her younger brother shook her indignantly;
E) temporary deafness that occurs as a reaction to severe fright with a sudden rustle; 37 times; the first case was a father’s suffocation attack when he choked
F) deafness that occurs in a state of deep absence; 12 times;
G) deafness due to listening so persistently and intensely to what was said that in the end, when someone spoke to her, she no longer heard anything; 54 times.
Of course, all these phenomena are mostly similar to each other. They, for example, can be reduced to the manifestation of absent-mindedness in a state of absence or the affects of fear (horror). But in the patient’s memories, these phenomena were so clearly divided into separate categories that as soon as she got lost here somewhere, she felt the need to restore the disturbed order again, otherwise the matter would remain stuck. Numerous details, due to their insignificance, as well as the amazing accuracy in their telling, suggested suspicion of far-fetchedness. Much of what was said could not be verified, since it related to subjective, internal experiences. And some of the circumstances that were associated with the appearance of symptoms were remembered by people around the patient.
There was nothing new going on here compared to “talking off” symptoms. The psychopathological phenomenon mentioned by the patient itself began to clearly come to the fore. For example, during the analysis of episodes of deafness, the patient stopped hearing me to such a large extent that at times I had to resort to notes to continue communicating with her. And the reason for the appearance of such episodes was always some strong horror she experienced while caring for her father, or an unforgivable omission on her part, etc.
Recalling previous events did not always go smoothly; sometimes the patient had to make enormous efforts for this. And one day the whole thing stalled for a long period. One of the memories did not want to appear; it referred to a hallucination that frightened the patient: instead of the usual image of the father whom the patient was caring for, she saw the head of a corpse. Anna O. and the people around her recalled how once, when she was still completely healthy, the patient went to visit one of her relatives, opened the doors of her apartment and immediately fainted. To cope with this, Anna O. now went there, but as before, she collapsed there unconscious on the floor, only having time to cross the threshold of the room. In the evening hypnosis, an obstacle was discovered and eliminated: entering the relative’s room, in the mirror standing opposite, the patient saw her pale face, and not even her own, but her father’s - the head of a corpse. - In working with Anna O., it often turned out that the fear that memories might reveal something very secret held them back, so that the patient or the doctor had to resort to additional efforts.
How strong the logic of her inner mental life was can be confirmed, among other things, by the following event. As already noted, at night the patient invariably remained in an “alternative consciousness” - that is, she was transported to 1881. One night she woke up, claiming that she had been taken away from home, and became indescribably excited, alarming the whole family. And the reason for her excitement was very simple. The previous evening, through the “talking cure,” the patient was able to eliminate visual disturbances (this also applied to alternative consciousness). Waking up in the middle of the night, the patient found herself in a room unfamiliar to her, since in the spring of 1881 the family changed apartments. Such unpleasant experiences were eliminated by the fact that in the evenings (at her request) I closed her eyes, suggesting that she would not be able to open them until I did it myself in the morning. A similar commotion in the house was repeated only once more, when the patient burst into tears in her sleep and woke up and opened her eyes.
Since the laborious analysis of the symptoms led to events dating back to the summer of 1880, when the patient's illness was just beginning, I was able to obtain a fairly complete idea of the incubation period and pathogenesis of the described case of hysteria, which I want to briefly outline here.
In June 1880, while at the dacha, my father became seriously ill with primary purulent pleurisy; His mother and Anna looked after him. One night the patient woke up in great anxiety and impatience because the surgeon who was to operate on her father was expected to arrive from Vienna. The mother went out for a while and Anna O. was left alone at the patient’s bedside. The patient was sitting with her right hand resting on the armrest of a chair. Anna O. was in a state of daydreaming, she saw how a black snake from the wall approached the patient to bite him (It is quite possible that in the meadow behind the house there were actually several snakes that had frightened the girl before, and now became material for her experiences hallucinations). She wanted to protect her father from danger, but she seemed paralyzed; her right hand, hanging over the armrest, “frozen” and went numb, but looking more closely, the girl saw with horror how her fingers turned into small snakes with the heads of the dead (in place of her nails). Most likely, the girl tried to drive away the snakes with her paralyzed right hand, which is why the associations between numbness and paralysis of the hand and hallucinations about snakes coincide. - When the snakes disappeared, the patient, continuing to be in a state of horror, wanted to pray, but her tongue did not listen to her, she could not utter a single word in any language, until finally she managed to recite an English nursery rhyme. From then on, she could think and pray only in this language.
The whistle of the locomotive, which brought the long-awaited doctor, interrupted the turmoil in the house. When the next day the patient reached out to get a hoop from the bushes that had accidentally fallen there during a game, the leaning branch again provoked a hallucination of snakes in the patient, and immediately the right arm stretched out and became stiff. This now began to repeat itself constantly as soon as a more or less suitable object was found to provoke emerging hallucinations - only a distant resemblance to a snake was enough. But like contractures, they arose only during short periods of absence seizures, which became more and more frequent after that ill-fated night. (This contracture became permanent only in December, when the completely exhausted patient could no longer leave the bed.) For some reason, the contracture of the arm was joined by a contracture of the right leg. I do not find any mention of the cause in my notes, and I have forgotten all the events related to the new symptom.
Now the patient has a tendency to autohypnotically fall into absence seizures. The next day (after the night of waiting for the surgeon) the patient was so absorbed in herself that she no longer heard the doctor appear in the room. The patient’s unrelenting anxious state created interference with eating, and in addition, Anna O. gradually began to develop a feeling of disgust. All specific hysterical symptoms usually arose against the background of experiencing strong emotions. It remains unclear whether they appeared only in a state of short absence seizures. Most likely this was the case, since in her normal state the patient knew nothing about the existence of such strong affects.
And only a small number of symptoms, apparently, arose not at the moment of absence, but in a waking state, at the peak of the affect she experienced, in order to later begin to appear in similar situations. Thus, most visual disorders were explained by individual more (or) less clearly understandable reasons, for example, when the patient was sitting at the bedside of a patient with eyes full of tears, he asked her to tell what time it was; because of the tears, the girl saw everything blurry, she made desperate attempts to get a better look at the dial, brought the watch close to her eyes, and that’s when the dial seemed terribly huge to her (macropsia and convergent strabismus); the girl made incredible efforts to hide her tears from the patient.
One of the quarrels, when the patient managed to restrain herself from responding with an offensive word, caused her vocal spasms, which began to be repeated in any similar situation.
She could lose her speech:
a) because of fear (this began to appear after experiencing a night hallucination)
b) after the mentioned quarrel, when she refrained from responding to the insult (active suppression)
c) after she was once unfairly scolded
d) in all similar situations (resentment).
A nervous cough appeared for the first time when, while on duty at the bedside of her sick father, dance music was heard from a neighboring house and the natural desire to be there caused strong self-recrimination in the patient. Since then, throughout her illness, the patient reacted to any truly rhythmic music with a nervous tussus.
I am not too disturbed that some of my notes, from lack of completeness of information, do not allow me to come to the conclusion that this whole case of the disease of hysteria can be completely reduced to reactions to the circumstances in which each of the symptoms first arose. Almost everywhere the patient was able to detect the primary cause that led to the appearance of the symptom, with the exception of the episode already mentioned above. And every symptom, after telling about the circumstances of its occurrence, disappeared without a trace.
This is how the patient’s illness was ended. The patient herself decided that on the anniversary of her forced move to the dacha she should completely cope with her illness. Therefore, starting from the very beginning of June, Anna O. indulged in “talking cure” with enormous, all-consuming energy. On the last day of treatment, with my help, the patient remembered that she had arranged her room to look like the room where her sick father lay. The patient re-experienced with all the vividness the hallucination described above, which terrified her so much and was the root of the entire disease; under its influence, Anna O. could think and pray only in English. And immediately after remembering the previous horror, Anna O. spoke in German, becoming completely free from the countless specific symptoms she had previously demonstrated in such abundance. For some time, Anna O. left Vienna to travel, but quite a lot of time passed before she managed to completely restore her mental balance. And since then she has enjoyed absolute health.
Despite the fact that I have omitted many details that are not without interest, the medical history of Anna O. turned out to be much more extensive than such an unusual case of hysteria might seem to deserve. There was no other way to clearly present this clinical case than to go into the details of the medical history, without which all the originality of the disease being described is lost, and this is precisely what can excuse me in the eyes of the readers for the fact that I abused their attention for so long. After all, the eggs of echinoderms are not of such great importance for embryological research because the sea urchin is an extremely interesting animal, but because its protoplasm is transparent enough to detect many physiological processes in it and then transfer the corresponding conclusions to eggs with turbidity. plasma.
The interest of the case of hysteria presented here lies primarily in its understandability and in the explainability of the pathogenesis of the disease.
As factors predisposing to hysteria, we can note two mental qualities found in Anna O.:
Monotonous life in the family of her parents, when the patient did not have the opportunity to engage in active spiritual activity, a huge excess of psychic energy remained unspent, which only remained to go into continuous fantasizing and
Tendency to daydreams (“private theater”), leading to the necessary prerequisites for the formation of dissociated (multiple) personalities. However, this may still remain within the normal range; Spontaneously manifested daydreaming or meditation in themselves in no way lead to a pathological splitting of consciousness, since such disorders can be easily eliminated, for example, by a call to gather, thereby restoring the unity of consciousness, and amnesia almost never occurs here.
But in the described clinical case, Anna O. had prepared the ground on which the affect of fear and fearful expectation took hold, after one day ordinary dreams took the form of a hallucinatory absence seizure. What is noteworthy is how perfect in this first manifestation of the incipient disease its main features are, which then remain constant for almost two years: the existence of an alternative state of consciousness, first manifested in the form of a transient absence seizure, and later forming in double conscience, the disappearance of speech under the influence of the anxiety she was experiencing, with some easing of restrictions after the English nursery rhyme came to her aid; the subsequent appearance of paraphasia and loss of the ability to speak German, completely replaced by English; finally, an accidental paralysis of the right arm, subsequently leading to right-sided contracture - paresis and loss of sensation. The mechanism of occurrence of the latter disorder is fully consistent with Charcot’s theory of traumatic hysteria, namely: traumatic hysteria is nothing more than a hypnotic state in which the future neurotic recreates the mental trauma he experienced in a lighter form.
