‘Actual Neurosis’ and Psychosomatic Medicine:

The Vicissitudes of an Enigmatic Concept

Peter Hartocollis
Out of the concept of neurasthenia, the main non-psychotic diagnosis of
nineteenth-century psychiatry besides hysteria, and on the basis of
psychophysiological problems of his own, self-diagnosed as neurasthenia, Freud
developed the notion of ‘actual neurosis’, a ‘contentless psychic state’ manifested
by various somatic symptoms and a depressive mood, which he attributed to a
chemical factor associated with aberrant sexual practices and in particular
masturbation. Rejected by post-Freudian analysts as such along with the
diagnosis of neurasthenia, the concept of ‘actual neurosis’ has survived under
various theoretical schemes that seek to explain psychosomatic illness and
somatisation, in general, with its concomitant poverty of affects and dearth of
fantasy life. In more recent years, the concept of ‘actual neurosis’ has resurfaced
under the label of chronic fatigue syndrome, a medical entity thought to be an
immunological deficiency, while in psychoanalysis Freud's idea of a contentless
mental state has been replaced by that of unconscious fantasy and symbolisation
at a pre-genital or pre-verbal level.

When he was approaching the age of 30, Sigmund Freud experienced episodes
of depression, with persistent fatigue and apathy, indigestion and intestinal pains
that weakened his power of concentration and his work efficiency. He spent these
years, between 1882 and 1885, as a clinical assistant in the General Hospital of
Vienna, after having abandoned the promising career of a researcher in
Professor Ernst Brucke's neuro-physiological laboratory and while far away from
his fiancée, presumably in a condition of celibacy (Gay, 1988). The symptoms
followed him to Paris, where he was on a six-month scholarship to study at
Charcot's neuropsychiatric clinic in the Salpetrière. In a letter to his future wife,
Martha Bernays, written on 2 February 1886, Freud self-consciously confessed:

I have recently decided to show you a special kind of consideration (you will
laugh): by making up my mind not to be ill. For my tiredness is a sort of minor
illness; neurasthenia it is called; produced by the toils, the worries and
excitements of these last years, and whenever I have been with you it has always
left me as though touched by a magic wand (E. Freud, 1960, p. 200).

Determined to make a name for himself by discovering something important in

medicine, Freud began experimenting with cocaine as a stimulant in cases of
nervous exhaustion and as an antidote to morphine addiction, also using himself
as a subject. ‘I take very small doses of it regularly against depression and
against indigestion with the most brilliant success’, he reported. And he
specifically noted that the drug was beneficial in ‘those functional states
comprised under the name of neurasthenia’ (Jones, 1953, pp. 81-3).

Around the turn of the nineteenth century, the two most prevalent psychiatric
disorders on the non-psychotic level were hysteria, considered to be primarily the
neurosis of women, and neurasthenia, considered to be primarily the neurosis of
men (Ellenberger, 1970). The term neurasthenia, introduced by the American
neuropsychiatrist George Miller Beard in 1867, no longer appears in
contemporary psychoanalysis and does so only marginally in American
psychiatry as the equivalent of the mixed depression and anxiety disorder in the
appendix of the DSM-IV (1994). It is still present in the nomenclature of the World
Health Organization (ICD-10). In more recent years it has resurfaced as chronic
fatigue syndrome. This diagnostic entity made its appearance in 1957 in Great
Britain under the name of ‘myalgic encepha-lomyelitis;’ it was introduced into the
United States in the mid-1980s under the names of ‘chronic syndrome of the
Epstein-Barr virus’1 and ‘post-viral fatigue syndrome’, later to become ‘chronic
fatigue and immune deficiency syndrome’. Its symptoms are identical to those
characterising the diagnosis of neurasthenia (Abbey & Garfinkel, 1991; Hickie
et al., 1997), and are implicitly or explicitly associated with depression.

Freud had another bout of neurasthenic symptoms a few years after his
experience with cocaine, presented as lumbago and heart disturbances, which
his friend Wilhelm Fliess attributed to nicotine addiction and Freud to myocarditis
following an attack of influenza. These symptoms were associated with
‘depression of spirits’ and ‘visions of death’ and all but disappeared during his
self-analysis (Freud, 1985, p. 82).

