Freud, Sigmund. The Standard Edition.... Two Case Studies. (Vol. 10) Translated by James Strachey. London: The Hogarth Press, 1955.

Vol. 10\Little Hans\Obsessive Neurosis\Phobias\Two Case Studies\Rat Man\ Anxiety Hysteria\

I: Analysis of a Phobia in a Five Year Old Boy.

Much of the reported case histories have been left out for reasons of brevity and to allow for concentration on the theoretical aspects of phobias and obsessional neurosis respectively.

Hans's anxiety: Freud claims that much of Hans's anxiety

1. corresponds to a repressed longing for his mother; (27)
2. comes out of his struggle to rid himself of his infantile masturbatory habit (a state of things that fits in well notion of Repression and the generation of anxiety) (28)
3. Hans acquired at least some of the anxiety from his concerns over the size of his 'widdler,' i.e., he perceived it as being too small and this distressing influence conflicted with the pleasure he achieved via masturbation.
4. The final point of his anxiety is out of a fear of and for his father, i.e., the conflict emerged out the ambivalence felt towards father. The precipitating cause came from witnessing seeing a horse fall down. When Hans saw this, he thought of his and thus associated his father to the activity of falling down and dying.

The anxiety over his father helps to make up the characteristics of Hans's case, which include:

1. appearance of the anxiety state is sudden--i.e., appearing at the first sight of the fallen horse;
2. prematurely aroused sexuality is also involved which is suddenly changed into anxiety.
3. Hans' affection to his mother was attempted to be displaced onto the horse.
4. There was an initial refusal to believe that women did not have a `widdler` (penis) lead to an increased concern to protect his own.
5. several phantasies emerged, including: a) a giraffe which signified the transference of a wish to sleep with his mother; b) criminal phantasies are connected to the previous wish to take possession of his mom--i.e., symbolic phantasies of intercourse with her.
6. There was a transference of fear of the father into a fear of horses.
7. This fear of horses turned into a fear of horses falling down and anything that contributed to this.
8. This was followed by Hans' remembering the precipating cause--a bus horse falling down--and being perceived as having died.
9. The sudden appearance of the 'lumpf' phantasy, which was unfortunately ignored by Hans' father.
10. The later admission of an association of the horse falling down and the case in which his friend (Fritzl) stubbing his foot and falling down, while playing at horses--i.e., Fritzl regarded as father as a substitute.
11. Hans' father finally looks into the `lumpf complex` and finds the association with a loaded down cart--as equivalent to being loaded down with faeces.
12. Plumber phantasies appear--as a remolded phenomena of procreation distorted by anxiety.
13. Then followed a sudden fear of baths (communal) which was associated to Hans' that his sister might be dropped in one and die.
14. Hans then alters the lumpf complex to his sister--i.e., there is an association made between the notions of a horse falling down and childbirth...therefore horse or lumpf complex takes on meanings of a) his father's death and b) his mother in childbirth.
15. The previous point is connected to unexpected revelation that Hans himself figured out, in general terms, childbirth.
16. There follows the appearance of various other phantasies--i.e., his sister's supposed procreative abilities is used for the purpose of getting back at his father for telling him the story of the stork as the origination of infants.

The synthesis of Hans's phobia accounts for:

1. mental constitution,
2. governing sexual wish,
3. experiences till time of sister's birth which caused a) degree of privation & b) an experience of pleasures he enjoyed as an infant--i.e., recalled by observing his mother with the newborn baby and therefore his sexual life was intensified but of which he received insufficient satisfaction,
4. appearance of Hans' sister forced him to deal with the thought of where babies come from, this is seen in his lumpf phantasy,
5. Still Hans noted that his father had something to do with child birth and therefore hated him as a rival.

Freud employs three views with which he analyses this material. These views include the following: 1) sexuality--i.e., from Three Essays on Sexuality. 2) Second, Freud looks at how Hans's case contributes towards and understanding of phobias. 3) Finally there is the consideration of the light shed on the mental life of children.