But if, when experimentally inducing hysterical paralysis in patients, Professor Charcot immediately restored their previous state, and even in carriers of traumatic neurosis, shocked to the depths of their souls by a terrible injury, the latter spontaneously disappeared after a short time, then the nervous system of our young patient took another four months successfully resisted healing. Contracture, like other gradually adding disorders, appeared only during short intervals of absences of alternative consciousness, but in a normal state the patient had complete power over her body and feelings, so that neither she herself nor the people around her noticed or guessed about the metamorphoses taking place in her . Everyone's attention was completely concentrated on the sick man (father), and therefore nothing else was noticed and could not have happened.
But absence seizures, accompanied by complete amnesia and hysterical phenomena, began to become more and more frequent after that first hallucinatory autohypnosis, their duration and the possibility of forming new symptoms increased, and those that had already been formed acquired greater strength as a result of increasing repetitions. It also turned out that over time, each of the affects tormenting the patient began to have an effect similar to absence (if the latter did not arise simultaneously with the painful emotion), random coincidences could lead to new pathological connections, disorders of the sensory organs or movements, which now appeared synchronously with the affect . But before the patient completely went to bed, all this lasted only a few moments, then disappearing without a trace; despite the fact that at that time Anna O. had a whole bunch of hysterical phenomena, no one knew about their existence. Only when the patient was completely broken by physical exhaustion, insomnia and unceasing anxiety, most of the time being in a state of alternative consciousness, only then did hysterical phenomena manage to invade the normal mental state of the patient, turning from temporary disorders manifested in the form of seizures into chronic symptoms.
We also need to clarify how much we can trust what the patient said, whether the pathological phenomena that existed in her actually arose precisely as a result of the events that Anna O told about. The reliability of what she reported regarding the most significant and fundamental phenomena did not raise any doubts in me. And here I rely not only on the fact that after the patient managed to speak out to the end, the symptoms disappeared; this could very easily be explained by the effect of suggestion on the part of the doctor. The sick girl was always characterized by sincerity, the things she told were completely connected with what was most sacred to her; all facts that could be verified were fully confirmed in conversations with people around the patient. And, in general, even the most gifted girl probably would not have been able to build a data system that would have such a powerful logic, as was manifested in Anna O’s confessions. Despite this, and even precisely as a result of the existence of such a strong logic, the reasons were distorted , leading to the occurrence of certain symptoms (and with the best intentions) - this was clearly not true. But I also consider this course of things to be quite natural. It is precisely the insignificance of such reasons, their irrationality, that justifies their existence. The patient did not understand why she was forced to cough in response to the sounds of dance music. Any arbitrarily fictitious construction would be simply meaningless here. Of course, it was easy for me to imagine that reproaches of conscience caused spasms of the vocal cords in the patient, and impulses to make movements turned the spasms into nervous tussis; Almost any girl who passionately loves dancing could react this way. So, as the reader can see, I consider the patient’s stories to be completely reliable and believable.
How fair is it to assume that in other patients the development of hysteria will proceed in a similar way, that similar things will happen where there is no such clearly expressed organization of “condition seconde”? I would like to draw the readers’ attention to the fact that the entire history of the development of events in the described disease could have remained unknown to both the patient and the doctor, if not for Anna O.’s ability, which we described earlier, to remember in hypnosis and talk about it. Moreover, in her usual normal state, she could not remember anything like this. So in other patients, nothing significant can be discovered as a result of questioning undertaken with individuals who are in waking consciousness, even if they have good will, they will not be able to provide us with any valuable information. And I have already mentioned above how blind people around neurotics are in this regard. - What is actually happening to sick people can, therefore, be known only by applying a method similar to techniques that have their origins in Anna O. Of course, it would be fair to assume that such spontaneous self-disclosure occurs more often than our poor knowledge of pathogenic factors allows mechanisms.
When the patient went to bed, and her consciousness alternately chose between a normal and an alternative state, another group of pathological phenomena was added to the horde of hysterical symptoms that constantly appeared alternately, having at first glance a different origin: contractures - paralysis of the left-sided limbs and paresis of the neck muscles that control movements heads. I single them out from the whole mass of hysterical symptoms, because if they managed to get rid of them at least once, then they never appeared again, even in the form of a short-term attack or in some veiled form, this also applies to the final phase of treatment , when many other symptoms revived again after a long slumber. That is why stories about them never appeared in hypnotic analyzes; it is difficult to attribute their appearance as a result of the influence of affects or fantasy activity of the patient. I am inclined to believe that the mentioned group of movement disorders owes its appearance not to the mental process that caused the other psychopathological symptoms, but is an extension of a condition still unknown to us, which serves as the somatic foundation of hysterical phenomena.
*** Bertha Pappenheim (1859-1936) was hiding under the pseudonym Anna O., who became ill while caring for her father, who was suffering from cavernous tuberculosis. The author of the famous three-volume biography of Freud, E. Jones (1953), “exposed” the patient. Freud learned about the patient's treatment from Breuer a few months after the completion of the treatment (November 1882). Freud was so fascinated by the case history that he could not understand why Breuer did not want to publish it, nor talk about the new treatment method he had created - “cathartic psychotherapy.” And only a year later, Breuer openly admitted to a young colleague that he was so involved in Anna O.’s treatment that he ultimately aroused his wife’s jealousy. He had to tell the patient that he was stopping treatment forever. And in the evening of the same day, he was urgently called to this patient, who was lying in “labor pains” from a false pregnancy and shouting: “Dr. Breuer’s child will be born!” Breuer put the patient into a hypnotic state and tried to calm her down, and the next day he and his wife left for Venice. In the same year, a month after the completion of Breuer's treatment, the patient became so ill that she was forced to be admitted for inpatient treatment to the famous Bellevue nervous sanatorium (“beautiful view” is the name often given to the area on which the beautiful palace is located) in Kreuzling on Lake Constance, where she remained from mid-July to the end of October 1882. There Anna O. was treated for various somatic symptoms (including trigeminal [trigeminal nerve] neuralgia), and large doses of morphine were used for this. In the evenings she again lost the ability to speak German and switched to English or French. In a letter to Stefan Zweig (Zweig), Freud wrote: “What actually happened to Breuer’s patient, I was able to unravel only many years after our breakup with him... At the last meeting with the patient, he had in his hands a key with which he could open the door to the mysteries of life, but he let it fall. For all his spiritual talent, he did not have anything Faustian in his character. Horrified by what he had done, he fled, leaving the care of the patient to one of his colleagues” (Freud S. Briefe 1873-1939. Frankfurt a. M. 1968, p. 427). And this was not the end of the matter, as Jones writes in the first volume of his famous biography of Freud: “About ten years later, while Freud was treating patients in collaboration with Breuer, the latter invited Freud to see his hysterical patient. Before going to see her, Breuer described her symptoms in detail, after which Freud said that this was very typical of a fantasized (false) pregnancy. This repetition of the previous situation was difficult for Breuer to bear. Without saying a word, he took his hat and cane and quickly left Freud” (Jones E. Das Leben und Werk von Sigmund Freud. Bern, 1960, p. 269). For some time, Anna O. abused morphine. Later, without any medical help, she became fully involved in social activities, although in life she ignored sex. She was quite famous as an outspoken fighter for the emancipation of women, especially Jews. The famous Jewish philosopher Martin Buber (1878-1965) once said: “There are people of spirit, there are people of passion, and both are not very often to be found, but even more rare are people who combine spirit and passion. . This is the kind of person with a passionate spirit that Bertha Pappenheim was” (1939). With her personal savings, she founded the “Haim (shelter) for abused girls and illegitimate children.” Taking care of the unfortunate children completely replaces the absence of her own children. But the memories of the cathartic treatment carried out continue to haunt her further; she strictly prohibits any type of psychoanalytic treatment of people in the institutions she founded. Anna Freud also recalls that Bertha Pappenheim was “hostile to analysis” throughout her life (see the article “Episodes from the Life of Bertha Pappenheim (Anna O.)” by Bernd Nitzschke in the leading German psychoanalytic journal “Psyche”, p. 819). Bertha Pappenheim herself says the following about psychoanalysis: “Psychoanalysis in the hands of a doctor is the same as confession in the hands of a Catholic priest; it will depend only on their personality and mastery of their method whether their instrument turns out to be good or a double-edged sword” (see the collection edited by D. Edinger “Bertha Pappenheim. Leben u. Schriften. Frankfurt a. M. 1963, pp. 12- 13). And Anna O. described her general position in life as follows: “Everyone, regardless of whether he is a man or a woman, must do what he must do, using either his strength or his weakness.” For Freud, understanding the power of transference and countertransference in this case history became the starting point for the transition from cathartic therapy to psychoanalysis. In his obituary for Breuer's death (1925), Freud wrote: "Breuer was confronted with the inevitable transference of the patient onto the doctor and was unable to understand the impersonal nature of this phenomenon." Mistaking the feelings of transference for the real feelings of the patient, Breuer responded to them with a massive reaction of unconscious countertransference, which even years later did not allow him to recognize the sexual nature of Anna O’s symptoms, so in a letter from Breuer dated November 21, 1907 to the famous psychiatrist August Forel: “I must confess to you , my taste disgusts me to dive into the realm of the sexual, both in theory and in practice. But what does my taste and my feelings have to do with it when it comes to the truth, discovering what is actually in front of us. The case of Anna O. proves that a sufficiently severe case of hysteria can arise, persist and be eliminated without sexual elements playing any role in it. My merit consisted mainly in the fact that I was able to understand that fate had placed in my hands an unusually instructive case, important for science, which I was able to carefully observe for quite a long time, and without disturbing its simple and natural course in any way. preconceived opinion. Then I learned a lot, I learned a lot of amazingly valuable things for science... But I also learned what needs to be given priority attention in practical activities. It is impossible for a private practitioner to treat such cases without completely destroying his activities and way of life through such treatment. I praise myself for the decision I made then to not allow such inhuman tests to happen again. When I had patients for whom I expected a lot from analytical treatment, but whom I myself could not treat, I referred them to Dr. Freud, who had returned from Paris and the Salpêtrière, a doctor with whom I was on the most friendly terms, and also in fruitful scientific contacts" (1907).
