When I was a young psychiatrist studying at the Société Du Magnétisme De La Nouvelle Orléans under Dabney Ewin, hypnotism was enjoying some resurgence of interest in the popular zeitgeist. I quickly developed a considerable caseload of patients who wanted me to get them to quit smoking, to lose weight, to enjoy sex again, or to help them deal with repressed trauma. But it was during my consults at Charity emergency room that I learned to respect the potential of this modality.
People in acute pain, panic, or trauma are very susceptible to suggestion. Dr. Ewin taught me that you can relax an agitated person with no medication, reduce someone's heart, breathing rate, or blood pressure, and (to my shock) even reduce acute bleeding. So when I was called to the ER to see what I could do with a young woman with psychosomatic paralysis of her legs, my first thought was to see what response I could get through hypnotism. She giggled at me as I tried. But I did get her to walk. Sure, she stumbled about dramatically for a while, much to the panic of the physical therapist who was with me. I do think she had not walked for at least two weeks, as she had developed the early beginnings of pressure sores on her heels and lower back, so she was a little deconditioned. But she was able to walk out the hospital with her mom.
And that's when I became interested in the Freudian concept of Inhibition, and when I first read this book. You see, I truly don't think the girl was being stubborn or just trying to get attention, like the ER physicians did who were sick of her mother bringing her in for the umpteenth time to the hospital because the outpatient docs couldn't find anything physically wrong with her. So what is this thing that can make a perfectly healthy young woman refuse to walk to the point where she developed pressure sores and her muscles weakened? What makes someone refuse to eat any meals, or vomit whatever they do eat? What makes an otherwise healthy man unable to maintain an erection during sex? And how had I inadvertently broken through this barrier to help my patient walk? Was it my skill as an amateur "mesmerist"? Hell no, and even if that were true, what did I actually do? Or had she felt sorry for this young goober trying to raise her to her feet like some tent revivalist, and I unwittingly unlocked an unconscious desire for her to please me by walking, and thus overcoming her psychological resistance to independent mobility?
Freud's book on Inhibitions is not his most famous work, but is a crucial part of how he changed the world. He too wondered why a patient of his could no longer walk whenever it seemed something happened to make the patient angry, or why another patient would starve herself when she felt anxious. He called inhibitions "restrictions in the function of the ego which have been imposed as a measure of precaution..." An inhibition doesn't necessarily have to result in something "bad," like a loss of bodily function. For example, healthy people with no psychiatric pathology would certainly refrain from telling their boss to piss off when given an impossible directive, but instead find more diplomatic means to navigate the situation. So Freud carefully separates inhibitions from symptoms.
In fact, he rightfully proposes that people repress and filter out unpleasant emotional states every day in order to behave appropriately to the situation at hand. We only notice it when this process fails. If someone gets in a major car crash and is injured, the brain mercifully shuts off the details. Studies have suggested that this happens neurologically by neuronal wiring literally getting short-circuited from the hippocampus (the seat of memory deep in our brains) to the cerebral cortex (where we experience consciousness). So the survivor of a car crash doesn't necessarily live the rest of life never riding in a vehicle again. But the brain is designed to protect us from potential harm. So it does encode warnings in subcortical structures that are readily available when needed. What if the accident happened on icy roads on the interstate in downtown Chicago with a tractor trailer? The survivor may remember the accident but be fuzzy on details, if any, and be able to drive just fine again with no significant anxiety for years, that is, until any combination of stimuli comes too close to reproducing the above circumstances of the historical trauma. Now the driver may have panic symptoms when on the interstate, or perhaps only until surrounded by big trucks, or maybe the driver will refuse to go to work during snowy weather. All of this happens automatically through this wonderful processing system we call a brain. And if these functions don't quite work the way we expect, then the fight-or-flight response happens seemingly spontaneously or in inappropriate situations.
Freud was able to figure this out over 100 years ago. He used different nomenclature, and referred to brain systems as the id, the ego, and the superego, but essentially his general outline remains valid with regards to our understanding of prolonged grief, PTSD, chronic depression, phobias, and anxiety disorders. He also pioneered the idea that the brain can protect us from INTERNAL threats as well as external. A hostile thought to kill the boss, for instance, or to sexually assault an attractive stranger standing next to you in line for theater tickets. The helpful inhibitions come from a complex system of encoded anxieties just beneath the fully conscious level (the subconscious) and come from a variety of interwoven sources--past experiences of negative consequences from certain actions, moral and ethical values enforced by society, cultural and religious beliefs, parenting, etc. Freud called this the superego.
