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NOTES ON A CASE OF DRUG ADDICTION l

By JULIA MANNHEIM, PH.D., loNDON

The case to be described is that of a female drug extensive symptomatology and included, among
addict who died towards the end of the fifth other phobias, self-imposed insomnia, severe clau-
year of her analysis, at the age of forty-two, of strophobia, manifest homosexuality, gambling, and
cerebral hemorrhage consequent on long- morphinism.
standing hypertension. Her death made me at Both parents were grossly pathological and many
of the patient's abnormalities were obvious reflec-
one time relinquish my intention to present her
tions of her childhood history. Her father was an
case. Further consideration, however, con- insatiable Don Juan type, and no female in his
vinced me that it provides such excellent clinical vicinity, including his own daughter, was spared
material on addiction as to merit description. from his advances. There is evidence of how he
It would prove an impossible task to compress seduced and stimulated her from her earliest age.
such a multi-faceted phenomenon as addiction Freud, although not invalidating his ideas on the
into the time allotted, and a violation of its com- vital effect of phantasy, reverted in his latest paper,
plexity to select one single aspect. Therefore, a • On Female Sexuality', to the recognition that,
solution will be attempted, I hope not too un- where actual seduction occurs, it invariably disturbs
satisfactorily, by conveying a few clinical fea- the natural course of psycho-sexual development
tures and indicating the salient points of their and has profound lasting consequences. This
father had only to touch the patient's hand in her
genesis. Thus anamnesis, clinical history, and adult life, as wellas in her childhood, to show signs
the course of analysis will be amalgamated. of an erection. In treatment she frequently used a
This unfortunately excludes a unilinear sequence German saying, 'Zeig' ihm einen Finger, und er
of description and requires the listener's indul- nimmt die ganze Hand'-' Show him a finger and
gence for a somewhat complex mode of presen- he grabs the whole hand'. The background of
tation. Dream material, too, will be restricted this saying was to become evident in many analytic
to relevant aspects. contexts.
The mother, like her child, was intelligent and
The patient married at seventeen, and her son well-bred but highly disturbed. She seems to have
was twenty-fourwhen she died. She was a feminine- suffered,among other peculiarities,from a particular
looking woman, very well-groomed, dressed with type of death-fear which took the form of an over-
conventional taste, except for her peculiar headgear, exaggerated wish to appear much younger than she
which varied from a single large feather to just an was. When pregnant with the patient she could not
enormous brim. Although of small stature, her admit to the idea of having reached child-bearing
weight at the outset of treatment was no less than age. She expected others to comply with her
14 stone, this having been constant for the last denials. Thus, even up to the time of the patient's
twenty years. This and other factors, including death, she was introduced by the mother as her sister
high blood-pressure,had led her physician,unknown or friend. The mother achieved a sublimation of
to her, to assess her expectation of life at a few considerable merit, owning a reputable and flourish-
months at most. Her oral anxieties had precluded ing institute for rejuvenation.
slimming, since food deprivation greatly increased The patient was born in spite of attempts at
her craving for morphia. Only during the course abortion, and the mother pursued every stage of the
of the treatment, when her anxiety was lessened, child's developmentwith strict disciplinary measures
could she undertake a diet which reduced her weight and frustrating tendencies. Nurses and governesses
by over 4 stone. Her blood pressure then fell who became friendly with the child were usually
considerably from the previous systolic figure of dismissed, and teachers were influenced not to
around 300. I ought to mention at this point that, promote the child to a higher form, to postpone
during the entire analysis, the patient was under the evil hour of having a daughter of school-leaving
constant and skilled medical supervision. Her age. The mother seems also to have had a severe
mental disturbances were further reflected in an masturbation problem and would not allow her

1 Paperread before the British Psycho-Analytical Society on 5 May, 1953.

166
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NOTES ON A CASE OF DRUG ADDICTION 167
daughter, until the age of fifteen, to bath alone or husband imparted to her the news that she was
to use the lavatory behind closed doors. without parents, home, or means. He was an open-
As the patient's material could give the impression hearted, affectionate man of high reputation in
of cover memories or masochistic phantasies, it business circles who not only married the already
seems necessary to emphasize that this history is sick, monstrously obese and penniless girl, but stuck
verified by outside sources as wellas clinicalevidence. to her through all ills to the end.
