Choice of Neurosis
As soon as a unified theory of neurosis had been formulated, the factors that determined the clinical form the neurosis assumed in particular cases had to be specified. The study of the choice of neurosis was concomitant, for Freud, with the development of the general theory of psychoneuroses.
The term neurosis, coined in the eighteenth century by Cullen, first referred to a heterogeneous set of illnesses attributed to a crisis of nerves. During the nineteenth century, the classificatory system was revised based on individualization of illnesses as different as exophthalmic goiter (Graves' disease) and Parkinson's disease. The idea of consolidating characteristic mental disturbances (the madness of doubt and phobias) and a neurosis (hysteria) within a single framework occurred after the psychological nature of hysteria ("the great neurosis") was established at the end of the nineteenth century, by Charcot in Paris and Breuer in Vienna. Freud (Charcot's student and Breuer's collaborator) and Janet (Charcot's student) were responsible for the two principal theoretical constructions that established the unified theory of neurosis. These two constructions differed in their conceptualization of the mechanisms and causes of neurosis, and the two theories also approached the choice of neurosis very differently.
For Freud, the explanation of the choice of neurosis evolved directly from the theory of neurosis, initially described in 1896. This is expressed clearly in Freud's correspondence with Fliess (especially the letters dated January 1, May 30, and December 6, 1896) and in two articles, "Heredity and the Etiology of the Neuroses" (1896a) and "Further Remarks on the Neuro-Psychoses of Defence" (1896b), situated within the framework of the traumatic theory of neuroses: Nothing in the nature of the trauma itself enables us to differentiate the choice of neurosis; the cause must be sought for elsewhere. Initially, Freud referred to a disposition of attitude at the time of the trauma. Sexual incidents passively experienced during childhood predisposed the subject to hysteria, while those in which the child played an active role predisposed the subject to obsessive neurosis. This theory was soon abandoned in favor of a chronological approach, and a decade later, Freud repudiated it explicitly.
Its replacement, the chronological theory, was based on the principle that the dates of childhood events play a decisive role. Initially, the date of the trauma was considered crucial. But, in a January 1897 letter to Fliess, Freud modified his position and claimed the key moment took place at the time of repression. In a letter of November of that same year, he concluded, "It is probable, then, that the choice of neurosis (the decision whether hysteria or obsessional neurosis or paranoia emerges) depends on the nature of the wave of development (that is to say, its chronological placing) which enables repression to occur—i.e. which transforms a source of internal pleasure into one of internal disgust" (1950a, p. 271).
The question was still not fully resolved, however, as Freud noted two years later in his December 9, 1899, letter to Fliess. Meanwhile, the theory of trauma had given way to the theory of libidinal development and intrapsychic conflict. Freud retained the chronological point of view, but what was important to him now was the type of relationship the relevant stage of development allowed one to establish with others: one of autoeroticism or alloeroticism (homo- or heteroeroticism). Curiously, hysteria and obsessional neurosis are lumped together, the second considered a variant of the first. What was important to him at this point was the distinction between them and paranoia, which, unlike hysteria and obsessional neurosis, originates in autoeroticism.
The approach that remained the basis for the theory of psychoanalysis and makes use of the concept of point of fixation can be dated to Three Essays on the Theory of Sexuality (1905d). In the last pages of the work, Freud discusses the role of regression, which, at the time of the conflict, leads the libido to return to an earlier stage, the choice of stage depending on an attraction factor, the tendency to fixation that characterized the earlier development of the libido. The chronological significance was no longer considered proactively (the age of the past event) but retroactively (the return to a particular position).
It is within this new conceptual framework that Freud developed the perspectives in "Formulations on the Two Principles of Mental Functioning" (1911b) and the psychopathological study that concludes the Schreber case (1911c). Moreover, this "canonical" version was used didactically in the twenty-second chapter of the Introductory Lectures on Psychoanalysis (1916-1917a). On the basis of a metaphor (the migration of a people, elements of which are established at different intermediate stages) and a biological model (his own histological work on the embryology of eel gonads), he introduces the concepts of fixation and regression before emphasizing the multiple factors that go into determining a neurosis and the role of "complemental series." By insisting on the role of intrapsychic conflict, he is led to consider the role of the ego and the defense mechanisms, a consideration he had already developed in "The Disposition to Obsessional Neurosis: A Contribution to the Problem of Choice of Neurosis" (1913i).