The evolution of Freud's ideas about neurasthenia, the sexual aetiology of the
neuroses and the distinction between the ‘actual neuroses’ and the ‘defence
psychoneuroses’ can be traced in his correspondence with Fliess from 1892 to
1895. Without making any obvious reference to his own case, Freud ascertained
that the proximal cause of neurasthenia was masturbation, ‘the frequency of
which runs completely parallel with the frequency of male neurasthenia’ (1985, p.
68). It should be noted, however, that the association of neurasthenia with
masturbation had been made repeatedly by investigators before Freud, beginning
with George Beard himself and including the eminent Viennese sexologist Krafft-
Ebing, who, incidentally, ridiculed young Freud's seduction hypothesis in hysteria
as a ‘scientific fairy tale’ (p. 167n.). But while the others included masturbation as
one factor in the aetiology of neurasthenia, Freud regarded it as its primary cause.
In fact, he also implicated childhood masturbation as a contributory factor in the

1
The same virus was recently linked to multiple sclerosis (The New York Times, 26 December
2001, p. A17).
development of hysteria (1905, pp. 74-5).

In writing about the psychotherapy of hysteria, Freud noted that neurasthenia,

unlike hysteria and obsessional neurosis, could not be attributed to a ‘psychic
mechanism’ (Breuer & Freud, 1893-5, p. 257). Later on, acknowledging Beard's
authority on neurasthenia as a valid diagnostic entity, and citing as its typical
symptoms intracranial pressure, spinal irritation and dyspepsia with flatulence
and constipation (his own symptoms), Freud (1895) detached from it a new
syndrome, to which he gave the name ‘anxiety neurosis’. Adding hypochondria,
he defined all three under the term ‘actual neurosis’, literally, ‘present-day
neurosis’ (1898).

Contrasting them to the ‘defence psychoneuroses’ (hysteria, phobia and

obsessive-compulsive neurosis), he declared that their aetiology was strictly
physical and thus not amenable to psychoanalytic treatment. Even though he
included both anxiety neurosis and hypochondria in what he called ‘actual
neurosis’, in discussing its aetiology Freud referred mainly to neurasthenia. In his
words:

The essence of the theories about the ‘actual neuroses’ which I have put forward
in the past and am defending today lies in my assertion, based on experiment,
that their symptoms, unlike psycho-neurotic ones, cannot be analyzed. That is to
say, the constipation, headaches and fatigue of the so-called neurasthenic do not
admit to being traced back historically or symbolically to operative experiences
and cannot be understood as substitutes for sexual satisfaction or as
compromises between opposing instinctual impulses, as is the case with
psychoneurotic symptoms (1912, p. 249).

He specified that neurasthenia is determined by toxic damage, which he

associated with excessive masturbation or sexual abstinence with frequent
nocturnal emissions, whereby accumulated excitation is transformed directly into
anxiety. Anxiety in those days for Freud was a consequence of accumulated
sexual tension. When anxiety was prominent among the symptoms of
neurasthenia, Freud spoke of anxiety neurosis, a different form of ‘actual
neurosis’. What prompted Freud to detach anxiety neurosis from neurasthenia
was the observation that neurasthenics who suffered from anxiety were often
sexually abstinent (1925, pp. 24-5).

Anxiety neurosis and hypochondria were handled by Freud as if they were

incomplete forms of ‘actual neurosis’, or part of a continuum, the centre of which
was occupied by neurasthenia (‘genuine neurasthenia’, as he put it (1895)), with
anxiety neurosis on the one side, lying closer to the psychoneuroses, and
hypochondria on the other, lying closer to the psychoses. As Freud himself said,
‘It seems to me that hypochondria stands in the same relation to paranoia as
anxiety neurosis does to hysteria’ (1911, p. 57).