The patient's masturbation was covered by the At the age of nineteen, after two years of marriage,
deepest amnesia, although various equivalents were following a surgical operation, she became and
readily detected, for example, in school she was remained a morphinist for eighteen years. During
allowed to knit because she could not concentrate this period the pathoplasticity of her body was so
without it. The serious consequences of excessive skilfully exploited that there was no doctor or nurse
anti-masturbatory severity have been stressed by who could resist giving her morphia whenever she
Helene Deutsch, Ruth Brunswick, etc., and, more produced pains, convulsions, spasms, gynaecological
recently, Anna Freud has emphasized, in particular, trouble, or the symptoms of gall or kidney-stones,
that complete suppression of phallic masturbation etc. With the onset of morphinism, she stopped
can lead to serious impairment of ego-activities, having intercourse with her husband and either
sometimes so far as to produce psychopathic engaged in manifest homosexual activity or spent
behaviour. The extreme prohibitive supervision in her days in drug elation and stupor. Throughout
this case was aggravated by the father's repeated her analysis, however, in spite of recurrent agonizing
seductions. From childhood, therefore, the patient desires, she maintained abstinence in both these
always swayed between prohibition and temptation, respects.
until in later life anxiety and wish became unalter- The well-known impatience and tension-intoler-
ably welded. ance of addicts disposes them against the slow
During the first three months of her life she method of analysis. Also they are reluctant to seek
encountered prolonged severe stress and nearly analytic help. It was actually a wave of paranoid
starved to death. This period of breast-feeding by homosexuality which swept her into my consulting
her mother was a succession of vomiting, diarrhoea, room. While under withdrawal treatment in a
breath-holding, convulsive crying, sleeplessness, and mental hospital, she fell in love with a woman
complete exhaustion. When all hope had been doctor who failed to notice her innuendoes. This
abandoned, the mother at last engaged a wet-nurse doctor had occasion to refer to me in appreciative
and profuse lactation was eagerly accepted. As soon terms. Thereupon the patient suspected an affair
as the baby's health improved, the wet-nurse was betweenus and became magneticallyattracted to me.
abruptly dismissed, the happy state came to an end, Hoping to win one of us by severing our imagined
and the old disturbances revived in full force. relations, she manoeuvred the Hospital Superinten-
dent into recommending analysis. This preformed
To anticipate the core of the case, she was the transference was unknown to me when I took her on.
rejected child of a sadistic mother and all her mental The initial house-on-fire transference had a dual
and psychosomatic disturbances bore the imprint structure. The superficial positive element also
of this fact. Her life was a desperate Odyssey in contained features of the libidinizing defence
search of the mother and the seeking for her breast against anxiety described by Fenichel in one of his
the phantasy content of her addiction and homo- articles. With the patient, it derived from the
sexuality, the same aetiology being responsible for childhood situation when her dread of the ever-
both disturbances. In the latency period, her changing nurses led to quick shallow contacts,
homosexual desires were already manifest and were inhibition of aggression, and mistrust of her own
then, as later, directed towards women in authority. projected affects. Underneath her initial love for
At the age of eight, she rose suddenly from her seat me was a thick layer of paranoid mistrust, since
to unbutton, in front of the whole class, the blouse she was seeking the woman doctor from the mental
of a beloved teacher. At 9, she produced pains all hospital, whomshesuspectedto behidden inmyhouse.