P. S. *** The case of Anna O.
Freud became friends with the physician Joseph Breuer (1842-1925), who became famous for his work on the process of breathing, as well as studying the functions of the semicircular canal in the human ear. Well settled in life and already wise in it, Breuer often gave the young Freud a variety of advice and even lent him money. For Freud, he was something like a father, a symbolic figure. Breuer apparently regarded Freud as a precocious younger brother. “Freud’s intellect soars to transcendental heights,” Breuer wrote to one of his friends. “I sometimes look at him like a chicken at a hawk” (quoted in: Hirschmulier. 1989. P. 315). They often discussed together difficult cases from Breuer's practice, including the case of Anna O. It was these events that were destined to play a decisive role in the development of psychoanalysis.
An intelligent and attractive 21-year-old woman, Anna O. suffered from a range of severe hysterical symptoms. She complained of paralysis, memory loss, mental disorders, nausea, visual and speech disturbances. These symptoms first appeared while she was caring for her dying father. Breuer treated her using hypnosis. He found that, under hypnosis, the patient could recall experiences that may have been the cause of these symptoms. Subsequent discussion of her experiences while in hypnosis seemed to improve her condition.
Breuer saw Anna O. every day for a year. During these meetings, Anna O. recalled the traumatic experiences that she had experienced during the day. And each time after such discussions, she reported an improvement in her health. She regarded her meetings with Breuer as "cleansing" or "healing conversations." As the treatment continued, Breuer realized (and told Freud about it) that the experiences Anna recalled under hypnosis often included thoughts and events that she regarded as disgusting. Release from traumatic experiences under hypnosis reduced or completely eliminated painful symptoms.
Over time, Breuer's wife began to show more and more anxiety and jealousy over the excessively close emotional intimacy between her husband and Anna. What happened to Anna was what later became known as positive transference (Positive transference is a process in which the patient communicates with the therapist as if he were his parent.).
In other words, she transferred her feelings towards her father to the doctor, especially since they were somewhat similar in appearance. Breuer may also have had an emotional attachment to his patient. “Her charm of youth, charming helplessness, even her very name... awakened in Breuer a dormant Oedipal attraction to his own mother” (Gay. 1988. P. 68).
But, in the end, Breuer assessed the current situation as dangerous and was forced to announce to Anna that he was stopping treatment. A few hours later, Anna began having hysterical labor pains. Breuer managed to relieve symptoms under hypnosis. According to legend, after this he arranged for his wife a second honeymoon in Venice, where she successfully became pregnant.
But in reality this is nothing more than a myth. A myth that was shared by several generations of psychoanalysts and historians of science. A myth that has existed for more than a hundred years. It is possible that Breuer and his wife did travel to Venice, but the birth dates of his children strongly suggest that neither could have been conceived at that time (Ellenberger. 1972).
In addition, subsequent studies showed that Breuer was in fact unable to permanently cure Anna O. (her real name was Bertha Pappenheim) using his cathartic method. After Breuer stopped his treatment, she was admitted to an inpatient facility. There she could sit for hours next to her father’s portrait, talking about how she went to his grave. Breuer spoke of her to Freud as hopelessly crazy and expressed the hope that only a quick death could save the poor woman from her suffering. It is not known exactly how she managed to recover, but Anna O. subsequently became a prominent figure in the social movement, a feminist advocating for the education of women. She wrote short stories of "wisdom, passion and resilience" and also published a play in support of women's rights (Shepherd 1993, p. 210).
The case of Anna O. is extremely important for the development of psychoanalysis, since it was here that Freud first came into contact with the method of catharsis, therapeutic conversation, which later played such a significant role in his own research.
To achieve his discoveries, Freud inevitably had to go through hypnosis, since this was one of the leading methods of psychotherapy for hysteria, which was of great interest to Freud. "The personal involvement of the physician has become the cornerstone of psychoanalysis."
The starting point in his medical career was his acquaintance with the story of Anna O. (Bertha Pappenheim), a patient of his friend and spiritual teacher Breuer.
This event confronted Freud with two major interrelated problems - hysteria and hypnosis. It was during the study of hysteria that the scientist’s interest shifted from physiology to psychology. Why did the story of Anna O. Freud become interested in 1882? In a number of sources from the founder of psychoanalysis, his followers and critics, we find recognition that Freud was always attracted to philosophy, but he never loved medicine. It is possible that patients with hysteria interested the scientist due to the specifics of his personality. It also did not go unnoticed that the case of Anna O. demonstrated the possibility of successfully treating hysteria in an unconventional way, the development of which Breuer refused and did not publish the case history for many years. Moreover, in publishing, Breuer omitted the significant event that brought an end to Anna O.'s treatment: the patient's unexpected manifestation of a powerful, unanalyzed positive transference of an irrefutably sexual nature.
But the main thing, in our opinion, is that the story interested Freud due to the unique combination in this disease of the problems of soul and body, mental and somatic, intuitive understanding of the possibility of a shift in its treatment from medicine to mysterious psychology, stunning in its consequences.
Fragment of the analysis of hysteria. (Dora's medical history). 1905
PREFACE.
After much hesitation, I finally decided to confirm the statements I made in 1895 and 1896 about the pathogenesis of hysterical symptoms and about mental processes in hysteria with a detailed report of the medical history and treatment. Here I cannot do without a preface, which, on the one hand, justifies my actions in different directions, and on the other hand, it must satisfy the expectations of the public.
Of course, it is risky that I publish the results of a study that is so striking and unpleasant that verification by colleagues will be simply impossible. But no less dangerous is the fact that I am now beginning to make accessible to the general understanding the special material from which I obtained those results. There is no way I can get around the reproaches. If earlier this reproach was manifested in the fact that I report absolutely nothing about my patients, now it will say that I report something about my patients that should not be reported. I hope that in both cases the same persons will be dissatisfied, who, using a new pretext, will only change the content of their reproach, and I refuse in advance to deprive these critics of their speech ever in the future.
The publication of my case histories still remains a difficult task for me, although I am no longer upset by these unreasonable ill-wishers. These difficulties are partly caused by the technical side of the treatment, but partly they come from the nature of the disease itself. If it is true that the cause of hysterical illnesses lies in the intimate psychosexual life of the patient and that hysterical symptoms are a manifestation of the most secret, repressed desires of these patients, then the explanation of any clinical case of hysteria cannot be anything other than the discovery of these intimate experiences and the solution these secrets. Of course, these patients would never have spoken if it had occurred to them that there was a possibility of a scientific evaluation of their confessions. It is also true that it is completely futile to ask permission from them to publish. Normally, delicate and timid persons would, under such conditions, place the doctor's duty of secrecy at the forefront and would express regret that the scientists were thus forced to lose their intelligence function. But I believe that the doctor assumes not only responsibilities towards the individual patient, but also towards science. And to science, this, in its essence, does not mean anything different - as is the attitude towards many other patients who are already suffering from the same thing or will still suffer. Public communication of what is known about the cause and structure of hysteria becomes a duty, and omission becomes shameful cowardice, if, of course, direct harm to a particular patient can be avoided. I believe that I did everything to prevent such harm in relation to my patient. I found a man whose drama was played out not in Vienna, but in a small town located to the side. Thus, the identity of my patient must be completely unknown to Vienna. From the very beginning, I kept the treatment secret so carefully that only one single, completely trustworthy colleague could know that the girl was my patient. After the completion of the treatment I waited another four years for an opportunity to publish, until I heard of a change in the patient's life which led me to believe that her own interest in the events and mental processes related here might now fade. It goes without saying that there will not be a single name here that could lead any of the readers who do not belong to the medical circle to the traces of real people. However, publication in a strictly scientific professional journal should be protection from such an incompetent reader. Naturally, I cannot prevent the patient herself from feeling a painful feeling of embarrassment if by some chance her own medical history falls into her hands. But she will not learn from it anything more than what she already knows. But one can also raise the question of who else, based on this medical history, can guess that we are talking about her personality.
I know that there are (at least in this city) many doctors who - with sufficient disgust - want to read one of these case histories, not as a contribution to the study of the psychopathology of neuroses, but as one of the novels intended for their amusement, in in which real people are exposed. I can assure this class of readers that all my somewhat later medical histories will be protected from their insight by similar guarantees of secrecy. But because of such aspirations I am forced to limit the material at my disposal to an unusual degree.
In this medical history, in which I am forced to introduce restrictions due to the medical duty of secrecy and due to an unfavorable combination of circumstances, sexual relations will be discussed with all frankness, the organs and functions of sexual life will be called by their real names. A chaste reader, based on my narrative, can easily come to the conclusion that I was not ashamed to talk with a young female person about this topic in such language. Probably I must now defend myself against such a reproach. But I simply resort to the law of gynecologists (or rather, much more modestly than that) and explain as a manifestation of one of the signs of perverse and strange lust that someone should assume that such conversations are a good means of exciting or satisfying sexual desires . Otherwise, I am inclined to wish to convey my opinion on this in a few words of Richard Schmidt (Contribution to the Study of Indian Erotica, Preface, 1902): “It is, of course, deplorable that such protests and assurances should have a place in scientific work, but not reproach me for this, but blame the spirit of the times, in which we have happily reached the point that now there is no longer a single serious book that would be closely connected with our lives.”