Pointing out that the diagnostic label of neurasthenia was greatly abused, Ernest
Jones identified its ‘true’ condition as a ‘primary fatigue neurosis, i.e. one that is
not merely a syndrome of another disease’ (1963, p. 183). And he agreed with
Freud that the aetiology of the condition was physical in nature, possibly related
to some toxic agent, without excluding the involvement of masturbation, qualifying
his opinion with the following statement: ‘onanism leads to neurasthenia only in
certain circumstances, namely, when it is accompanied by an unusually intense
moral conflict’ (p. 183). So far as treatment was concerned, Jones advocated two
types: ‘radical’ treatment, consisting of ‘measures calculated to diminish or
abolish the unsatisfactory auto-erotic habits of the patient’, and ‘palliative’
treatment, such as rest, change of environment and occupation, hydrotherapy,
electrotherapy and so on, reserving psycho-analysis for special ‘obstinate’ cases.

Echoing Freud's view, Sandor Ferenczi attributed neurasthenia to ‘sexual

malpractice’. But instead of associating it with some toxic factor, he blamed
feelings of guilt generated by socially condemned sexual practices like
masturbation. He also associated neurasthenia with depression, pointing out that
the clinical picture of both conditions, in particular ‘insomnia, weariness,
temperature below normal, headaches, and obstinate constipation’ (1921-2, p.
210), was identical.

Wilhelm Reich, on the other hand, used Freud's concept of ‘actual neurosis’ as a
springboard for his ‘orgone’ theory and the treatment of neurosis by means of
orgasmic experience. Identifying ‘actual neurosis’ (or ‘stasis neurosis’, as he
preferred to call it) with the ‘somatic core’ of the psycho-neuroses, he attributed it
to dammed-up libido (‘stasis of the libido’), which he considered to be
inaccessible, except through its somatic contents. He thought that making
conscious the unconscious meaning of the repressed conflict might bring some
symptomatic relief but not real cure, unless the underlying tension found genital
sexual gratification. A ‘satisfactory genital life’, by eliminating the somatic core of
neurosis, would also eliminate the ‘psychoneurotic superstructure’ (1933, p. 14).

‘Actual neurosis’ as a psychological condition devoid of conscious or unconscious

mental content, even though maintained by Freud to the end of his life, was
rejected by post-Freudian analysts until recent years. As Robert Wealder put it:

Psychoanalysts who were a generation or more younger than Freud did not
follow him in this point but claimed that they had never themselves encountered a
clear case of actual neurosis; they were inclined to think that this was a diagnosis
of the early days when the clinical eye had not yet sharpened enough to spot
more hidden neurotic features and that cases classified as actual neuroses at the
beginning would have qualified as full-grown neuroses at the later date (1960, pp.
154-5).

But with Freud gone, the concept surfaced in a disguised form as the
characteristic of psychosomatic and, in general, pre-verbal pathology.

The term ‘psychosomatic’, believed to be invented by the poet Coleridge in the

latter part of the eighteenth century (Nemiah, 1987), was never used by Freud
and only sporadically by other analysts. One of them was Edward Glover, who
asserted that psychosomatic disorders ‘did not have any psychic content and
therefore they are not psychoneuroses’ (1939, p. 173). Addressing himself
directly to Freud's notion of ‘actual neurosis’, Glover explained that, while anxiety
as a reaction to danger from an early situation of helplessness can be met by the
ego and its defences so as to prevent its spread, in the ‘actual neuroses’ the
danger is undischarged excitation originating in the id, in which case ‘the ego
tends to be overcome with repetitive anxiety’ (1926, p. 73).