1) In the first instance--i.e., Three Essays: Human sexual life is considered in terms of Hans' widdler. Furthermore there is a discussion of infantile sexual investigations, consideration of auto-eroticism--i.e., genital zones as providing the most pleasure and the excretory function as providing a secondary source of pleasure --both of which were severely repressed. (This was obviously written before Freud`s work on Narcissism appearing in his Metapsychological Papers in which Freud postulates a stage between auto-eroticism and object choice proper--i.e., Narcissism). A) Hans' development showed a marked polygamy (aim to sleep with his female playmates). In this we find the transference of affection from the mother to other objects but during times of scarcity, Hans' affection regressed back to the mother which lead to a breakdown into neurosis. B) Hans is also interpreted as a "little Oedipus"--he wanted his father out of the way and this is seen as progressing from the removal of his presence to permanent removal--i.e., dead. Hans' fear of this death wish towards his father is considered to be the chief obstacle in the analysis.

2) The understanding of Phobias: a) Hans' sudden anxiety attack (upon the sight of a horse) exposed the motive for the illness--i.e., the advantage derived from it (the secondary gain of a neurosis). Freud classes anxiety attacks as a syndrome generally attributed to anxiety hysteria. The difference between phobias and anxiety hysteria is found in that Anxiety hysteria the libido liberated from pathogenic material is not converted to a somatic innervation but is freed and released as anxiety. In Studies on Hysteria, Freud suggests that anxiety hysteria comes out of somatic excitations and not psychical ones. Anxiety hysteria is "par excellence the neurosis of childhood." That is, it is the neurosis least dependent upon a constitutional predisposition. Anxiety hysteria tends to develop more and more into phobias--an sufferer of anxiety hysteria may rid himself or herself of the anxiety but this is done at the cost of all kinds of inhibitions and restrictions and therefore there is no alternative but to cut off every possible occasion which may lead to the development of anxiety by erecting mental barriers in the nature of precautions, inhibitions and prohibitions.

Freud brings up the notion of over determinism of the neurosis as discussed in Studies. He reminds us of 1) the convergence on several factors 2) via a series of provoking causes. He continues to note the impossibility to cure phobias via violent means--i.e., through the deprivation of the patient's defenses and putting him into a position from which he can not escape the liberation of his anxiety into expression. Freud calls this type of phobia "contingient"--i.e., it does not inspire fear in the normal people

Repression is next discussed as the "Essence of repression lies simply in turning something away and keeping it at a distance from the unconscious." ("Repression." p.147. 1915. Book 4-5 139ff.) Types of repression discussed include: 1) primal--the first phase of psychical repression appears as the instinct is denied entrance into consciousness--at this point a fixation is established--i.e., which represents unaltered form from then on as the instinct remains attached to it. 2) Repression proper--this form of repression effects mental derivatives of repressed representatives, originating elsewhere, which have come into associative contact with it. The result of such associations is that such ideas share the same fate as what had been primally repressed.

The types of things that are repressed:

1. ideas;
2. affects (quota of affect).

1. cause the disappearance of the ideas from consciousness;
2. ideas that are held back from consciousness are about to become conscious--i.e., preconscious vicissitude of affect, which include the following:
   1. the instinct is altogether repressed,
   2. the instinct appears as affect, or
   3. the instinct is metamorphosed into anxiety.

Thus, in Hans' case, an instinctual impulse is said to have been repressed (the libidinal attitude towards father appears as fear for the father which is coupled with fear of father (ambivalence)). After the repressed impulse had vanished from consciousness a substitute for the father was found which more or less devolved into an object for the boy's anxiety.

Freud continues to note that it is impossible to find the exact cause of anxiety in Hans's case. That is, the roots of Hans' anxiety is a) the inability to intellectually deal with the notion or phenomenon of child birth; or, b) a constitutional intolerance of masturbatory gratification in which he regularly indulged

Still, it is noted, Hans' phobia began at the instance of witnessing the collapse of the bus horse and this permitted the development that horses to become the symbolic object of his anxiety. This development is not sufficient but the association of the playmate Fritzl to Hans' father provided a sufficiently traumatic effect to start the neurosis, and from this moment the path was cleared for the return of the repressed (i.e., the ambivalence of the Oedipal wishes). The pathogenic material was then remodeled and turned into the horse complex.