I will now report how in this case report I overcame the technical difficulties involved in presenting the report. Such difficulties are very great for the doctor, who must carry out six or eight such psychotherapeutic treatments daily and cannot even take notes during a session with the patient, so as not to arouse the patient’s mistrust and prevent himself from fully grasping the incoming material. A still unsolved problem for me is how I could prepare for reporting the history of a treatment that lasted quite a long time. In the clinical case presented here, two circumstances came to my aid: first, that the duration of treatment did not exceed three months, second, that all explanations are grouped around two dreams told in the middle and at the end of the course of treatment, the verbatim plot of which was written down immediately after the session, and which proved to be a reliable support for the subsequent interweaving of interpretations and memories. I wrote down the medical history itself from memory only after completing the course of treatment, since my memory was still fresh, and due to my interest in the publication, sharpened. Therefore, this recording is not absolutely - phonographically - correct, but can still lay claim to a high degree of reliability. In this case history, nothing else that would be significant has been changed, except that in some places the sequence of explanations has changed, which I did out of love for the logic of the presentation. Now I want to highlight what can be found in this message and what is omitted from it. At first this work was called "Dreams and Hysteria," as it seemed to me especially suitable for showing how the interpretation of dreams is included in the history of treatment, and how the work of recovering forgotten things and explaining symptoms benefits from such assistance. Not without good reasons, in 1900 I prefaced a painstaking and in-depth study of dreams in the publications I had planned on the psychology of neuroses (“Interpretation of Dreams”). Of course, from the way it was received, one can see with what insufficient understanding our colleagues still regard such efforts. At the same time, the reproach that my positions, due to the scarcity of material, does not allow me to come to a conviction based on additional verification is not justified. After all, everyone can use their own dreams for analytical research, and the technique of dream interpretation can be easily learned on the basis of the instructions and examples I have given. I must today, as before, affirm that an inevitable condition for understanding mental processes in hysteria and other psychoneuroses is a deepening into the problems of dreams, and that no one has the opportunity to advance even a few steps in this area if he wants to avoid such preparatory work. work. Thus, since the reading of this case history presupposes knowledge of dream interpretation, it will be extremely unsatisfactory for anyone who does not have this knowledge. He will only be unpleasantly stunned, instead of finding in it a sought-after explanation and, of course, will be inclined to project the reasons for this unpleasant amazement onto the author, taken for a dreamer. In fact, such unpleasant amazement is associated with manifestations of the neurosis itself; understanding is hidden from us only because of our medical habit and appears again when we try to explain. A complete elimination of misunderstandings would, of course, be possible only if we were able to completely explain neurosis by factors that are already known to us. But everything speaks in favor of the fact that, on the contrary, when studying neurosis, we receive an incentive to accept and understand many new things, which later can gradually become the subject of reliable knowledge. The new always awakens unpleasant surprise and resistance.
It would be a mistake to think that dreams and their interpretation occupy as large a place in all psychoanalysis as in this example.
If the present medical history prefers to pay great attention to dreams, then in other points it is more meager than I would like. But precisely these shortcomings are connected with the conditions that made it possible to publish it. I have already said that I could not cope with the material of any treatment history that extends over more than one year. This just three-month story can be seen in its entirety at once and remembered anew; but its results remained deficient in several points. The treatment was not completed to the set goal, but was interrupted at the request of the patient when a certain intermediate result was achieved. By this time, we had not yet begun to fully understand some of the mysteries of the clinical case, and others had not been fully clarified. Continuing our work, we would probably penetrate into all points, right down to the last possible explanation. Thus, I can only offer a fragment of the analysis here.
It is possible that the reader who is familiar with the analytical techniques presented in “Etudes on Hysteria” will be surprised that in three months it was not possible to bring to complete disappearance at least those symptoms that had already been vigorously tackled. But this will become clear if I say that since the Etudes, psychoanalytic technique has experienced a fundamental revolution. Previously, our work was based on symptoms and aimed at their consistent elimination. Lately I have completely given up this technique, since I found it completely inconsistent with the subtle structure of neuroses. Now I allow the patient himself to determine the theme of daily work and, therefore, start from the plane on which the unconscious opens to his attention. But then I get what is inextricably linked with the symptom itself, in the form of separate torn pieces, woven into various combinations and distributed over a widely divergent period of time. Despite this apparent drawback, the new technique is in many ways superior to the old one and, undoubtedly, is the only one possible.
In view of the incompleteness of my analytical results, I have no choice but to follow the example of those researchers who were so lucky that they managed to extract priceless, albeit distorted, remains of antiquity from centuries-old oblivion. I completed this unfinished work according to the best examples known to me from other analyses, but, like a conscientious archaeologist, I did not miss the opportunity in each case to show where my designs are authentic.
I intentionally create another kind of incompleteness myself. In general, I have not shown the work of interpretation that is carried out regarding the associations and messages of the patient, but have given only its results. Thus, the technique of analytical work that does not concern dreams is revealed only in some places. In this case history, I tried to show only the determination of symptoms and the internal structure of a neurotic disease. If I tried to perform other tasks at the same time, it would only cause irreparable confusion. To substantiate the technical, most often empirically found rules, it would probably be necessary to collect material from many treatment histories. Meanwhile, the reduction caused by the concealment of technology can be considered not particularly large. Even the most difficult part of the technique was out of the question when working with this patient, since the “transfer” factor, which will be discussed at the end of the medical history, is not affected during this short treatment.
For the third type of incompleteness of this message, neither the patient nor the author is to blame. On the contrary, it goes without saying that one single case history, even if it is completed and does not raise any doubts, cannot answer all the questions that arise in the problem of hysteria. One medical history cannot reveal all types of illness, all forms of the internal structure of neurosis, all types of mental and somatic connections possible in hysteria, and in fairness, one cannot demand more from one clinical case than it can give. Likewise, the conviction of the general and exclusive practicality of the psychosexual etiology of hysteria is unlikely to be achieved by someone who still cannot believe it through familiarization with a single case history. At best, he will postpone his opinion until he himself, through his own work, acquires the right to belief.
Addendum (1923)
The treatment described here was interrupted on December 31, 1899, a report about it was written within the next 2 weeks, but was published only in 1905. It should not be expected that over two decades of ongoing intensive work nothing should have changed in the understanding and ways of presenting such a clinical case, but it would obviously be absolutely pointless to bring this case history up to date with proofs and expansions. time.), adapting it to the current state of our knowledge. So, I left the main text unchanged, but only corrected negligence and inaccuracies in the text, which were brought to my attention by my excellent English translators, Mr. and Mrs. Strachey. What seemed acceptable to me to add critically, I cited in the additions to the medical history, so the reader has the right to assume that even today I firmly adhere to the views presented in the text, if he does not find any objection in the additions. The problem of maintaining medical confidentiality, which occupied me in this preface, is not considered in other case histories contained in volumes VII, VIII and XII of my “General Collection of Works” (Gesammelte Werke), since three case histories were published after obtaining the consent of the patients themselves, and for little Hans - with the consent of his father, in one case (Schreber) the object of analysis was not a person at all, but a book published by him. In Dora's case, the secret remained until this year. Recently I heard that a girl who had long disappeared from my sight fell ill again, but for different reasons. She revealed to her doctor that the girl had been the subject of my analysis, and such a confession made it easy for a knowledgeable doctor to recognize her as the Dora of 1899. The fact that three months of the previous treatment did not achieve anything more than the elimination of the then conflict, that the treatment could not also achieve immunity in relation to subsequent diseases, no fair person would reproach analytical therapy.
I. DISEASE STATUS
In my book “The Interpretation of Dreams,” published in 1900, I proved that dreams can usually be interpreted, that they can be replaced by exemplary thoughts that are easily introduced into a soul connection in certain places. In the following pages of my new book I want to give an example of the only practical application which the art of dream interpretation seems to admit of. I have already mentioned in my book (The Interpretation of Dreams, 1900) how I approached the problem of dreams. I discovered it on my path when I tried to treat psychoneuroses with the help of a special method of psychotherapy, in which the patients, along with other events from their mental life, communicated to me dreams, which, apparently, sought to weave into the already woven relationships between the symptom of the disease and the pathological idea . Then I learned how to translate the language of dreams without any outside help into ways that the language of our thinking understands. I strongly assert that this knowledge is absolutely necessary for the psychoanalyst, since the dream is one of the ways through which that psychic material can be realized, which, due to the opposition caused by the content of the dream, is pushed away from consciousness, repressed and therefore becomes pathogenic. In short, dreams are one of the roundabout ways to bypass repression, one of the main means of the so-called indirect modes of manifestation in the psyche. The way in which the interpretation of dreams contributes to psychoanalytic work should now be shown by the fragment we offer from the history of the treatment of a hysterical girl. At the same time, he should give me for the first time an opportunity, in a breadth that no longer causes misunderstandings, to publicly present part of my views on mental processes and organic conditions of hysteria. For such a broad approach, I perhaps need no longer apologize, since it is universally recognized that the enormous claims that hysteria makes for the doctor and the researcher can only be kept up with an interested delving into the problems, and not with an arrogant underestimation of them. Certainly,
"Skill and science are important here,
But also patience
Lives in creation!
To offer the reader a case history that is free of gaps and smoothly completed would mean to place him from the very beginning in completely different conditions than those experienced by the observing physician. What is usually reported by the relatives of the patient (in this case, the father of an 18-year-old girl) often presents a very vague picture of the course of the disease. Although then I begin treatment by asking the patient himself to tell me the whole story of his life and illness, and what I hear in response is not yet enough for a complete orientation. This first story can be compared to a stream impassable for ships, where the bottom is sometimes lined with piles of rocks, sometimes divided by sandbanks. I can only be surprised that some authors have produced polished and accurate case histories of hysterics. In reality, patients are simply not able to provide information about themselves of this nature. Although patients can inform the doctor quite well and coherently about this or that period of their life, a little later there still comes a moment when their information becomes superficial, leaving gaps and mysteries, and at other times you are generally faced with a completely dark period of time, in in which everything is completely incomprehensible, despite any explanations from the patient. Relationships, even the most obvious ones, are most often broken, the sequence of various events is unreliable, during the story itself the patient, repeating himself, changes some fact or date, and then after much hesitation, for example, returns again to what he said earlier. The inability of patients to coherently present their life stories, since they coincide with their medical histories, is not only characteristic of neuroses, but is not without great theoretical significance. [One day one of my colleagues referred his sister to me for psychotherapeutic treatment, who, as he said, had been unsuccessfully treated for years due to hysteria (pain and difficulty walking). This brief information seemed entirely consistent with the diagnosis: in the first sessions I allowed the patient herself to tell her story. Since her story, despite the interesting facts outlined in it, turned out to be completely clear and logical, I told myself that this case could not be hysteria. Immediately after this I carried out a thorough somatic examination. The result was a diagnosis of moderately progressive tabes (Tabes dorsalis (lat.)), a significant improvement in the picture of which then occurred after mercury injections (Ol. cinereum, carried out by Professor Lang)]. The lack of coherence in the portrayal of personal life in patients has the following justification. Firstly, patients consciously and deliberately hide part of what they know well and what they had to tell, because of shyness and shame that have not yet been completely overcome (restraint if other significant persons appear in the story); it's part of a deliberate lack of candor. Secondly, during this story, without any conscious intent, part of the anamnestic information that patients usually freely have is hidden: this is part of the unconscious lack of frankness. Thirdly, one can always detect actual amnesia, lapses in memory, and not only old, but even completely new impressions are erased; it is possible to identify false memories that are formed a second time to obscure such failures. [Amnesia and false memories stand in a complementary relationship. Where large memory gaps are revealed, you always come across some false memories. As well as vice versa, the latter can at first glance completely hide the presence of amnesia.] Where the event itself has been retained in memory, there the same intention that causes amnesia is manifested by eliminating the connection. And this connection is most surely broken if the time sequence of events changes. The latter constantly turns out to be the most vulnerable, the most often subject to repression, an integral part of the memory storehouse. Some memories are, so to speak, still in the first stage of repression; they are tainted with doubt. And some time later, this doubt would be replaced by forgetting or false memory. [When presented with something with a touch of strong doubt, as the rule learned from experience teaches us, we can completely ignore the expressed opinion of the narrator. If the narrative oscillates between two statements, then the first is considered to be more likely true, and the second is a product of repression.]