Otto Fenichel was reluctant to use the term ‘psychosomatic’, arguing, as does
contemporary thinking on psychosomatic medicine, that it suggested a false
dualism, as every disease, whether organic or psychological, is more or less
psychosomatic. Concerning neurasthenia or, more specifically, ‘actual neurosis’,
Fenichel, like Freud, saw it as the result of ‘dammed-up’ instinctual energy, but
attributed it to neurotic conflict that had the impact of a traumatic experience. In
Fenichel's words: ‘The decrease in discharge resulting from the neurotic conflict
creates a condition which is identical with that brought about by the heightened
influx from a trauma’ (1945, p. 310). And, rather than ascribing the clinical picture
of chronic fatigue and various somatic complaints to a weakness of the nervous
system, as Beard did, he spoke of a depletion of available energy caused by the
neurotic defensive struggle, concluding:

Where the instinctual need is not adequately satisfied, the chemical alteration
connected with the gratification of the drive is lacking and disturbances in the
chemistry of the organism result. Undischarged excitement results in the
abnormal quality of hormones and thus in alteration in physiological functions (pp.
310-1).

According to Fenichel, ‘unconscious affects’ are of special significance in the

formation of somatic symptoms which accompany states of dammed-up libido.
Such affects or ‘affect equivalents’ lose their mental content, whereas their
physiological concomitants persist. Fenichel's idea was developed further by
Franz Alexander (1950) and the Chicago school of psychosomatics, which
connected the concept of ‘actual neurosis’ with unconscious conflicts at various
levels of the psychosexual development and with specific personality structures.
Closer to Fenichel's view was Florence Dunbar (1943), who saw psychosomatic
disorders as devoid of symbolic significance, the result of inappropriately or
inadequately expressed affect that created chronic tension and concomitantly
chronic negative interactions and, finally, organic damage. On the basis of
behavioural observations rather than psychoanalytic exploration, Dunbar, co-
founder of the American Psychosomatic Society and first editor of the journal
Psychosomatic Medicine, described personality profiles of psychosomatic
disorders, among them the profile of patients suffering from coronary heart
disease, which was later adopted by non-analytic psychosomatic medicine
(Rosenman & Chesney, 1982).

In dealing with the phenomenon of somatisation, Max Schur (1955) underlined

the existence of narcissistic and pre-genital elements, serious impairment of ego
functions and regression of physiological functions, without, however, excluding
meaningful latent fantasies, such as punishment by an internalised object.
Likewise, Angel Garma (1950, 1957) spoke of a regression that might occur not
only in the psychic, but also in the somatic sphere. Thus anxiety about the image
of an internalised aggressive object could cause regression and find symbolic
expression in some disturbance like peptic ulcer. Melita Sperling (1971) also saw
psychosomatic symptoms as defences against pre-genital oral and anal sadistic
impulses responsible for illnesses like ulcerative colitis and psychogenic anorexia.
Other analysts (Grinker, 1953; Margolin, 1953), however, adopted the notion of
‘pre-genital conversion’, already mentioned by Fenichel (1945) in connection with
stuttering, tics and bronchial asthma, proposing that pre-genital drives, such as
aggression and oral dependency, were converted through the autonomic nervous
system into dysfunctions of the major internal organs, thus creating
psychosomatic illnesses. On the basis of the theory of psychophysiological
regression, S. G. Margolin tried what he called ‘anaclitic therapy’, whereby
hospitalised psychosomatic patients were helped to regress to a condition of
intense dependency that satisfied both their verbal and pre-verbal wishes.

On the other hand, Heinz Kohut spoke about conditions whose pathology had its
roots in the earliest stages of mental development, in which ‘it was operationally
decisive that persistent introspection (even in the form of free associations and
resistance analysis) could not uncover any psychological content beyond anxiety
in anxiety neurosis; or beyond fatigue and aches in neurasthenia’ (1959, p. 467).
It is obvious that Kohut referred to Freud's ‘actual neurosis’ rather than
psychosomatic illness in the sense used by post-Freudian psychoanalysts,
differentiating ‘true’ neurasthenia from anxiety neurosis in attributing anxiety to
the latter and fatigue to the former. It should be noted that, except for Glover and
Garma, no other analyst dealing with psychosomatic illness made reference to
anxiety, speaking instead about tension or about poorly verbalised affect.

Kohut suggested that, with patients who suffer from ‘actual neurosis,’ the
therapist should use ‘loose empathic approximations’, referring to ‘tension’ rather
than ‘wish’, to ‘tension decrease’ rather than ‘wish fulfilment’, and aiming at
‘condensation and compromise formations instead of problem solving’ (1959, p.
468).