over her body so as to be massaged by an adored When this subsided, it was followed by a very
nurse. Her identifications with her teachers, positive but infantile imitative identification with
although homosexual in nature, were important the analyst. She readjusted her household, catered
incentives for learning. for good meals and, instead of a lavish squandering
At sixteen, still believing that she could thus of her husband's often hard-earned money on
become pregnant, she encouraged the manager of homosexual love-objects, renewed and refurnished
her father's business to kiss her and told him that her home, in particular building up a substantial
she now expected marriage. The mother tried to library. She became interested in people and their
dissuade the man and she might have succeeded in problems and became well-loved by many whom
preventing the marriage, which actually took place she could help. This dramatic change at the end of
one year later, had not the father become bankrupt the first period of analysis stood in sharp contrast
and fled abroad, while the mother, also, departed to the paranoid beginning, representing the good
with her younger daughter. The patient's future introjects of the short-lived oral satisfaction phase,
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168 JULIA MANNHEIM

the quick assimilation in the transference corre- mounting rage 'lt being kept waiting, This attitude
sponding to the satisfaction experienced with the certainly fused oral impatience and anal com-
wet-nurse. pliance, and wasthe reflection of her bitter childhood
experiences in the early paranoid phase of the
In her homosexual desires the conditiosinequa non transference. The loosening of it was marked by
was that the woman had to be older than herself and, the following dream: She is racing along the street
to tempt her, she had to be motherly with volumi- to her analysis, chased by a little chamber pot with
nous breasts. In her manifest homosexual relations, a smiling face. This dream, the last of an anal dream
a well-developed clitoris was of great importance. series, was followed by a functional autonomy so
Towards men, in contrast, she was extremely that, to test and to enjoy her newly acquired
aggressive, dominated by penis-envy and her patience, she carne early to her sessions and dealt
revenge-type castration complex, as Abraham at busy shops where she knew she would be kept
called it. waiting. At the same time, it marked the fading
She soon began to play cards for high stakes, out of the oral-anal •too early', • too late', or •to
exclusively with men and, at the card-table, earned get stuck' fears, although these were to appear in
the nickname of ' The Fortress Commander'. Her genital context, as will be shown by the way in which
earnings from these men were spent on presents for her father's seductions impinged adversely upon
prospective love-objects. Thus gambling, one of her sublimations.
her major addictions, was solely in the service of
homosexuality. One motive was made clear beyond She had the ambition to be a pianist, specializing
all doubt by her use of such expressions as ' tearing' in Bach, but her playing was invariably affected by
or ' wrenching' the money away from men, stripping, an attack of anxiety. In many dream versions, a
robbing and humiliating them. To borrow Ella small brook, in German • Bach', grows into a
Sharp's phrase, • The physical background was turbulent river, ending in a frightening waterfaH.
always apparent behind her metaphors'. In a It was not difficult to refer this to her father's habit
dream, she wrenches away from a man a diamond- of urination in her presence. Her talent would have
studded revolver, to give it to a beloved woman. justified the career of a pianist but the fear of
Thus she starts the conquest of woman in the guise getting stuck, and an urge to accelerate, precluded
of a man and a provider soon after, however, this. Adagio or largo was involuntarily increased
feeling frustrated in the active role. To describe to presto, prestissirno. Her unconscious guilt also
this, one feels tempted to reverse the the title of prevented her playing by heart, except two pieces
Joan Riviere's paper and call it 'Masculinity as played on an occasion when she noticed the music
Masquerade'. What she really wanted was the professor nodding approval to her mother. In
deepest longing of the addict, to be the child, many dreams she sits on something warm, with her
suckled, petted, and engulfed in the mother. Usually back to an upright piano, her feet not touching the
she felt cheated, since the partner wanted, at least peda1s-a child on a man's knees. She tries hard
to some extent, the same thing. Whereas mother- to play but, since the keys of the piano feel like a
child interchange is usually possible in non-addict sponge, eiderdown, or hairy cushion, no sounds
homosexual relations, with her and, perhaps, with are elicited. Her father was a precocious ejaculator
addicts in general, the strength of their oral greed and, when misusing the child, would snatch or
does not seem to allow this. Thus her relations thrust away her hand according to his needs,
came regularly to a bitter end. The actual sequence leaving the wrought-up girl excited and frustrated.
of events was that shc produced excruciating pains, In another dream version, just as the sound seems
inducing the partner to procure and administer to be corning, she notices with horror that her hands
morphia on an increasing scale. The partner, are sticky and so, again, gets stuck in her playing.
complying for the sake of the relationship, was of In her fifth year, her great disappointment in her
course disappointed, since,apart from relief of pains, father coincided with the birth of her sister, JIll event
the effectof morphia on such predisposed individuals of decisive importance. He promised her then a
is what Rado calls' the pharmacogenic orgasm'. little boy in a Tyrolean hat with a feather, to play
Morphia, by direct action on the central nervous with her and be her sole possession. Her crazy
system,short-circuits the peripheral sexualapparatus hats remained a life-long allusion to what this
and, by substituting an alimentary pharmacogenic broken promise meant to her. She had no oppor-
orgasm, leads to the turning from object love to the tunity of mothering her newly-born sister since the
drug which then becomes the only love. two children were largely kept apart, even having
The oral frustrations and the lack of early mother- separate governesses. This disappointment marked
ing were succeededby further rejections and frustra- another stage towards the final outcome of homo-
tions in the anal phase and a too strict habit training sexuality, the other basis of which was the oral dis-
in which she had to perform immediately or the position and the deprivational fixation to the mother.