One such state of memory related to the medical history is a necessary, theoretically required correlate in the symptoms of the disease. Later in the course of treatment, the patient brings in something that he had hidden or that previously simply did not occur to him, although he always knew it. False memories turn out to be fragile, gaps in memory are filled. Only at the end of treatment can a consistent, understandable and complete medical history appear in itself. If the practical part of the treatment is aimed at eliminating all possible symptoms and replacing them with conscious thoughts, then another, theoretical goal of the work can be to cure the patient of all memory impairments. Both goals coincide: if one is achieved, then the other will also be won; the same path leads to both.
From the nature of the things that form the material of psychoanalysis, it follows that in our case histories we must pay as much attention to the purely human and social relationships of the patients as to the somatic data and symptoms of the disease. “First of all, our interest turns to the family relationships of the patient, and to other relationships, as will be seen later, only if they are somehow related to the detected heredity.
The family circle of the 18-year-old patient included her parents and brother, who is one and a half years older than her. The dominant person was the father, due to his intelligence and qualities of character, as well as his life circumstances, which formed, as it were, a platform for the history of our patient's childhood and illness. At the time when I undertook to treat the girl, he was a man in the second half of his fifties, with absolutely extraordinary liveliness and talent, a very wealthy manufacturer. The daughter was attached to him with special tenderness, and her prematurely awakened criticism awakened an even stronger negative impulse towards some of his actions and qualities.
This tenderness of hers was, moreover, enhanced due to the many serious illnesses to which her father was subject, starting from the sixth year of her life. At that time, his illness with tuberculosis was the reason for the family to move to one of the small, climatically more favorable cities of our southern provinces. The pulmonary disease immediately subsided. But for the next ten years or so, due to necessary precautions, this town, which I will further designate B., remained the main place of residence for parents and children. At times, when he was well, his father was absent, visiting his factories. For the middle of summer, some high-mountain resort was always looked for.
When the girl was about 10 years old, her father needed dark therapy due to a detached retina. The consequence of this disease was that my father was left with poor eyesight. The most serious illness occurred about two years later. It consisted of a fit of insanity, which was then joined by manifestations of paralysis and mild mental disorders. One of his friends, whose role will later occupy us, encouraged the patient, who had only slightly recovered, to go with his doctor to Vienna to consult with me. For some time I hesitated as to whether I should admit that he had paralysis caused by tabes, but then I nevertheless decided on the diagnosis of diffuse vascular lesions, and after the patient recognized the presence of a specific infection before marriage, I undertook strong antisyphilitic treatment, in as a result of which the remaining violations were completely eliminated. Perhaps I should be grateful to such a fortunate intervention for the fact that four years later the father introduced me to his daughter, who had become clearly neurotic, and two years later he handed her over for psychotherapeutic treatment.
Meanwhile, in Vienna, I also met the patient’s somewhat older sister, in whom I was forced to recognize one of the severe forms of psychoneurosis without characteristic hysterical symptoms. This woman died after a marriage life filled with misfortunes, under circumstances that are not fully clear, from rapidly progressing insanity.
The patient's older brother was a hypochondriac bachelor; sometimes I met him.
The girl who became my patient at the age of 18, from time immemorial, gave her sympathies to her father’s family, and after she herself fell ill, she saw her ideal in the mentioned aunt. I also had no doubt that she, both in her natural talent and early intellectual development, and in her morbid predispositions, belonged to this family. I never saw my mother. According to the information received from the father and the girl, I could create the idea that she was a poorly educated, but, above all, stupid woman who, especially after her husband’s illness and subsequent alienation from him, concentrated all her interests on the household and, thus thus represented an image of what could be called “housewife psychosis.” Without the slightest understanding of the living interests of her children, she spent the whole day busy organizing and maintaining cleanliness in the apartment, on furniture and appliances to such an extent that it made it almost impossible to use or enjoy them. Here we cannot pass over in silence the fact that this state, hints of which can be found quite often among all housewives, is somewhat reminiscent of forms of obsession associated with washing or other cleanliness activities; but still, such women, like the mother of our patient, completely lack awareness of the disease, and this is precisely the essential sign of “obsession neurosis.” The relationship between mother and daughter had been very unfriendly for years. The daughter did not notice her mother, harshly criticized her and almost completely avoided any influence on her part.
[I do not take the simple point of view that the only cause in the etiology of hysteria is heredity. But I would like, precisely in connection with the earlier publication in the Revue neurologiue (1896), in which I overcame such ambiguity, not to awaken the appearance that I underestimate the factor of heredity in the etiology of hysteria or even consider it unnecessary. In the case of our patient, there is a very obvious painful burden, based on what is reported about the father and his sister. Of course, anyone who believes that morbid conditions like the one the mother has are impossible without hereditary predisposition would consider the heredity in this case to be convergent. It seems to me that another point is more significant for the hereditary or better to say constitutional predisposition of a girl. I have already mentioned that before marriage, my father suffered from syphilis. And a surprisingly large percentage of my psychoanalytic clients come from fathers who suffered from tabes, or paralysis. Due to the novelty of my therapeutic method, only the most severe cases fell to my lot, when patients were treated for a number of years without any success. Tabes, or paralysis, of a parent can be taken by any adherent of the hereditary doctrine as an indication of a syphilis infection that has taken place, which in a number of cases I have established in such fathers. In the last discussion about the offspring of syphilitics (XIII International Medical Congress in Paris on August 2-9, 1900, reports by Finger, Tamowsky, Jullien, etc.), I did not notice any mention of the fact, which my experience as a neurologist forces me to admit. Namely: that syphilis of the parents can with a high probability be taken into account as an etiological factor for the neuropathic constitution of children.]
The girl’s only brother, who was a year and a half older, had previously been her ideal, and she simply adopted many of his ambitions. In recent years, the brother-sister relationship has weakened. The young man, as far as possible, tried to avoid family turmoil. Where he still had to take someone else's position, he stood on his mother's side. Thus, the usual sexual attraction of father and daughter, on the one hand, and mother and son, on the other, brought them even closer together.
Our patient, whom I will henceforth call Dora, was already exhibiting nervous symptoms at the age of eight. Then her illness manifested itself as continuous, paroxysmal, increasing suffocation, which appeared for the first time after a short mountain walk and was therefore explained by overwork. This condition gradually disappeared over the course of six months as a result of the rest and precautions imposed on her. The family doctor, apparently, did not hesitate for a single minute in diagnosing a purely nervous disorder and excluding organic causes, but it is also obvious that he considered the diagnosis he established to be consistent with the etiology, which explains everything by overwork [For a possible reason for this first disease, see below ].
The baby suffered from common childhood infectious diseases without any complications. As she (meaningfully hinting) said, her brother usually began to get sick, and his illness was mild, and after that her illness followed with severe manifestations. At the age of twelve she developed migraine-like, unilateral headaches and attacks of nervous coughing, which at first always occurred together, and then gradually both symptoms separated, and each received its own development. Migraines became less frequent and completely disappeared at the age of sixteen. Seizures of nervous cough, which were probably caused by ordinary catarrh, persisted all the time. When she came to me for treatment at the age of eighteen, she had recently been coughing in a special, characteristic way. The number of such attacks could not be determined, but their duration ranged from three to five weeks, once even several months. During the first half of such an attack, at least in recent years, the most painful symptom was the complete absence of voice. The diagnosis regarding the neurotic nature of these symptoms has long been established. Various conventional treatments, even hydrotherapy and local electrification, had no success. A child who grew up in such conditions imperceptibly turned into a mature girl, very independent in her judgment, accustomed to ridiculing the efforts of doctors, and, in the end, completely refusing any medical help. However, from time immemorial she had resisted any attempts to consult a doctor, although she had no aversion to the person of their family doctor. Any offer related to the opportunity to consult a new doctor caused her resistance, and only her father’s powerful word made her come to me.
I first saw her at sixteen at the beginning of the summer, burdened with a cough and hoarseness. Even then I suggested mental treatment, which was later refused, since this somewhat longer-lasting attack passed spontaneously. In the winter of the following year, after the death of her beloved aunt, she was in the house of her uncle and his daughter and fell ill with a fever. This painful condition was then diagnosed as appendicitis. And in the following fall, the family finally left B.’s resort, since, apparently, the father’s health allowed it. At first they moved to the place where their father’s factory was located, and a year later they settled firmly in Vienna.