In the early nineteen sixties, a group of French analysts centred around Pierre
Marty, namely Michel Fain, Michel de M'Uzan and Christian David, began a
movement that became known as the Paris School of Psychosomatics (Marty &
de M'Uzan, 1963; Marty & David, 1963). Adopting a combination of Freud's
topographical and structural points of view (première and deuxième topique), they
interpreted the somatic symptoms of neurasthenia—headaches, backaches and
various ‘allergic’ manifestations—as ego defences that substituted for neurotic
mechanisms gone astray or defunct. Designating it ‘behavioural neurosis’, Marty
and his associates applied the concept to psychosomatic patients, in whom they
discerned a kind of thinking that was devoid of conscious or unconscious
representations. This particular kind of mentality, which they called ‘operational’
(pensée opératoire), they attributed to a defective preconscious that cannot
mediate properly between the conscious and the unconscious and therefore
cannot provide adequate defences against traumas, so that strong affects
become directly expressed in somatic experiences deprived of symbolic
significance. Marty's contention that depression is a major psychological
mechanism in psychosomatic disorganisation provides one more link to
neurasthenia (Freud's model of ‘actual neurosis’) and its contemporary version,
chronic fatigue syndrome.

In a critical review of the French psychosomatic literature, E. Fine (1997) makes

the point that Marty's theory has the appearance of Freud's concept of ‘actual
neurosis’. Marty (1980) himself made reference to Freud's concept and its
implication of a lack of organisation or of a disorganisation of the mental
apparatus, but instead of attributing it to a biochemical agent related to some
sexual malpractice as Freud had, he put the blame on a specific regressive pull
related to fixation in pathological processes during the intra-uterine development
of the human being or, alternatively, to a pathological interplay of the death and
life instincts. Fain (1966), on the other hand, spoke of a regression to a primitive
defence system of the ego, while de M'Uzan (1974) attributed the surmised
deficiency of the psychic structure of psychosomatic patients to a failure to satisfy
hallucinatory needs in infancy.

As Kohut did with his theory of narcissism, Marty has used his psychosomatic
theory, derived from Freud's concept of ‘actual neurosis’, as a springboard for a
metapsy-chology of his own. In speaking about individuals with a ‘poorly
structured character neurosis’ (1968, p. 246), he extended his theory to include
patients with no manifestations of psychosomatic pathology, to potentially
psychosomatic individuals with a borderline personality disorder similar to Freud's
‘Wolf Man’, which he and his group call ‘behavioural neurosis’. And as with the
case of the Wolf Man, Marty and his colleagues use reconstruction as the main
therapeutic tool, albeit reconstruction of affects rather than of irretrievable early
experiences.2

Some time after Marty's group in Paris, John Nemiah and Peter Sifneos (1970) of
Boston developed their concept of ‘alexithymia’, a kind of affective aphasia seen
in psychosomatic patients who cannot express their feelings verbally.3 According
to Sifneos (1996), alexithymia predisposes to the development or persistence of
medically unexplained physical symptoms such as those met in chronic fatigue
syndrome. The condition, especially in its later version which distinguishes
between ‘primary alexithymia’ (caused, presumably, by some brain dysfunction)
and ‘secondary alexithymia’ (caused, presumably, by some shocking experience,
as in the case of traumatic neurosis), approximates Freud's contention about
‘actual neurosis’ as being devoid of psychic content and therefore unrelated to
psychodynamic processes like fixation, regression and conversion at any level.
Following the therapeutic approach of Marty's Paris School of Psychosomatics,
Nemiah et al. (1976) recommend that alexithymic patients be ‘taught’ to emote in
a face-to-face therapy based on the working alliance.

Early traumatic experience is blamed by Alexander Mitscherlich of Frankfurt,

Germany, for psychosomatic illness, the weakened ego attempting in vain to
have recourse to the ‘characteristic infantile somatic correlates of affects—
specifically the affect of anxiety—in cases of relatively trifling stress’ (1963, p.
237).