pot was removed. Assuming a similar strictness in From that time on, her passive wishes towards
the analyst, she dreaded to come late to her sessions, her father changed into the wrenching away attitude
yet she could not come early, fearing her own and it was thus that she approached the homosexual
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NOTES ON A CASE OF DRUG ADDICTION 169

love-object with the phantasy of having obtained sucking, as first mentioned by lsakower and later
a penis. by Lewin, seemed never to have occurred. Sleep
The disappointment in both of her parents inversion was, of course, also developed under these
distorted her object relationships and consolidated conditions, forced sedatives only redoubling her
her depressive disposition, as noted in two papers efforts and, as she could keep awake under morphia,
by Edith Jacobson: 'The Oedipus Complex in the even when semi-stuporous, she presumed this was
Development of Depressive Mechanisms' (1943) the safest and most agreeable way to keep alive.
and 'The Effect of Disappointment of Ego and Apart from morphia, to her all medicines were
Superego Formation in Normal and Depressive poisonous.
Development' (1946). It led to unusual de- Her dreams, like those of children, abounded in
precation of her parents and to seeking for other, both symbolism and day elements, which latter,
highly idealized objects, blocking the way to besides other determinants, helped to reduce the
realistic relationships. Either a wholesale displace- difference between sleep and waking, dream-life
ment of her dissatisfaction and disappointment and reality. Well over a thousand dreams were
took place, as in her relation to her husband, recorded during her analysis, the average nocturnal
or complete idealization held sway. A difficult production being three. They occurred either in
analytic problem was created by a cast-iron trans- dream-pairs or showing a threefold dialectic of
ference resistance in which the idealization of the frustration, longing with very near gratification,
analyst reached extraordinary heights. It not only and finally, utter frustration. Such dreams are
defended the object against her hatred, as Balint similar to those described by Victor Tausk in his
qualifies idealization, but had a much more patho- paper, 'The Alcoholic Occupational Delirium',
logical function. It served to deny that the analyst representing the incapacity for orgasm, and the
might have the faintest possible similarity in any traumatic frustrations in the life of the dreamer, but
respect to her parents and, on one occasion, when nevertheless attempting a belated but traumato-
this defence was threatened seriously, she reacted philic mastery.
with an intense but transitory depersonalization. Her dreams entailed the oceanic longing for
One dramatic feature of her numerous anxieties sheltered existence and oral satiation, but were
was a pathological fear of death which was bound reproduced only on the basis of Tantalus situations
up with her sleep phobia. This latter, once estab- from which she fell into the abyss of frustration.
lished, is well known to lead easily to insomnia and A recurring item in these dreams was the sea, in
claustrophobia by equating foetal existence, sleep German 'das Meer ', In innumerable versions
and death. The equation between death and she tries to reach the sea but mountains, barricades,
intercourse was illustrated by a variety of dreams or icebergs make her efforts vain. Sometimes the
in which she, as a little girl, is followed by a man sea is in sight, but the nearer she approaches, the
who wants to murder her. In utter despair she lifts further it recedes and her heartbroken nostalgia
her skirts, showing herself naked, preferring rape is almost indescribable. One day, when she
to murder. The background to her primal phan- understood that 'das Meer' also represented
tasies was that, until her sister's birth, she slept in a , la Mere' (the mother), she burst into tears. Such
room adjacent to her parents. She understood what situations occurred in the transference dreams, too,
was going on in terms of execution, retaining all where she stands in front of my door, waiting in
her life both the typical symptoms of hyper- torment for admittance. Very often the doorbell
acusis and the fear of being taken away by mistake is missing and she gropes desperately for it.
for execution. Her childhood reaction had been At this point I wish to cite an interesting daydream
to feign death by a rigid stillness. From childhood which recurred in varying versions over a period of
up to the third year of analysis, she tried by various years. The hero is a young man who, because of a
methods to avoid deep sleep, including copious slight but incurable leg injury, can never leave the
water drinking so as to be roused by the need to house, which is run by the patient and her motherly,
urinate. This was for some time acted out by beloved partner. The house itself is a splendidly
drinking glasses of water before her sessions, in equipped maternity home in which continuous
order to interrupt them by urination. Drinking childbirth takes place smoothly. In this paradise
was shown in many dreams to be a matter of life and no baby cries, feels hungry, or dies, and the three
death. She also developed a complexive hyper- people live in complete harmony. This idealized
sensitivity to words which contained even a far- trinity represented mother and daughter united with
fetched allusion to death. The word 'griindlich' the borrowed male genital, formerly father's and
(deep or thorough) had to be avoided because it later her son's. This daydream was understood
contained the syllable' grund' (ground). She could when a repressed memory was recovered via a dream.