Meanwhile, Dora turned into a blossoming girl with intelligent, pleasant features, but she still created a lot of problems for her parents. The main symptoms of her illness were bad mood and changes in character. It is obvious that she was dissatisfied with herself and her loved ones. She met her father unfriendly and generally could no longer tolerate the presence of her mother, who wanted to somehow involve her in household chores. She tried to avoid communication. As much as the fatigue and absent-mindedness of which she complained could permit, she occupied herself with hearing reports for the ladies and with serious study. One day, the parents were horrified to find on the desk (or inside it) a letter from the girl in which she said goodbye to them, since she could no longer endure such a life. [This treatment, as well as my vision of the relationship of events in the medical history, as I have already reported, remained only fragmentary. Therefore, in some points I cannot give any information at all, but express myself only with hints or assumptions. When the topic of this letter came up at one of the sessions, the girl asked in surprise: “How did they find the letter? It was locked with a key in my desk.” But since she knew that her parents had read this draft of a farewell letter, I assumed that she had slipped it into their hands.]
The father’s considerable knowledge allowed him to guess that the girl did not have a serious intention to commit suicide, but this story shocked him so much that one day, after a minor squabble between father and daughter, when the latter had her first seizure with loss of consciousness, and then amnesia, it was decided, despite her resistance, that she would go to me for treatment. [I believe that convulsions and delirium were also observed in this attack, but since the analysis did not reach this event, I have no idea
Sigmund Freud: Famous Cases from Practice
ISBN: 5-89353-219-8
"Sigmund Freud: Famous Cases from Practice": Cogito Center, 2007
annotation
The book contains descriptions of the six most famous therapeutic cases to which S. Freud was involved. The presentation of the dramatic circumstances of the life and progress of treatment of patients, commented by the creator of the new science, still serves as an indispensable tool for studying the foundations of psychoanalysis. The book will be of interest to both specialist psychologists and a wide range of readers.
Translation from German by V.I. Nikolaeva, A.M. Bokovikov.
Sigmund Freud:
Famous cases from practice
Preface
Fräulein Anna O. D. Breuer
Fragment of the analysis of hysteria. (Dora's medical history). 1905
Analysis of a phobia of a five-year-old boy (Little Hans). 1909
From the history of a childhood neurosis. (The Case of the Wolf Man). 1914-1915
Notes on a case of obsessional neurosis. (The Case of the Rat Man). 1909
Psychoanalytic notes on an autobiographical description of a case of paranoia. (Schreber case). 1911
Classic Freudian cases. The further fate of the patients Martin Grotjahn
LITERATURE
Preface
Currently, scholars studying Freud's scientific and creative legacy have direct information about 43 patients who were analyzed by Freud. The contribution that the description of these cases made to the development of psychoanalytic theory is, of course, unequal. Thanks to some of them, such phenomena of the therapeutic process as transference and countertransference, negative therapeutic reaction, etc. were discovered, which formed the basis of Freud’s most important theoretical postulates; others are rather visual illustrations of his theoretical positions. Be that as it may, all these cases served as factual material that allowed Freud to defend his theory with all conviction and not be in a state of uncertainty and uncertainty from speculative reasoning.
Among the cases to which Freud was involved in one way or another, six stand out in this volume. As a matter of fact, only three of them relate to the direct therapeutic work of Freud himself - the cases of Dora, Wolfsmann and Rattenmann (“the wolf man” and the “rat man”, as other authors call these patients, without really thinking about how incorrect and offensive and even these names sound absurd). Freud was indirectly related to three other cases - Anna O., “little Hans” and Schreber: Anna O. was treated by Freud’s senior colleague J. Breuer, “little Hans” was treated by the boy’s father, Freud’s student, and the analysis of the Schreber case was carried out on the basis of the patient’s memoirs.
The case of Anna O., which is rightly recognized as the first step taken on the path to the development of psychoanalysis, continues to attract the attention of various authors to this day - both orthodox psychoanalysts and representatives of modern trends in psychoanalysis. The reader can find new and unexpected approaches to the interpretation of this case in Summers (1999), Tolpin (1993), Hirschmuller (1989), and others.
There is probably no need to dwell in detail on the cases described in this book. The reader will find all the necessary information in the preliminary notes to each chapter, as well as in the article by Martin Grotjahn, which tells about the further fate of the patients.
Considering these works from a modern perspective, we see that not everything in Freud’s approach to analysis is correct. We notice that along with absolutely amazing insights there is a tendency to squeeze the received material into prepared diagrams. We are aware that numerous interpretations, which for Freud are beyond doubt, are now outdated and hardly correspond to reality. All this is true. But let's not forget that at that time it was an uncharted path, which often had to be groped. And we can only be grateful to the founder of psychoanalysis for the fact that he dared to follow this path and enriched us with a wealth of knowledge about the driving forces and internal conflicts of the human psyche.
The most famous case among psychoanalysts is that of Anna O. The pseudonym Anna O. was given to Bertha Pappenheim (1859-1936), who fell ill while caring for her father, who had cavernous tuberculosis. The patient was “exposed” by E. Jones, the author of the famous three-volume biography of Freud (1953). Freud learned about the patient's treatment from Breuer a few months after its completion (November 1882). Freud was so fascinated by the story of her illness that he could not understand why Breuer did not want to publish it, nor talk about the new treatment method he had created - “cathartic psychotherapy.” And only a year later, Breuer openly admitted to a young colleague that he was so closely involved in the treatment of Anna O. that he aroused his wife’s jealousy. He had to tell the patient that he was stopping treatment forever. In the evening of the same day, he was urgently called to a patient who was lying in “labor pains” from a false pregnancy and shouting: “Dr. Breuer’s child will be born!” Breuer put the patient into a hypnotic state and tried to calm her down, and the next day he and his wife left for Venice. In the same year, a month after the completion of Breuer's treatment, the patient's condition deteriorated so much that she was forced to be admitted for inpatient treatment to the famous Bellevue nervous sanatorium in Kreuzlingen on Lake Constance, where she remained from mid-July to the end of October 1882. There Anna O. was treated for various somatic symptoms (including trigeminal neuralgia), and large doses of morphine were used for this. In the evenings she lost the ability to speak German and switched to English or French. In a letter to Stefan Zweig, Freud wrote: “What actually happened to Breuer’s patient, I was able to unravel only many years after our breakup with him... At the last meeting with the patient, he had in his hands a key with which he could open the door to the mysteries of life, but he let it fall out. Despite all his spiritual talent, Breuer had nothing of Faust in his character. Horrified by what he had done, he fled, leaving the care of the patient to one of his colleagues" (Freud S. Briefe 1873-1939. Frankfurt a M., 1968, S. 427). And this was not the end of the matter, as Jones writes in the first volume of his biography of Freud: “About ten years later, while Freud was treating patients in collaboration with Breuer, the latter invited Freud to see another hysterical patient of his. Before going to see her , Breuer described her symptoms in detail, after which Freud said that this was very typical of an imaginary (false) pregnancy. This repetition of the previous situation was difficult for Breuer to bear. Without saying a word, he took his hat and cane and quickly left Freud" (Jones E. Das Leben und Werk von Sigmund Freud. Bern, 1960. S. 269). For some time, Anna O. abused morphine. Later, without without any medical help, she completely devoted herself to social activities. She was quite famous as a fighter for the emancipation of women, especially Jews. The famous Jewish philosopher Martin Buber (1878-1965) once said: “There are people of spirit, there are people of passion , both of them are not very often to be found, but even more rare are people who combine spirit and passion. This is the kind of person with a passionate spirit that Bertha Pappenheim was" (1939). With her personal savings, she founded the "Shelter for abused girls and illegitimate children." Caring for the unfortunate children completely replaces the absence of her own children. But the memories of the time spent cathartic treatment continues to haunt her later, she strictly prohibits any type of psychoanalytic treatment of people in the institutions she founded. Anna Freud also recalls that Bertha Pappenheim was “hostile to analysis” throughout her life (see . article "Episodes from the life of Bertha Pappenheim (Anna O.)", published by Bernd Nitzschke in the leading German psychoanalytic journal "Psyche". S. 819). Bertha Pappenheim herself says the following about psychoanalysis: "Psychoanalysis in the hands of a doctor is the same that confession is in the hands of a Catholic priest; it will depend only on their personality and skill in mastering their method whether their instrument turns out to be good or a double-edged sword" (see collection edited by D. Edinger, Bertha Pappenheim. Leben u. Schriften. Frankfurt a. M., 1963. S. 12-13). And Anna O. described her general life position as follows: “Everyone, regardless of whether he is a man or a woman, must do what he must do, using either his strength or his weakness.” For Freud the understanding of the power of transference and countertransference revealed in this case history became the starting point for the transition from cathartic therapy to psychoanalysis. In his obituary on the death of Breuer (1925), Freud wrote: "Breuer was confronted with the inevitably existing transference of the patient to the doctor and was unable to understand the extrapersonal the nature of this phenomenon."
Sigmund Freud: Famous Cases from Practice
ISBN: 5-89353-219-8
“Sigmund Freud: Famous Cases from Practice”: Cogito Center, 2007.
annotation
The book contains descriptions of the six most famous therapeutic cases to which S. Freud was involved. The presentation of the dramatic circumstances of the life and progress of treatment of patients, commented by the creator of the new science, still serves as an indispensable tool for studying the foundations of psychoanalysis. The book will be of interest to both specialist psychologists and a wide range of readers.
Translation from German by V.I. Nikolaeva, A.M. Bokovikov.
Sigmund Freud:
Famous cases from practice
Preface
Fräulein Anna O. D. Breuer
Fragment of the analysis of hysteria. (Dora's medical history). 1905
Analysis of a phobia of a five-year-old boy (Little Hans). 1909
From the history of a childhood neurosis. (The Case of the Wolf Man). 1914-1915
Notes on a case of obsessional neurosis. (The Case of the Rat Man). 1909
Psychoanalytic notes on an autobiographical description of a case of paranoia. (Schreber case). 1911
Classic Freudian cases. The further fate of the patients Martin Grotjahn
LITERATURE
Preface
Currently, scholars studying Freud's scientific and creative legacy have direct information about 43 patients who were analyzed by Freud. The contribution that the description of these cases made to the development of psychoanalytic theory is, of course, unequal. Thanks to some of them, such phenomena of the therapeutic process as transference and countertransference, negative therapeutic reaction, etc. were discovered, which formed the basis of Freud’s most important theoretical postulates; others are rather visual illustrations of his theoretical positions. Be that as it may, all these cases served as factual material that allowed Freud to defend his theory with all conviction and not be in a state of uncertainty and uncertainty from speculative reasoning.