Elaborating on the significance of early trauma for the appearance of the

‘psychosomatic phenomenon’, as he puts it, and using British object-relations
theory, another German analyst, Samir Stephanos postulates a ‘pathologically
clinging’ relationship of the patient to his/her mother as his/her ‘only, omnipotent
object’ during the triangulation period of early infancy. Such an exclusive
relationship and the absence of a transitional object, under the impact of a severe
emotional trauma may lead to a ‘withdrawal of the internal objects’ and a
concomitant ‘delibidinisation of the psychic apparatus’ (1980, p. 224).

According to D. W. Winnicott, the splitting of the psyche from the soma is a

2 2
Inthis connection, it may be of interest to recall Andre Green's statement that borderline states
[may] play the same role in modern clinical practice as the ‘actual neurosis’ played in Freudian
theory, with the difference that borderline states are durable organizations capable of evolving in
different ways. We know that what characterizes these clinical pictures is the lack of structure
and organization—not only when compared with neuroses but also in comparison with
psychoses' (1975, p. 5).
3 3
Non-psychiatric
psychomaticians use the term ‘emotional inhibitors’ for patients with
alexithymia (Davison & Pennebaker, 1996).
regressive phenomenon mobilised by archaic forces operating in the defensive
organisation of the individual. More specifically, psychosomatic illness implies ‘a
split in the individual's personality, with weakness in the linkage between psyche
and soma, or a split organized in the mind in defense against generalized
persecution from the repudiated world’ (1989, p. 113).

Following Renata Gaddini's (1975) idea of a prodromal phase of Winnicott's stage

of transitional objects, Frances Tustin (1980) suggested that the persistent use of
‘autistic objects’, such as parts of the infant's own body (thumb, fist, tongue) or
parts of the mother's body or clothes (hair, earlobes, buttons) makes difficult or
prevents the development of symbols, fantasies and the ability to play,
predisposing to psychosomatic illness.

Disagreeing with Freud's conceptualisation of ‘actual neurosis’ as a distinct

nosological entity, Leo Rangell (1968) saw it as a ‘dynamic-economic’ state or a
transient ‘psycho-economic’ condition, which sometimes accompanies
psychoneurosis. Agreeing with Rangell, Helen Gediman tried to account for the
notion of ‘actual neurosis’ psychodynamically, imputing in such cases a low
stimulus barrier, either biological in nature or resulting from repeated early
traumas. She views both actual and psychoneurotic phenomena as compatible in
the same individual, ‘the actual neurotic dynamic-economic state [being]
necessarily elaborated in conscious and unconscious fantasy and thereby...
woven in with any or all of the components in the compromise formations of the
psycho-neuroses’ (1984, p. 194).

Among past and present psychoanalytic writers, who deal with psychosomatic
illness, French psychoanalyst Joyce McDougall (1980, 1989) is the most explicit
in acknowledging her debt to the concept of ‘actual neurosis’. Agreeing with
Freud that somatic symptoms such as those belonging to the old-fashioned
diagnosis of neurasthenia are activated by ‘actual’—in the sense of everyday—
tension, she attributes this activation to a specific kind of mental functioning,
which she calls ‘discharge in action’. But rather than implicating the noxious
influence of some sexual malpractice, she postulates the unconscious presence
of primitive fantasies involving an extremely dangerous internal mother-object
and a damaged paternal imago, a pathological internal parental constellation that,
among other negative consequences, disturbs the normal transitional phenomena
described by Winnicott, hindering the individual's capacity to integrate mind and
body and to connect thoughts with feelings.

Speaking of ‘psychobiological processes of a preverbal order [that] have failed to

be transformed into authentically symbolic processes capable of psychic
representation’, McDougall (1980, pp. 437-8) sees ‘actual neurosis’ as an archaic
form of hysteria, a psychological condition experienced as an ‘empty’ or ‘sterilized’
space, which, in the course of analysis and through the elaboration of oedipal
conflicts, may acquire a better psychosomatic equilibrium and turn into neurotic
hysteria. Criticising Nemiah and Sifneos for making ‘a hasty and uncreative
hypothesis’ (p. 437) in concluding that alexithymia, the American version of
Marty's ‘operational thinking’, is an irreversible biological defect, she also rejects
the idea of a ‘psychosomatic personality’ advanced by the Paris School of
Psychosomatics, arguing that the imputed absence of mental representations in
individuals who somatise is only apparent, based on inadequate knowledge.