3) Mental life of Children: In terms of the mental life of children, Freud mentions the following: 1) hereditary is not seen to be a determining factor; 2) Hans is not a degenerate child; 3) the ultimate aetiology of all neurosis is said to be found in infantile sexuality

Notes on a Case of Obsessional Neurosis. Found in: "Further Remarks on the Neuropsychoses of Defense" (1896, S.E. vol. 3. pp. 159ff)

EDITOR's NOTE: This text was written before the abandonment of "Seduction theory." In it Freud gives a formula for the onset of obsessive ideas: such ideas are said to invariably be transformed self-reproaches which have re-emerged from their repressed state and which always relate to some sexual act that was performed with pleasure during childhood The course of action: 1) there are experiences of sexual seduction which will later make repression possible; 2) this is followed by acts of sexual aggression against the other sex, which will later appear in the form of acts involving self reproaches; 3) sexual maturation is considered to be the end of the first phase; 4) the individual's self reproaches now become connected to the memory of those pleasurable actions--in order to replace these memories with the primary symptom of defense (repression ?); 5) then follows a return of the repressed which is a failure of the defenses in a form that is a compromise between the repressed ideas and the repressing ones.

The secondary defenses: i.e., when the Ego attempts to fend off derivatives of the repressed memories. If this activity is successful, the result is obsessive activities

The notions of the obsessive neurotic that arise out of Freud`s writings which include the seduction theory are not considered in the Rat-Man case.

Extracts from Rat Man's case history: 1) Infantile sexuality: Freud uncovered instances in which the subject at the age of 4-5 years was encouraged to finger the genitals of governess. This is said to have caused a desire to see female body as well as resulting with erections at 6 years of age.

All this activity was connected to a fear that his parents knew his thoughts the patient himself took this to be the beginning of his illness, i.e., his desire to see naked girls was accompanied with the fear that something terrible would happen to someone he loved. Therefore, the Rat Man developed all sorts of "rituals" used to prevent this clamity from occurring.

Freud states that this is not the beginning of the illness but a manifestation of the illness itself. That is, the is child under the domination of a part of the sexual instinct (socophillia) and the result is that the child become subject to constant recurrence of a very intense wish to view females in states of undress and that later this wish corresponded to the obsessional idea. In other words, since the wish was regularly accompanied by the distressing affect, which was already clothed in an characteristic indeterminentness, it thereafter become an invariable feature of every manifestation of his neurosis and thus caused those impulses to eventually develop into the protective measures that the patient adopted. Therefore we find:

1. an erotic wish and an revolt against it;
2. that the wish is not yet compulsive but the fear struggling against the wish is; and,
3. that there is the development of a resulting distressing affect and an compulsion towards the performance of various defensive acts--out of the delusion that his parents knew his thoughts because he spoke aloud without his knowing it.

The Great Obsessive fear:

The Rat Man's obsessions: 1) fear that something may happen to those of whom he was fond; 2) he suffered from numerous compulsive impulses of self-punishment, e.g., there was a compulsion to cut his throat with a razor; 3) there were also several prohibitions.

The name Rat Man came out of the description of a particular form of torture which he had heard when in the military. In this form of torture, rats were said to burrow into one's anus. Upon hearing the story, Rat Man displayed several reactions which are as follows: a) horror at the story, b) a pleasure of his own of which he was not aware (unconscious), c) a compulsive fear that this torture was happening to someone dear to him which caused the simultaneous construction of a "sanction", i.e., a defensive measure which he was obliged to adopt in order to prevent the phantasy from coming true, and d) a simultaneous belief that this punishment was being applied to his father (who had been dead for nine years previously)

Initiation and the Nature of the Treatment:

Freud finds (d) above to elate to a long repressed wish to kill his father, which originated out of the infantile period of mental development, and which manifests itself in response to the inherent ambivalence towards the father who had incited such ambivalence whenever Rat Man entered into an intense affectual relationship. Freud also found that the intensity of Rat Man's illness resulted from the intense sorrow felt at the time of his father's death (feelings which were repressed at the time) and that the sorrow had found a pathological release in his illness

Mourning and Melancholia 1917, Vol. 14, pp. 243ff.