Among the cases to which Freud was involved in one way or another, six stand out in this volume. As a matter of fact, only three of them relate to the direct therapeutic work of Freud himself - the cases of Dora, Wolfsmann and Rattenmann (“the wolf man” and the “rat man”, as other authors call these patients, without really thinking about how incorrect and offensive and even these names sound absurd). Freud was indirectly related to three other cases - Anna O., “little Hans” and Schreber: Anna O. was treated by Freud’s senior colleague J. Breuer, “little Hans” was treated by the boy’s father, Freud’s student, and the analysis of the Schreber case was carried out on the basis of the patient’s memoirs.
The case of Anna O., which is rightly recognized as the first step taken on the path to the development of psychoanalysis, continues to attract the attention of various authors to this day - both orthodox psychoanalysts and representatives of modern trends in psychoanalysis. The reader can find new and unexpected approaches to the interpretation of this case in Summers (1999), Tolpin (1993), Hirschmuller (1989), and others.
There is probably no need to dwell in detail on the cases described in this book. The reader will find all the necessary information in the preliminary notes to each chapter, as well as in the article by Martin Grotjahn, which tells about the further fate of the patients.
Considering these works from a modern perspective, we see that not everything in Freud’s approach to analysis is correct. We notice that along with absolutely amazing insights there is a tendency to squeeze the received material into prepared diagrams. We are aware that numerous interpretations, which for Freud are beyond doubt, are now outdated and hardly correspond to reality. All this is true. But let's not forget that at that time it was an uncharted path, which often had to be groped. And we can only be grateful to the founder of psychoanalysis for the fact that he dared to follow this path and enriched us with a wealth of knowledge about the driving forces and internal conflicts of the human psyche.
The most famous case among psychoanalysts is that of Anna O. The pseudonym Anna O. was given to Bertha Pappenheim (1859-1936), who fell ill while caring for her father, who had cavernous tuberculosis. The patient was “exposed” by E. Jones, the author of the famous three-volume biography of Freud (1953). Freud learned about the patient's treatment from Breuer a few months after its completion (November 1882). Freud was so fascinated by the story of her illness that he could not understand why Breuer did not want to publish it, nor talk about the new treatment method he had created - “cathartic psychotherapy.” And only a year later, Breuer openly admitted to a young colleague that he was so closely involved in the treatment of Anna O. that he aroused his wife’s jealousy. He had to tell the patient that he was stopping treatment forever. In the evening of the same day, he was urgently called to a patient who was lying in “labor pains” from a false pregnancy and shouting: “Dr. Breuer’s child will be born!” Breuer put the patient into a hypnotic state and tried to calm her down, and the next day he and his wife left for Venice. In the same year, a month after the completion of Breuer's treatment, the patient's condition deteriorated so much that she was forced to be admitted for inpatient treatment to the famous Bellevue nervous sanatorium in Kreuzlingen on Lake Constance, where she remained from mid-July to the end of October 1882. There Anna O. was treated for various somatic symptoms (including trigeminal neuralgia), and large doses of morphine were used for this. In the evenings she lost the ability to speak German and switched to English or French. In a letter to Stefan Zweig, Freud wrote: “What actually happened to Breuer’s patient, I was able to unravel only many years after our breakup with him... At the last meeting with the patient, he had in his hands a key with which he could open the door to the mysteries of life, but he let it fall out. Despite all his spiritual talent, Breuer had nothing of Faust in his character. Horrified by what he had done, he fled, leaving the care of the patient to one of his colleagues" (Freud S. Briefe 1873-1939. Frankfurt a M., 1968, S. 427). And this was not the end of the matter, as Jones writes in the first volume of his biography of Freud: “About ten years later, while Freud was treating patients in collaboration with Breuer, the latter invited Freud to see another hysterical patient of his. Before going to see her , Breuer described her symptoms in detail, after which Freud said that this was very typical of an imaginary (false) pregnancy. This repetition of the previous situation was difficult for Breuer to bear. Without saying a word, he took his hat and cane and quickly left Freud" (Jones E. Das Leben und Werk von Sigmund Freud. Bern, 1960. S. 269). For some time, Anna O. abused morphine. Later, without without any medical help, she completely devoted herself to social activities. She was quite famous as a fighter for the emancipation of women, especially Jews. The famous Jewish philosopher Martin Buber (1878-1965) once said: “There are people of spirit, there are people of passion , both of them are not very often to be found, but even more rare are people who combine spirit and passion. This is the kind of person with a passionate spirit that Bertha Pappenheim was" (1939). With her personal savings, she founded the "Shelter for abused girls and illegitimate children." Caring for the unfortunate children completely replaces the absence of her own children. But the memories of the time spent cathartic treatment continues to haunt her later, she strictly prohibits any type of psychoanalytic treatment of people in the institutions she founded. Anna Freud also recalls that Bertha Pappenheim was “hostile to analysis” throughout her life (see . article "Episodes from the life of Bertha Pappenheim (Anna O.)", published by Bernd Nitzschke in the leading German psychoanalytic journal "Psyche". S. 819). Bertha Pappenheim herself says the following about psychoanalysis: "Psychoanalysis in the hands of a doctor is the same that confession is in the hands of a Catholic priest; it will depend only on their personality and skill in mastering their method whether their instrument turns out to be good or a double-edged sword" (see collection edited by D. Edinger, Bertha Pappenheim. Leben u. Schriften. Frankfurt a. M., 1963. S. 12-13). And Anna O. described her general life position as follows: “Everyone, regardless of whether he is a man or a woman, must do what he must do, using either his strength or his weakness.” For Freud the understanding of the power of transference and countertransference revealed in this case history became the starting point for the transition from cathartic therapy to psychoanalysis. In his obituary on the death of Breuer (1925), Freud wrote: "Breuer was confronted with the inevitably existing transference of the patient to the doctor and was unable to understand the extrapersonal nature of this phenomenon." Mistaking the transference feelings for the patient's real feelings, Breuer responded to them with a massive reaction of unconscious countertransference, which, even years later, did not allow him to recognize the sexual nature of Anna O's symptoms. , Breuer, in a letter dated November 21, 1907, writes to the famous psychiatrist August Forel: “I must confess to you that my taste disgusts me to plunge into the field of sexuality, both in theory and in practice. But what does my taste and my feelings have to do with it if it is a matter of truth, of discovering what we are really confronted with. The case of Anna O. proves that a sufficiently severe case of hysteria can arise, persist and be eliminated without sexual elements playing any role in it. My merit lies in Basically, I was able to understand that fate had placed in my hands an unusually instructive case, important for science, which I was able to carefully observe for quite a long time, without disturbing its simple and natural course with any biased approach. I learned a lot, I learned a lot of amazingly valuable things for science. But I also learned what it is necessary to pay priority attention to in practical work. It is impossible for a private practitioner-therapist to treat such cases without completely destroying his work and life way of life I praise myself for the decision I made then not to allow such inhuman tests to happen again. If I had patients who had excellent indications for analytical treatment, whom I myself could not treat, then I referred them to Dr. Freud, who acquired rich practical experience in Paris and the Salpêtrière, to a doctor with whom I was on the most friendly terms. relationships, as well as in fruitful scientific contacts" (1907).
Sigmund Freud: Famous Cases from Practice
ISBN: 5-89353-219-8
“Sigmund Freud: Famous Cases from Practice”: Cogito Center, 2007.
annotation
The book contains descriptions of the six most famous therapeutic cases to which S. Freud was involved. The presentation of the dramatic circumstances of the life and progress of treatment of patients, commented by the creator of the new science, still serves as an indispensable tool for studying the foundations of psychoanalysis. The book will be of interest to both specialist psychologists and a wide range of readers.
Translation from German by V.I. Nikolaeva, A.M. Bokovikov.
Sigmund Freud:
Famous cases from practice
Preface
Fräulein Anna O. D. Breuer
Fragment of the analysis of hysteria. (Dora's medical history). 1905
Analysis of a phobia of a five-year-old boy (Little Hans). 1909
From the history of a childhood neurosis. (The Case of the Wolf Man). 1914-1915
Notes on a case of obsessional neurosis. (The Case of the Rat Man). 1909
Psychoanalytic notes on an autobiographical description of a case of paranoia. (Schreber case). 1911
Classic Freudian cases. The further fate of the patients Martin Grotjahn
LITERATURE
Preface
Currently, scholars studying Freud's scientific and creative legacy have direct information about 43 patients who were analyzed by Freud. The contribution that the description of these cases made to the development of psychoanalytic theory is, of course, unequal. Thanks to some of them, such phenomena of the therapeutic process as transference and countertransference, negative therapeutic reaction, etc. were discovered, which formed the basis of Freud’s most important theoretical postulates; others are rather visual illustrations of his theoretical positions. Be that as it may, all these cases served as factual material that allowed Freud to defend his theory with all conviction and not be in a state of uncertainty and uncertainty from speculative reasoning.
Among the cases to which Freud was involved in one way or another, six stand out in this volume. As a matter of fact, only three of them relate to the direct therapeutic work of Freud himself - the cases of Dora, Wolfsmann and Rattenmann (“the wolf man” and the “rat man”, as other authors call these patients, without really thinking about how incorrect and offensive and even these names sound absurd). Freud was indirectly related to three other cases - Anna O., “little Hans” and Schreber: Anna O. was treated by Freud’s senior colleague J. Breuer, “little Hans” was treated by the boy’s father, Freud’s student, and the analysis of the Schreber case was carried out on the basis of the patient’s memoirs.
The case of Anna O., which is rightly recognized as the first step taken on the path to the development of psychoanalysis, continues to attract the attention of various authors to this day - both orthodox psychoanalysts and representatives of modern trends in psychoanalysis. The reader can find new and unexpected approaches to the interpretation of this case in Summers (1999), Tolpin (1993), Hirschmuller (1989), and others.