Morton Reiser (1978), a prolific writer about psychosomatic illness, has criticised
the theory of pre-genital conversion, arguing that somatic symptoms could
become associated secondarily with fantasies and emotions, and therefore the
symbolism revealed in psychoanalytic treatment might be unrelated to the
creation of a psychosomatic disorder, contributing to the maintenance of the
disorder but not to its genesis. According to Reiser (1968), a contributory factor in
the creation of the physiological mechanisms responsible for the development of
psychosomatic illness is an altered state of consciousness, an idea reminiscent of
Joseph Breuer's (1893-5) ‘hypnoid state’ as a condition favouring the
development of hysteria in the case of Anna O.

Another French analyst who has dealt with the notion of ‘actual neurosis’ is Andre
Green. He points out that Freud established three nosological entities:
transference neurosis, actual neurosis and narcissistic neurosis, with the
implication that sexuality undergoes different transformations in each case. As
Green sees it, ‘actual neurosis results from a lack of elaboration of the libido and
leads to direct discharge of tensions in the soma’ (2000, p. 2), an idea that, as
Green is ready to acknowledge, underlies the understanding of psychosomatic
disorders as developed by Marty and his psychosomatician colleagues. Green's
own concept of ‘negative hallucinations of thinking’ in borderline cases is akin to
the notion of ‘actual neurosis’. In such cases ‘it frequently happens that
representations are absorbed by direct instinctual movements, in short circuit,
leading to expulsion through action or discharges in the soma’ (1998, p. 37).

It is obvious that all those analysts who theorise on pathological conditions that
involve somatisation, in striving to account for the seemingly contentless
psychopathology of such disorders, fall back to Freud's concept of ‘actual
neurosis’ and the then popular diagnosis of neurasthenia, which has resurfaced
recently in general medicine under the name of ‘chronic fatigue and immune
deficiency syndrome’. And they all refer to psychopathology in the pre-genital
phases of psychosexual development, a trend that gained ground after Freud's
time under the influence of Kleinian theory and its emphasis on the unconscious
fantasy of the infant —defining unconscious fantasy as ‘the mental equivalent of
an instinct’ (Isaaks, 1952).

Returning to the concept of ‘actual neurosis’, Freud reasserted his faith in the
chemical nature of neurasthenia:

From a clinical standpoint the (actual) neuroses must necessarily be put

alongside the intoxications and such disorders as Graves' disease. These are
conditions arising from an excess or a relative lack of certain highly active
substances, whether produced inside the body or introduced into it from outside
— in short, they are disturbances of the chemistry of the body, toxic conditions. If
someone were to succeed in isolating and demonstrating the hypothetical
substances concerned in neuroses, he should have no need to concern himself
with opposition from the medical profession. For the present, however, no such
avenue of approach to the problem is open (as quoted by Jones, 1953, p. 259).

Freud's view of neurasthenia as being caused by some chemical substance or

toxin, rather than by repressed traumatic or conflictual memories like the defence
psycho-neuroses, would seem to justify the search for some virus or
immunological deficiency in its homologous medical disturbance of modern times,
chronic fatigue syndrome (Wesseley, 1997). It should be mentioned, however,
that in a different edition of his statement about the nature of ‘actual neurosis’,
Freud noted, ‘To avoid misconceptions, I should like to make it clear that I am far
from denying the existence of mental conflicts and of neurotic complexes in
neurasthenia’ (1925, p. 26). Did Freud mean secondary conflicts and complexes,
equivalent to Bleuler's (1950) secondary symptoms (delusions and hallucinations)
in schizophrenia, which Bleuler himself attributed to some mysterious toxic agent;
or did he mean archaic, pre-verbal conflicts such as those McDougall discusses,
as he does himself in discussing the case of the Wolf Man when he refers to
phylogenetically inherited schemata which are concerned with the business of
‘placing’ the impressions derived from actual experience' (1918, p. 119)? It is
hard to say.