argue cogently that a dreamless sleep might end in In this dream, a little girl wanting genital stimulation.
death and the antidotes were vigilance and the lifts her skirts to a man; but either she or the man
constant production of dreams. She could not rolls back as in a wheel-chair and she is left frus-
remember a dreamless sleep and the blank dream trated. The wheel-chair is a historical dream
screen denoting the empty flattened-out breast after element connected also with the previously men-
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170 JULIA MANNHEIM

tioned daydream. When she was three, her father too, she tried to obtain inside information about me
injured his leg and, being confined to the house, from various sources, including workmen in my
propelled himself around in a wheel-chair in which house. These dreams illustrate also the interplay
he also stimulated himself, using the child's hand. between the active and passive wish and the fear of
Her attitude to her father was reflected in her eating, or being eaten by, the mother which is the
feelings for her husband. Until treatment, his fixation point of paranoia in women, as Freud and
Parsifal-like loyalty remained quite unnoticed by Melanie Klein pointed out.
her and she lived in the virtually delusional belief Just as she claimed ability to smell whether food,
that he was a cruel black-marketeer who married even in the refrigerator, was to-day's or yesterday's,
her for convenience. The displacement of her so she also conjectured sexual intercourse from the
contempt from father to husband was exemplified smell of a woman's breath and for this reason often
by transferring to him unjustifiably the saying, changed otherwise satisfactory hairdressers. This
• Give him a finger and he grabs the hand '. Also, olfactory hypersensitiveness was used both in life
in her dreams, she has full control, including and in analysis as a sensorial tool in the service of
castration, over the body of her son, the penis being paranoid suspicion. Freud mentioned this in one
represented by a top or an opera-hat. Another of his case histories, while Ferenczi, Jones, Imre
aspect of her relation to her son was shown in her Herman, and Helene Deutsch made relevant
first reaction to his birth. She remembered clearly contributions. Although, in her case, the classical
her thought on this occasion, • Now I have a penis finding that faeces are the original persecutors was
and it's mine.' On a particular occasion she dreamt easy to confirm, there was also full evidence that
that a minor leg operation was to be performed on her paranoid fears had strong oral determinants, in
her son. It was to consist of cutting away the origin probably the smell of the bad and unwhole-
cuticle, which she also called foreskin, on a toe-nail. some milk. Actually she had had only one true
In agony, she implores the surgeon not to cut more attack of paranoid projection when, at the age of
than is really necessary, since she cannot go on fifteen, after an appendix operation, she wrote a
living if her son is maimed. This dream was desperate letter to her father, begging him to return,
provoked by the fact that her son wished to introduce since her mother was trying to poison her with
a girl to his mother, hoping for her approval. What medicines. Her father at this time wanted to divorce
happened was most instructive. The patient rose his wife for another woman who was also adored
to welcome the girl on meeting and literally made by the patient. He returned and reassured the
a faux pas, breaking her toe and having to be driven patient about her mother but wanted to use the
home immediately by her son. Here, a complete, letter in evidence. She, however, protested strongly
or as James Strachey would say, mutative inter- and never again parted with any documents until,
pretation could be given which enabled her to one day in her analysis, she presented me with the
recognize the narcissistic and possessiverelationship maternity-home daydream, written out in full,
to what she called her madly-beloved son. The aim calling attention to her trust in me. Her own bad
of her penis-envy was, as has been said, the mother. conscience at wishing her father to marry this other
The ultimate aim of the libido was complete unity woman whom she desired had, of course, led to her
with the mother, which is a narcissistic and not an paranoid distrust of her mother and so to the fear
object investment. In the previously-mentioned of being poisoned. This gift to me was the
maternity-home daydream, the continuous child- acknowledgement of her understanding.
birth represented her wish for immortality.