Some obsessional ideas and their explanation in the Rat Man case:

Obsessional ideas usually appear to be without a motive and this causes problems in attributing sense to them as well as their status in the subjects mental life. The solution to obsessional neurosis may be effected by "bringing the obsessional ideas into temporal relationship with the patient's experiences."--i.e., finding out where and when they first occurred and what kinds of circumstances are apt to cause a recurrence -- obsessional impulses arise as reactions to a intense feeling of rage, which was inaccessible to the patient's consciousness and was directed against someone which had interfered with the course of his love life--here it is his father--all such products of Rat Man's illness depended upon certain circumstances which at that time dominated his relationship to his woman friend--i.e., his ambivalence towards this her--thus the battle between love and hate was represented in a plastic form and by his compulsive and symbolic acts. In other words, the two opposing tendencies find satisfaction singly, one after the other, though an attempt is naturally made to find some sort of a logical connection between the two antagonistic affects.

In this instance, Rat Man fell ill, to avoid completing his studies and marrying another woman as his family desired, so he could remain with the woman he loved. Hence it was the plan for this marriage that precipitated the illness.

The Father Complex and the Solution of the Rat Idea: Freud found some tension in the sexual sphere between the father and son--i.e., the father coming into some opposition to his son's prematurely developed sexual life. This was found in the masturbatory impulses Rat Man had at 25 years old, after his father's death, which Freud found to be a result of the following: 1) a prohibition against masturbation and 2) a defiance against a command issued by the patient's father. Freud concluded that this, to a great extent, explains his phantasy (at 25 years of age) that his father was still alive and might appear at any time. Freud felt he confirmed this notion, when Rat Man's mother relayed a story that the patient did not remember. The story consisted upon the fact that his father beat him for masturbating as a child.

Solution of Rat Obsession:

During military service Rat Man identified himself with his father-- Freud felt that the rat story, etc. must have jarred some hyperaesthetic spots in Rat Man's unconscious to provoke such violently pathological reactions and father identifications. There were further identifications with the father which emerged from the Rat Man going into debt. Yet another identification developed due to the act that he had divided romantic interests over two different women. (This situation is considered to be intensely affectual.)

RATS:

Rat were given a symbolic meaning by the obsessions. The Rat torture stirred up his suspended anal eroticism (due to a bout with worms) Rats also, due to the second of the three means of father identifications in this case, became associated with money (German: "Ratten" = rats; "Raten" = installments) Another sexual association is developed through the fact that rats are carriers of disease and, in some way in this case have become symbolic of male sex organs (i.e., as carriers of syphilitic infection). A further association is one which sees rats as dirty--they feed on excrement (as a boy he was a dirty wretch that bit people)

Theoretical:

A): The originating cause of the illness: in obsessional neurosis the infantile pre-conditions of the illness may be overtaken by the amnesia (often incompletely--cf., in hysteria the amnesia is usually successful), but the immediate occasions of the illness is retained in the individual's memory. Repression, in contrast, uses a simpler mechanism--i.e., instead of being forgotten, the trauma is deprived of its affective cathexis so that which remains in consciousness is nothing but the ideational content. Therefore it is not uncommon for obsessionals, who are troubled by self-reproaches but have connected their affects to false causes, will also tell the analyst the true causes without having the least suspicion that their self-reproaches have simply become detached from them. Thus what appears to be a consequence of the illness is in reality the cause or motive for falling ill. In "Repression" (1915, pp.156ff.) Freud states that the obsessional form of repression has a basis in a sadistic trend that is substituted for an affectionate one. It is the hostile impulsion against someone who is loved that is repressed.

Thus at first the repression is completely successful (i.e., both idea and affect are repressed) but the subject and the symptom do not coincide. In obsessional neurosis, then, repression causes a withdrawal of libido but it makes use of a reaction formation to do so (by intensifying an opposite of the repressed idea). Hence the formation of the idea operates with the same mechanism as repression and at the bottom it coincides with the mechanism while it is chronologically distinct from the formation of a symptom. The ambivalence which enabled the repression to take place (via the reaction formation) is also the point at which the repressed contents succeed in returning. That is, the vanished affect returns in its altered form as moral anxiety, social anxiety, and unlimited self-reproaches. The rejected idea, therefore, is replaced by a substitute through the mechanism of displacement The failure of repression to rid the patient of the affect brings into play the same mechanism as flight response through avoidance, prohibitions and hysterical phobias. Still the rejection of the idea is obstinately maintained.