Freud predicted that the ‘actual neuroses’, in particular neurasthenia and anxiety
neurosis, would one day be considered as ‘toxicoses’ and more specifically, as
‘diseases of the endocrine glands’ (1917, p. 115). Oddly enough, neurasthenia
has nearly disappeared from the psychiatric and psychoanalytic vocabularies, to
reappear in internal medicine as an immunological disorder, while the
psychoneuroses (except for hysteria) have been placed under the heading of
anxiety disorders, one of Freud's triad of ‘actual neuroses’. It might also be noted
that psychosomatic illness, like neurasthenia, has in recent years suffered a
virtual eclipse in psychoanalysis, at least in the English-language world, as
progress in medicine makes it imperative that psychosomatic symptoms be
promptly treated by medical means before they become chronic and irreversible.
As a result, psychoanalytic treatment of psychosomatic symptoms is nowadays
important only as complementary to medical treatment, important for the handling
of ‘mental conflicts and neurotic complexes’ associated with ‘actual neurosis’, as
Freud put it in clarifying his position regarding the nature of neurasthenia. In
Freud's own words, ‘On the other hand I will grant today what I was unable to
believe formerly—that an analytic treatment can have an indirect curative effect
on “actual” symptoms’ (1912, p. 249). In reviewing the status of psychoanalytic
theory and treatment regarding psychosomatic illness more than two decades
ago, Lawrence Deutsch, an American analyst, concluded, ‘The core of
psychosomatic (and psychiatric) teaching for the current generation of
practitioners and students represents an ever-growing trend to emphasize the
sociological and physiological sciences while relegating psychoanalysis to an
insignificant role’ (1980, pp. 653-4).

In closing this historical review of the vicissitudes of Freud's concept of ‘actual

neurosis’, I might add that one important reason why it met with scepticism or
rejection for a rather long time was probably the master's insistence on aberrant
sexual practices and in particular masturbation as its cause, in spite of his
strenuous efforts to counter such objections, shared by early disciples like Sandor
Ferenczi and Wilhelm Stekel (Freud, 1912). Curiously, Freud also believed that
masturbation was ‘the primal addiction’, an antecedent condition to adult
addictions from drug and tobacco addiction to gambling, which he attributed to an
adolescent fantasy of having one's mother ‘initiate him into sexual life in order to
save him from the dreaded injuries caused by masturbation’ (1928, p. 193).
Incidentally, Freud's ‘adolescent fantasy’ comes very close to McDougall's
primitive fantasies involving the pre-verbal mother-child relationship in
psychosomatic illness.

It is obvious, however, that when Freud wrote about the ‘actual neuroses’, he was
not concerned with psychosomatic illness as manifested in Alexander's (1950)
‘basic seven’ (bronchial asthma, rheumatoid arthritis, ulcerative colitis, essential
hypertension, neurodermatitis, thyrotoxicosis and duodenal ulcer, to which
contemporary psychosomatic medicine has added coronary heart disease,
anorexia nervosa and the chronic fatigue syndrome), but with neurasthenia, in
which he had a self-acknowledged interest. Yet, while virtually ignoring the old
diagnosis of neurasthenia, as well as its contemporary version, chronic fatigue
syndrome, post-Freudian psychoanalysts have adopted the concept of ‘actual
neurosis’ with its ‘empty’ psychic content for all psychosomatic phenomena,
either on the whole, i.e. both aetiologically and phenomenologically, or partially,
trying to deal with its apparent emptiness by resorting to the psychodynamics of
repression and conversion at a very early, pre-verbal level of mental development.

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Article Citation
Hartocollis, P. (2002). ‘Actual Neurosis’ and Psychosomatic Medicine. Int. J.
Psycho-Anal., 83:1361-1373