Much has been said of her longing for her mother, In her fifth year she had a desperately anxious
and it is time to turn to the other side of the picture. period during her mother's pregnancy. Analytic
Her pronunciation of the word • mountain' in a reconstruction revealed this phase as the crystalliza-
series of dreams was in striking contrast to her usual tion of her claustrophobia. Her former feeding
North German accent. To our surprise, the South disturbances revived in full strength and, for a
German version was found to coincide with the while, her life was again endangered by neither
name of her mother. Some of the violent devouring eating nor sleeping. Her oral wishes and anxieties
elements of these dreams will be found also in her were localized in the growing abdomen of her
claustrophobia. In one dream, her former head- mother. She screamed convulsively at a children's
master, whose name was the exact combination of play where the witch's big tummy proved to her
her parents' names, has to have intercourse with that Gretel, who was actually running about the
every girl in the school. Alternatively, he can eat stage, had been eaten up. In the analysis, dreams
them up, as the lions did the early Christians. In and phantasies illustrated her ideas of oral impreg-
another, she has to eat a mountain of baked beans nation which explained her hysterical nausea,
or semolina from a woman's vagina, but the smell other eating difficultiesand phobias. Both versions
of semolina, meaning semen, nauseates her. Asso- of how the foetus enters the mother's body were
ciations pointed to ideas of oral intercourse, to represented, the one being swallowed or eaten by the
birth phantasies, and the wish to intrude into the mother, the other the baby eating its way in. It is
mother by eating her way in. In the transference, clear how her claustrophobia is connected with these
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NOTES ON A CASE OF DRUG ADDICTION 171

phantasies,which also illustrated the specific quality of aggressive impulses and the ensuing tension,
of this anxiety in claustrophobia, to which Melanie constitute the dominant psychological factors in
Klein and Lewin have drawn particular attention. essential hypertension. The clinical picture was
It should be mentioned here that, in the first year alarming.
of her life, apart from the wet-nurse, the father was
the only person who could deal with the baby, Many analysts agree that in the treatment of
feeding, bathing, and silencingher miraculously by borderline cases, severely traumatized at all
stroking and fondling her body and, likely enough, stages, some modifications, without impairing
her genitals. Thus the role of the firstas wellas the the neutral reserve of the analyst, are found to
second seducer was played by the father, surely a
be necessary. Their panic-stricken anxiety, de-
fact of significance. Thus also a narcissistic hypo-
chondriacal body-ego was prematurely forced to riving in part from lack of parental support,
develop. The rubbing stimulated her skin erotism must come to a first abatement. Unless they can
and fostered the later body-phallus phantasy, in rely on the analyst in the r6le of • the ordinary,
which she copulates with her mother by identifying devoted mother', they behave like traumatized
her own whole body with the father's genital. pre-oedipal infants and their anxiety excess does
Lewin stressed the importance of skin erotism not permit them to gain insight. Their surplus
for the formation of this phantasy in claustrophobia. of narcissism calls for postponement in dealing
Conversation with a newsagent about the delivery with the negative transference, and as many total
of her twelve German weekly newspapers, another interpretations as possible should be given,
manifestation of her addictive search for inside fusing present-day, childhood, and transference
information, evoked the following dream. She
finds herself in a round newspaper kiosk which material. Greenacre suggests that the larger out-
turns first into a child's cot with iron railings, and lines of behaviour tendency should never be
then into a narrower cage containing an upright omitted as a framework for interpretation of the
piano on which she is expected to improvise The final details. She agrees, also, with providing
Merry Widow and Die Fledermaus. She is unable some extra-analytic security in such cases if neces-
to move, there is no exit, and the narrowness is sityarises. In the present case, the taboo on inter-
suffocating. Attempting to suck her way out, she vention had already been broken on two former
is hindered by suffocationand her mouth seemsfull. occasions. Messages had been received from her
Ignoring the various genital items and the implica- specialist that, unless she could be enabled to
tions of The Merry Widow and Die Fledermaus, and lose weight and to sleep, she has no chance
just dealing with the features of immobility, suffo-
cation, and the full mouth, I would like to mention to survive. First, I had decided to work out
that Willi Hoffer, in his article on • Mouth, Hand with her what proved to be a very successful diet.
and Ego Integration', noted that, in the life of the She had responded by presenting me with a loaf
neonate, the useof the hands as organs of prehension of special bread and analytic material by quoting
does not start before the end of the third month. a poem, • Als das Brot gebacken war, lag das
Previous to that something is stuck into its mouth. Kind auf der Totenbahr " which means' By the
This intimates the oral origin of this patient's fears time the bread was baked, the child was dead '.
of suffocation, of being poisoned, of dying, and of Secondly, since she could not accept any seda-
sleep. In these anxieties, a number of convergent tives from medical attendants, I had given her
factors from all later strata were fused and the some pills, a compound of hops and valerian,
deferred elaboration of cumulative impressions was
which she had been able to use. Being ques-
integrated into the claustrophobia.
tioned, I had had to admit that I also took them,
After a long period of steady improvementin her and to this she replied with a sentence, verbatim,
physical and mental state, a sudden deterioration from Alice Balint: • What is good for the
setin, accompaniedbyan increaseof claustrophobia. mother, is good for the child.'