There is probably no need to dwell in detail on the cases described in this book. The reader will find all the necessary information in the preliminary notes to each chapter, as well as in the article by Martin Grotjahn, which tells about the further fate of the patients.
Considering these works from a modern perspective, we see that not everything in Freud’s approach to analysis is correct. We notice that along with absolutely amazing insights there is a tendency to squeeze the received material into prepared diagrams. We are aware that numerous interpretations, which for Freud are beyond doubt, are now outdated and hardly correspond to reality. All this is true. But let's not forget that at that time it was an uncharted path, which often had to be groped. And we can only be grateful to the founder of psychoanalysis for the fact that he dared to follow this path and enriched us with a wealth of knowledge about the driving forces and internal conflicts of the human psyche.
The most famous case among psychoanalysts is that of Anna O. The pseudonym Anna O. was given to Bertha Pappenheim (1859-1936), who fell ill while caring for her father, who had cavernous tuberculosis. The patient was “exposed” by E. Jones, the author of the famous three-volume biography of Freud (1953). Freud learned about the patient's treatment from Breuer a few months after its completion (November 1882). Freud was so fascinated by the story of her illness that he could not understand why Breuer did not want to publish it, nor talk about the new treatment method he had created - “cathartic psychotherapy.” And only a year later, Breuer openly admitted to a young colleague that he was so closely involved in the treatment of Anna O. that he aroused his wife’s jealousy. He had to tell the patient that he was stopping treatment forever. In the evening of the same day, he was urgently called to a patient who was lying in “labor pains” from a false pregnancy and shouting: “Dr. Breuer’s child will be born!” Breuer put the patient into a hypnotic state and tried to calm her down, and the next day he and his wife left for Venice. In the same year, a month after the completion of Breuer's treatment, the patient's condition deteriorated so much that she was forced to be admitted for inpatient treatment to the famous Bellevue nervous sanatorium in Kreuzlingen on Lake Constance, where she remained from mid-July to the end of October 1882. There Anna O. was treated for various somatic symptoms (including trigeminal neuralgia), and large doses of morphine were used for this. In the evenings she lost the ability to speak German and switched to English or French. In a letter to Stefan Zweig, Freud wrote: “What actually happened to Breuer’s patient, I was able to unravel only many years after our breakup with him... At the last meeting with the patient, he had in his hands a key with which he could open the door to secrets of life, but he let it fall out. Despite all his spiritual talent, Breuer had nothing of Faust in his character. Horrified by what he had done, he fled, leaving him in charge of
Preface
Currently, scholars studying Freud's scientific and creative legacy have direct information about 43 patients who were analyzed by Freud. The contribution that the description of these cases made to the development of psychoanalytic theory is, of course, unequal. Thanks to some of them, such phenomena of the therapeutic process as transference and countertransference, negative therapeutic reaction, etc. were discovered, which formed the basis of Freud’s most important theoretical postulates; others are rather visual illustrations of his theoretical positions. Be that as it may, all these cases served as factual material that allowed Freud to defend his theory with all conviction and not be in a state of uncertainty and uncertainty from speculative reasoning.
Among the cases to which Freud was involved in one way or another, six stand out in this volume. As a matter of fact, only three of them relate to the direct therapeutic work of Freud himself - the cases of Dora, Wolfsmann and Rattenmann (“the wolf man” and the “rat man”, as other authors call these patients, without really thinking about how incorrect and offensive and even these names sound absurd). Freud was indirectly related to three other cases - Anna O., “little Hans” and Schreber: Anna O. was treated by Freud’s senior colleague J. Breuer, “little Hans” was treated by the boy’s father, Freud’s student, and the analysis of the Schreber case was carried out on the basis of the patient’s memoirs.
The case of Anna O., which is rightly recognized as the first step taken on the path to the development of psychoanalysis, continues to attract the attention of various authors to this day - both orthodox psychoanalysts and representatives of modern trends in psychoanalysis. The reader can find new and unexpected approaches to the interpretation of this case in Summers (1999), Tolpin (1993), Hirschmuller (1989), and others.
There is probably no need to dwell in detail on the cases described in this book. The reader will find all the necessary information in the preliminary notes to each chapter, as well as in the article by Martin Grotjahn, which tells about the further fate of the patients.
Considering these works from a modern perspective, we see that not everything in Freud’s approach to analysis is correct. We notice that along with absolutely amazing insights there is a tendency to squeeze the received material into prepared diagrams. We are aware that numerous interpretations, which for Freud are beyond doubt, are now outdated and hardly correspond to reality. All this is true. But let's not forget that at that time it was an uncharted path, which often had to be groped. And we can only be grateful to the founder of psychoanalysis for the fact that he dared to follow this path and enriched us with a wealth of knowledge about the driving forces and internal conflicts of the human psyche.
The most famous case among psychoanalysts is that of Anna O. The pseudonym Anna O. was given to Bertha Pappenheim (1859-1936), who fell ill while caring for her father, who had cavernous tuberculosis. The patient was “exposed” by E. Jones, the author of the famous three-volume biography of Freud (1953). Freud learned about the patient's treatment from Breuer a few months after its completion (November 1882). Freud was so fascinated by the story of her illness that he could not understand why Breuer did not want to publish it, nor talk about the new treatment method he had created - “cathartic psychotherapy.” And only a year later, Breuer openly admitted to a young colleague that he was so closely involved in the treatment of Anna O. that he aroused his wife’s jealousy. He had to tell the patient that he was stopping treatment forever. In the evening of the same day, he was urgently called to a patient who was lying in “labor pains” from a false pregnancy and shouting: “Dr. Breuer’s child will be born!” Breuer put the patient into a hypnotic state and tried to calm her down, and the next day he and his wife left for Venice. In the same year, a month after the completion of Breuer's treatment, the patient's condition deteriorated so much that she was forced to be admitted for inpatient treatment to the famous Bellevue nervous sanatorium in Kreuzlingen on Lake Constance, where she remained from mid-July to the end of October 1882. There Anna O. was treated for various somatic symptoms (including trigeminal neuralgia), and large doses of morphine were used for this. In the evenings she lost the ability to speak German and switched to English or French. In a letter to Stefan Zweig, Freud wrote: “What actually happened to Breuer’s patient, I was able to unravel only many years after our breakup with him... At the last meeting with the patient, he had in his hands a key with which he could open the door to the mysteries of life, but he let it fall out. Despite all his spiritual talent, Breuer had nothing of Faust in his character. Horrified by what he had done, he fled, leaving the care of the patient to one of his colleagues" (Freud S. Briefe 1873-1939. Frankfurt a M., 1968, S. 427). And this was not the end of the matter, as Jones writes in the first volume of his biography of Freud: “About ten years later, while Freud was treating patients in collaboration with Breuer, the latter invited Freud to see another hysterical patient of his. Before going to see her , Breuer described her symptoms in detail, after which Freud said that this was very typical of an imaginary (false) pregnancy. This repetition of the previous situation was difficult for Breuer to bear. Without saying a word, he took his hat and cane and quickly left Freud" (Jones E. Das Leben und Werk von Sigmund Freud. Bern, 1960. S. 269). For some time, Anna O. abused morphine. Later, without without any medical help, she completely devoted herself to social activities. She was quite famous as a fighter for the emancipation of women, especially Jews. The famous Jewish philosopher Martin Buber (1878-1965) once said: “There are people of spirit, there are people of passion , both of them are not very often to be found, but even more rare are people who combine spirit and passion. This is the kind of person with a passionate spirit that Bertha Pappenheim was" (1939). With her personal savings, she founded the "Shelter for abused girls and illegitimate children." Caring for the unfortunate children completely replaces the absence of her own children. But the memories of the time spent cathartic treatment continues to haunt her later, she strictly prohibits any type of psychoanalytic treatment of people in the institutions she founded. Anna Freud also recalls that Bertha Pappenheim was “hostile to analysis” throughout her life (see . article "Episodes from the life of Bertha Pappenheim (Anna O.)", published by Bernd Nitzschke in the leading German psychoanalytic journal "Psyche". S. 819). Bertha Pappenheim herself says the following about psychoanalysis: "Psychoanalysis in the hands of a doctor is the same that confession is in the hands of a Catholic priest; it will depend only on their personality and skill in mastering their method whether their instrument turns out to be good or a double-edged sword" (see collection edited by D. Edinger, Bertha Pappenheim. Leben u. Schriften. Frankfurt a. M., 1963. S. 12-13). And Anna O. described her general life position as follows: “Everyone, regardless of whether he is a man or a woman, must do what he must do, using either his strength or his weakness.” For Freud the understanding of the power of transference and countertransference revealed in this case history became the starting point for the transition from cathartic therapy to psychoanalysis. In his obituary on the death of Breuer (1925), Freud wrote: "Breuer was confronted with the inevitably existing transference of the patient to the doctor and was unable to understand the extrapersonal nature of this phenomenon." Mistaking the transference feelings for the patient's real feelings, Breuer responded to them with a massive reaction of unconscious countertransference, which, even years later, did not allow him to recognize the sexual nature of Anna O's symptoms. , Breuer, in a letter dated November 21, 1907, writes to the famous psychiatrist August Forel: “I must confess to you that my taste disgusts me to plunge into the field of sexuality, both in theory and in practice. But what does my taste and my feelings have to do with it if it is a matter of truth, of discovering what we are really confronted with. The case of Anna O. proves that a sufficiently severe case of hysteria can arise, persist and be eliminated without sexual elements playing any role in it. My merit lies in Basically, I was able to understand that fate had placed in my hands an unusually instructive case, important for science, which I was able to carefully observe for quite a long time, without disturbing its simple and natural course with any biased approach. I learned a lot, I learned a lot of amazingly valuable things for science. But I also learned what it is necessary to pay priority attention to in practical work. It is impossible for a private practitioner-therapist to treat such cases without completely destroying his work and life way of life I praise myself for the decision I made then not to allow such inhuman tests to happen again. If I had patients who had excellent indications for analytical treatment, whom I myself could not treat, then I referred them to Dr. Freud, who acquired rich practical experience in Paris and the Salpêtrière, to a doctor with whom I was on the most friendly terms. relationships, as well as in fruitful scientific contacts" (1907).