But sometimes we see no way out from anticipated danger, and so a bodily function is "converted" into a substitute. Freud called this a neurosis. We call it conversion disorder now. Performance and separation anxiety mixed with intense fear of displeasing parents may lead a teenager to not be able to walk after graduating highschool and admission to an out-of-state university. Now the child has found a solution to her dilemma without being entirely conscious of it. She can avoid the stress of the new alien environment of university and her own fear of independence without incurring the wrath of a rageful and abusive father, while her doting and enabling mother frets over her illness and allows her to return to a more pleasurable, albeit more infantile, state. The longer this exploited opportunity is relied upon to maintain and protect the self, the more it becomes engrained. The unconscious brain organ isn't aware that one problem has been substituted for another--for the time being, problem solved. This is perhaps why my own "paralyzed" patient had an affect divorced from her presentation. She did not seem concerned about her body's failing her, and as I said, even giggled flirtatiously during my examination and treatment of her. Hell, I'd think that if I were her, I'd be freaking out!
The keys to treating such an occurrence is to catch it early, to be absolutely sure of the psychosocial history of the target symptom, and then slowly rebuild a conscious connection so the patient has insight and control again. Freud called this process psychoanalysis.
He was also careful to avoid overemphasizing the brain's ability to make these compensations. Otherwise, he says, you run the danger of assuming a soldier intentionally got his leg blown off in war so he could live off disability and not work anymore. Unfortunately, I've seen this happen with many clinicians, including myself in my personal life. You've heard it before: "The real reason you are this way is to punish ME!" We all need to be careful not to fall into the temptation of quickly jumping to such ridiculous conclusions, seeing everything through one lens and using the same tool as a solution to everything, or by taking things personally.
Unlike intellectuals whose influence comes from the void of the classroom, the lecture hall, the library, the home office, and the elite cocktail party, Freud's ideas sprang from the clinic, from his devoted interest in and experience with people at a deep level. Freud has become the subject of jokes in the public consciousness these days, and many contemporary psychological theorists venerate Freud's role in kicking off a new profession, but otherwise see his ideas as antiquated.
I, too, do not subscribe to every little thing he has said, but each time I revisit his writings, I am reminded how much of a friggin genius this guy was, and how spot on we have found him to be even now as we tease out the source of conscious volition, emotion, behavior, and automatic organ function through neural network mapping and neurotransmitter feedback loops. He didn't have our technology at his disposal. He had the works of Dostoevsky and other intuitive novelists and poets, as well as the great philosophers of mind, with which he would correlate his observations of behavior and diligently obtained life histories of his patients.
I would not recommend this monograph as the first thing to read if you have no experience with Freud. That is reserved for "The Interpretation of Dreams." This book also already assumes you need no explanation as to what things like an Oedipus complex or a reaction-formation or the pleasure principle are. For those concepts, I refer you to "The Ego and the Id" and "Beyond the Pleasure Principle." But I would place it in the first four of his works you should read if you want a deep dive into an understanding of Freud. And of course, if you are a student of psychology or psychoanalysis, or a mental health professional, make sure you have given this book some attention. Here's why:
This book, as a foundational work in "hysteria," is perhaps more important now as ever. Because in today's productivity-based medicine, people suffering from physical disabilities caused by symptoms of depression and anxiety are often shunted from specialist to specialist, racking up huge debt without getting any closer to recovery. When they finally see a psychiatrist, they are prescribed a cocktail of polypharmacy which in turn has its own consequences.
Or just the opposite happens: people get branded as psychosomatic or even "faking it" before a thorough medical workup is complete. I've encountered a patient with uncal herniation who had previously been branded by three neurologists as having "hysterical migraines." Another patient had a rash on his back that his doctors said was him "picking at it." I repeat--On his BACK! Have you tried picking a zit between your shoulder blades? Well, maybe he had a significant other with overdeveloped grooming instincts who watched too much "Dr. Pimple Popper." But the simplest of dermatologic workups revealed the cause as a very treatable fungal infection. Speaking of fungi, another case of a patient with hysterical paralysis turned out to have untreated HIV and thus a huge fungal ball in his brain. And I can't tell you how many patients with pseudoseizures actually ended up having the real thing.
Let's face it. Medical professionals simply don't have or make the time to put in the work needed to unravel cases of potential psychosomatic origin. And many therapists and counselors are poorly trained to deal effectively with these presentations, only able to provide well-meaning support and encouragement. In today's fast-paced world, we just don't take interest in people with problems we don't readily understand.
We could all learn a thing or two from Freud.