This year, the fifth of her analysis, was emotionally During the final alarming phase of increased
a repetition of the fifth year of her life. The claustrophobic symptoms, although much in-
exacerbatingfactor was a gynaecological operation, sight was gained from interpretation, the primary
the extent of which was beforehand in doubt but anxiety could not be allayed. In what were to
which, in the event, had to be hysterectomy. The prove unfortunately the last few weeks of her
final realization of her inability to bear more
life, her specialist considered it vital for her to
children, although already excluded entirely in
reality by other factors, aroused in her the former take a new brand of hypotensive tablets. Against
emotional upset, as when her father disappointed these she struggled with all her might, stating
her. Her blood pressure rose with her oedipal that her claustrophobia increased to a rigid panic
anxieties. It is common knowledge that excessive after one attempt to swallow and she felt
anxiety, together with the accompanying inhibition drugged. Her anxiety became so intolerable that
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172 JULIA MANNHEIM

it prevented her even from reading, which, as a the weak ego left the canalization of unbearable
major interest, expanded during analysis, had tension. Under increased tension somatic dis-
functioned as a benign addiction, a canalization turbance ensued, and this, in turn, caused further
of her former noxious one. This situation increase of tension; a vicious circle arrested
jeopardized the only respite from her anxieties temporarily by the drug. Taking this into
and made a catastrophe imminent. I then account, addiction appears in a constructive
offered to go to the specialist to discuss her aspect. Without it, the alternative for the
medication. Unfortunately there proved to be patient would have been psychosis. The quieta
no time to act on this offer. That very afternoon non movere principle was based, therefore, on
she had a fatal cerebral haemorrhage. Thus the trying to keep the patient on the level of ali-
claustrophobia, which related to her deepest mentary orgasm and to prevent a deeper
point of regression and to her paranoid and oral regression. In the strategy of treatment, which
fears of annihilation, ironically enough, also was, I hasten to say, not preconceivedbut rather
precipitated her death. imposed by the nature and possibilities of the
case, the therapeutic aim was the conservation
The clinical data of the case suggest a few of addiction. This absurd-sounding aim might
hypotheses, more in the nature of queries than seem less bizarre if re-stated as an attempt to
of statements. The first concerns the symptoma- break down the noxious addiction into harmless
tology; the second the strategy of treatment; equivalents.
and the third, the function of her addiction.
It was evident from the beginning that she Of the patient's non-pharmacological addic-
suffered from those disorders which entail a tions, time only allows me to cite one example.
close connection between anxiety development She was in the habit of devouring several books
and symptom formation. Thus she showed the a day and read with what one could call an
complex picture of anxiety neurosis, conversion • emphatic index'. She swallowed what was
and anxiety hysteria, insomnia, addiction and good or relevant for her unconscious purpose,
psychomatic disorders such as hypertension and not taking in what was not or ejecting it, like a
cardio-respiratory symptoms. The original pro- first expulsion from the ego, as described in the
longed painful stimuli which, in infancy, had paper on • Negation '. She also distorted issues
invaded her body and organs induced a narcis- in her reading, according to unconscious wishes
sistically hypercathected body image with hypo- and memories; or she involuntarily synchron-
chondriacal properties which remained the ized different readings to a wishful pattern. She
representative sample of her ego. The original produced, for example, in good faith, the idea
traumata and their somatic discharge left an that Cordelia had replied, to Lear's famous
increased tendency for the use of this channel, question, that she loved him as much as salt.
the psycho-physical substratum of her make-up, Being banished, she returned in the guise of a
draining subsequent conflicts into bodily symp- kitchen-maid and served his food regularly
toms. This accounts for the extensivelay-out of without salt, until he spat it out and called her to
her symptoms, every one of which is a compound judgement. He was then forced to acknowledge
of all the aetiological factors in her mental her and his mistake. These and other similar
disturbance. Symptoms which can, with other products of her reading addiction show such
patients, be special entities, are, in her, inter- mechanisms as occur in dreams and were ana-
dependent symptom complexes aiding and abet- lysed accordingly. James Strachey's findings on
ting one another. They suggest a syndrome- reading addiction could be fully verified.