In this last text, Freud describes the chronological factor as dependent on the development of infantile sexuality. But, while providing a now-classic description of the stages of this development, he suggests that the predisposition to the choice of neurosis has as much to do with the libidinal relationship to the object as it does to the ego defense mechanisms associated with each of the steps. He firmly maintains the chronological reference, as long as the development of the ego as well as that of the libido is taken into consideration.
This change in the Freudian outlook cannot be understood without reference to the early work of Karl Abraham. In a series of articles published between 1921 and 1925, Abraham made significant contributions to the establishment and refinement of the relation between libidinal development and nosological categories. In 1924 he published "A Short Study of the Development of the Libido, Viewed in the Light of Mental Disorders," an essay that falls well within the bounds of the Freudian perspective but goes beyond it in its description of the neuroses, proposing a chronological model that explains all aspects of mental pathology.
A few years before this, in "Stages in the Development of the Sense of Reality" (Ferenczi, 1913/1980), Ferenczi had expanded the hypothesis advanced by Freud according to which the choice of neurosis is determined by the development of the ego and the libido, specifying that development of the ego could be understood with reference to the sense of reality.
Subsequently, the term "choice of neurosis" disappeared from the vocabulary of Freud and his successors. The term itself had not been very well chosen in the sense that it was not describing choice actively made by the subject but a complex process resulting from a set of determinants. Subsequent interest turned to the comparative determination of neuroses and psychoses.
In the field of neuroses the issue then shifted from the causes determining the "choice" of neurosis (or the factors predisposing to it) to the study of structural traits that could be used to distinguish obsession from hysteria. There was less interest in symptoms than in the underlying structure. The distinction was based on a theory of the ego and libido, in keeping with the thinking that inspired it. An especially illustrative example of this type of approach is the work of Jacques Lacan and a number of his students. But these structural models tend to describe the process more than its genesis.
At the end of the twentieth century and beginning of the twenty-first, the psychoanalytic theory of neurosis and choice of neurosis were been approached from two different perspectives. The first, inspired by behaviorism, questions the principle of a neurotic structure and focuses instead on the mechanisms of conditioning that explain the production of the symptom. The second questions the unitary concept of neurosis and, within the framework of recent American nosological classifications, many clinical neuroses have lost their labels and are found scattered among heterogeneous nosological categories, implying the existence of a number of pathogenic explanations. In both cases the question of choice of neurosis never appears, at least not in the terms in which psychoanalysis has traditionally presented it. Thus the concept that had so strongly aroused Freud's interest at the beginning of psychoanalysis seems to attract less attention from psychoanalysts a century later. The question may again become relevant if the unified concept of neurosis returns to a prominent place in nosography.
* Abraham, Karl. (1949). A short study of the development of the libido, viewed in the light of mental disorders. In Selected papers of Karl Abraham, M.D. (D. Bryan and A. Strachey, Trans.). London: Hogarth. (Original work published 1924) * Ferenczi, Sándor. (1980). Stages in the development of the sense of reality. In First contributions to psychoanalysis. New York: Brunner/Mazel. (Original work published 1913) * Freud, Sigmund. (1896a). Heredity and the etiology of the neuroses. SE, 3: 141-156. * ——. (1896b). Further remarks on the neuro-psychoses of defence. SE, 3: 157-185. * ——. (1905d). Three essays on the theory of sexuality. SE, 7: 123-243. * ——. (1911b). Formulations on the two principles of mental functioning. SE, 12: 213-226. * ——. (1911c). Psycho-analytic notes on an autobiographical account of a case of paranoia (dementia paranoides). SE, 12: 1-82. * ——. (1913i). The disposition to obsessional neurosis: a contribution to the problem of choice of neurosis. SE, 12: 311-326. * ——. (1916-17a [1915-17]). Introductory lectures on psycho-analysis. Parts I & II, SE, 15-16. * Freud, Sigmund, and Fliess, Wilhelm. (1985c [1887-1904]). The complete letters of Sigmund Freud to Wilhelm Fliess 1887-1904 (Jeffrey Moussaieff Masson, Trans.). London: Belknap/Harvard University Press.