B) General Characteristics of Obsessional Neurosis: Obsessional neurosis is depicted as being based upon transformed self- reproaches which have emerged from repression and which always relate to some sexual act that was performed with pleasure in childhood. Such comments appear to be too general, perhaps it is better to say that obsessional structures can correspond to every sort of psychical act, including the following: wishes, temptations, etc. There are two means by which we may acquire a precise knowledge of obsessional structures which are as follows:

1. obsessional commands which may have its actual text revealed in a dream in the form of a speech (usually one which is very distorted in consciousness).
2. If a number of obsessions succeed one another they are often ultimately one and the same--i.e., the original form is the correct one in that it displays its meaning quite openly.
3. Obsessional ideas exhibit (via distorted speech) traces of its primary defensive struggle and the distortion of speeches allows the obsessional ideas to persist, since conscious thought is compelled to misapprehend it (due to 1) obsessional ideas and 2) products of the secondary struggle--i.e., that of a protective formulae)

Some psychological peculiarities of obsessional neurotics--i.e., mental characteristics.

1. superstitions--obsessional neurotics usually have two different and contradictory convictions and the oscillation between the two obviously depends upon the obsessional neurotic's momentary attitude towards the obsessional disorder--e.g., "educated superstition" i.e., the Rat Man believed in premonitions but not in the more pedestrian superstitions.
2. Obsessional neurotics need uncertainty in their lives--this is a means of drawing the obsessional neurotic away from reality and isolating him or her from the external world; this allows the obsessional person to turn attention to subjects upon which we are all uncertain and upon which our knowledge and judgments must necessarily remain in doubt. This aspect of uncertainty is also used to the fullest extent to aid in the formation of symptoms and includes notion of the "omnipotence of thoughts" and feelings--i.e., obsessionals overestimate the effects of their thoughts and feelings on the external-world because a large pt of their internal, mental effects escape their conscious knowledge.
3. Death--obsessional neurotics need the possibility of death as a solution to unsolved conflicts.

The instinctual life of obsessional neurotics and the origins of compulsions and doubts:

Rat Man was constantly a victim of conflicts between love and hate in regard to both his woman friends and his father. A necessary conduit for the occurrence of this ambivalent relationship must originate in the prehistory of infancy where the two opposites (love and hate) should have been split apart and one of them (usually hatred) has been repressed. Love hate are considered to be the most frequent, marked and important characteristics of obsessional neurotics.

Doubts: if intense love is opposed by an almost equally powerful hatred are at some point inseparably bound together, the immediate consequence is a partial paralysis of the will and an incapacity for coming to a decision upon any of these actions for which love ought to provide the motivating power--i.e., such doubts are in reality doubts of the obsessional neurotics love of the other. "If one doubts his love he [sic] must doubt all else." This notion leads to a uncertainty in the obsessive neurotic's protective measures and a continual repetition of them in order to banish such uncertainties.

Compulsions: hence there is an attempt to compensate for such doubts and this is an attempt at a correction of the intolerable conditions caused by the inhibition to which the doubt bears witness.

Compulsive quality of thinking: a thought process is obsessive when, in consequence of an inhibition at the motor end, it is undertaken with an expenditure of energy which is normally reserved for actions only. In such instances obsessive thoughts must be secured against the efforts of consciousness in order to resolve the situation. Such protection may occur in the form of distortions which occur before they become conscious. Furthermore, each obsessive thought is removed from the situation in which it originated--i.e., it becomes dissociated. Therefore, 1) an interval of time occurs between the pathogenic situation and the obsession which arises from it; 2) the verbal content of the obsession becomes generalized by being taken out of its particular setting; and, 3) the obsession is protected at its source via ambiguous wording.