like formation under the impact of excessive In such cases as this, primary anxiety of long
traumatic primary anxiety, reinforced by the duration and intensity can be lessened but not
traumata of all later stages and built on a consti- reliably deleted. This certainly limits the scope
tutional insufficiency of the protective barrier; of treatment unless channels of sublimation can
anxiety-readiness and low-tension toleration be found. That they could not be satisfactorily
being most marked in former generations of her developed in this case leads to the intriguing
family. problem of why some male addicts, in contrast
In spite of the vast lay-out of her symptoma- to femaleaddicts, show remarkable sublimations.
tology, a surplus of anxiety was left unbound. In the present case, in spite of achievements of
The binding of this surplus was the function of non-pharmacological addictions, the adhesive-
the addiction, to which, failing other mastery, ness and inflexibility of the patient's libidinal
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terms & conditions (see terms.pep-web.org).

NOTES ON A CASE OF DRUG ADDICTION 173

attachment to the mother did not allow of truly perception of an altered environment: only a
desexualized activities. The expansion during hypochondriacal ego-change. Although the re-
analysis of these harmless addictions compared gression goes back to the first oral phase and
with the alternative of a relapse into morphinism could be considered paranoid, the "affects are
was regarded as a therapeutic gain, and their bound within the mental structure and not pro-
stabilization, as has been indicated, was a major jected on to the external world.
aim, failing, of course, the possibility of true
sublimation which would have been the ideal It is customary to classifyaddiction under one
and might have been reached had she lived. of the three dominant aspects according to
The cycle of hunger and satiation leaves in- whether the paranoid, the depressive, or the
delible imprints on the melancholiac too, but- homosexual factor plays the leading role. A
taking the wide constitutional variety in the en- close examination of the case under discussion
dowment of sadism as axiomatic-his stronger does not invite its subsumption under only one
sadistic charges induce a sadistic superego which of these three aspects, since they appear com-
has to be overthrown by mania to bring about a bined, integrating in almost equal proportions,
fusion with the ego. Compared with mania, the thus strongly suggesting a centre of aetiological
elation of the addict is at a low ebb. The de- convergence. The historical basis in this case
cisive fixation point of manic depression is the for the combination of these three aspects is
second oral phase, whereas that of addiction considered to lie in the tri-phasic basic experi-
seems to be the first. Although the first oral ence of the patient's earliest life, with the two
phase is considered, according to Edward periods of excessive frustration and the inter-
Glover's and Paula Heimann's corrections, vening period of intense gratification by the wet-
ambivalent and not pre-ambivalent as Abraham nurse. These three phases became decisivepoints
thought, the sadistic charges are considered of fixation. The first was a paranoid projective
weaker than those of the second; also there is with indelible marks of primary anxiety. The
no strong superego to be overthrown and the second, called by Rado alimentary orgasm, was
pressure is more that of anxiety than that of introjective. The third entailed an oceanic
aggression. Although the guilt systems in this longing for the previous alimentary stage and
case do not seem strong, the superego was not produced the phantasies in which gratification
lacking. The patient was not, like some other was unobtainable; this is thought to be the
addicts, a delinquent who steals the drug; fixation point for her homosexuality.
rather she produced symptoms in order to ob- Finally, a hypothesis suggested by the case is
tain it. However, good introjects were poor and that in female homosexuality distinction should,
the superego was not based on reliable identifica- perhaps, be made between one variety which
tions, appears sui generis, and another which is an
The building up of an autonomous, in place integral part of the addiction syndrome. In this
of her heteronomous, superego was another aim case, which I have reason to believe is not
of therapy, as wasalso an increase of ego strength unique, the pregenital antecedents of the Oedipus
to the level of signal anxiety and toleration ot situation have a relatively stronger determining
depression. They were to" some extent achieved. effect.
An article by Therese Benedek assisted in Both the particular and the general validity of
drawing a line of demarcation between the these conclusions can, of course, be verifiedonly
patient's ideas about the poisonous qualities of by the analysis of other similar cases.
medicines and true paranoid projection. With
this patient it was the drug that was noxious, not (Received I July, 1953)
people who poisoned her. There is no delusional
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