In the late nineteenth century, the ailments now classified by neurologists as psychogenic movement disorders and by psychiatrists as subtypes of conversion disorders were regarded as symptom complexes falling under the broader rubric of hysteria. Thought by many historians of psychiatry to have been a far more prevalent illness than now (3), hysteria was inarguably a topic of enormous medical and broad cultural interest at the time in Europe and North America. Freud, a neurologist and neuroscientist by training, became interested in hysteria initially as a student of Jean-Martin Charcot in the 1880s. Among his contemporaries, Freud was hardly alone in his interest in hysteria; Pierre Janet, among many others, was deeply interested in the subject (3, 4, 5). But it was through his contact and work with Josef Breuer in the 1880s and 1890s that Freud developed a theory that went far beyond the ideas of his contemporaries, specifying the mechanism of psychogenesis of hysterical symptoms. Although Freud’s theory continued to evolve substantially over the next half century, some key notions in Freud’s mature theory were concepts of unconscious conflict and fantasy, a dynamic unconscious, repression, defense, and the notion of infantile sexuality.

With the apparent epidemiologic decline of hysteria in the early decades of the 20th century, as well as the internal development of his own theory, Freud’s focus on hysterical
symptomatology also gradually shifted toward other forms of psychogenic symptomatology, primarily including inhibitions, anxiety, and character pathology. Freud and his followers, however, often continued to interpret hysterical motor symptoms in much the same way as they interpreted all psychogenic symptoms: as related to conflict and psychological defense.

This paper will briefly sketch the development of Freud’s notions about hysterical symptomatology, commenting also on developments in psychoanalysis since Freud. I will also suggest that the historical evolution of Freud’s interest in psychogenic symptomatology—from the study, early in his career, of the more florid hysterical symptoms that characterize psychogenic movement disorders to more subtle forms of neurotic conflict as his theory evolved—was in part responsible for a legacy of overreaching by psychoanalysts. This overreaching proceeded along at least two principal lines: In emulation of Freud’s early interpretive style and the dramatic symptoms it addressed, 20th century psychoanalysts often presumed psychological causes for both psychogenic and organic disorders, and interpreted them in order to construct an apparently coherent illness narrative even without adequate data. Furthermore, they often assumed (in accordance with Freud’s earliest, but later superseded, theories of psychotherapeutic action) that simple explication of a previously repressed experience by the physician (“making the unconscious conscious”) would constitute an effective psychotherapeutic treatment. This double error contributed to both poor therapeutic results and widespread skepticism about psychoanalytic theory and practice.

The earliest unequivocal assertion that a patient’s life history is the source of hysterical symptomatology is to be found as early as 1888 in Freud’s article on hysteria for Villaret’s medical encyclopedia (6). Shortly after returning from his studies with Charcot in Paris, Freud makes reference to the new method of Breuer in treating hysteria: to “lead the patient under hypnosis back to the psychical prehistory of the ailment and compel him to acknowledge the psychical occasion on which the disorder in question originated (7,8).” This new method of treatment, Freud stressed, not only produced “successful cures” otherwise unobtainable, but was the method most appropriate to hysteria because it “precisely imitates the mechanism of the origin and passing of these hysterical disorders (7,8).” This was a radical statement for this time, when hysteria was largely regarded (by Charcot and Janet, among others) as determined by hereditary degeneration. (Today we make essentially the same etiologic case when we assign responsibility to “genetic factors.”)

In Freud’s early studies of the 1890s, under the twin influences of Charcot and Breuer, he emphasized the role of trauma in hysteria. In asserting that psychical trauma was the basis of all hysteria, Freud was already departing from Charcot’s notions of traumatic hysteria. Freud emphasized that hysterical symptoms had to be explained in patients who had not suffered physical traumas at all (7,9). Making use of Breuer’s earliest psychotherapeutic techniques at this point, such as questioning under hypnosis, Freud formulated his first crucial postulate:

There is a complete analogy between traumatic paralysis and common, non-traumatic hysteria…. In the latter there is seldom a single major event to be signaled, but rather a series of affective impressions—a whole story of suffering (7,9).

But Freud went still further at this point, citing a number of case histories from his collaborative work with Breuer (Studies on Hysteria) to conclude that:

…the phenomena of common hysteria can safely be regarded as being on the same pattern as those of traumatic hysteria, and that accordingly every hysteria can be looked upon as traumatic hysteria in the sense of implying a psychical trauma, and that every hysterical phenomenon is determined by the nature of the trauma (7,9).

Furthermore, and interestingly always with the aid of hypnosis, once the traumatic event could be remembered and put into words along with the accompanying affect, the symptom would disappear. In clinical practice, Freud found that the memory would often be reproduced with extraordinary vividness, and the affect accompanying it was as intense as it had been during the original traumatic event.

Thus was born the famed cathartic cure, which was the basis of Freud and Breuer’s work of the late 1880s and early 1890s. Of interest to the present audience, Freud addressed the question of how affective memory is created and either “worn away” or preserved intact:

If a person experiences a psychical impression, something in his nervous system which we will for the moment call the sum of excitation is increased. Now in every individual there exists a tendency to diminish this sum of excitation once more, in order to preserve his health. The increase of the sum of excitation takes place along sensory paths, and its diminution along motor ones. So…it depends on this [motor] reaction how much of the initial psychical impression is left…. For quite slight increases in excitation, alterations in his own body may perhaps be enough: weeping, abusing, raging, and so on. The more intense the trauma, the greater is the adequate reaction…. If however, there is no reaction whatever to a psychical trauma, the memory of it retains the affect which it originally had…. We have found that in hysterical patients there are nothing but impressions which have not lost their affect and whose memory has remained vivid…observation shows that, in the case of all the events which have become determinants of hysterical phenomena, we are dealing with psychical traumas which have not been completely abreacted, or completely dealt with. Thus we may assert that hysterical patients suffer from incompletely abreacted psychical traumas (7,9).