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Psychoanalysis of acne vulgaris.pdf by jizhen1947

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        Journal Title: The psychoanalytic review.             Charge
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        Volume: 26
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        MonthNear: 1939                                       Harvard University
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        Article Author:                                       Cambridge MA 02138
        Article Title: Montgomery; Psychoanalysis of
        acne vulgaris                                         Fax: 617-495-2129
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     From the collections ofthe Center for Research Libraries             www.crl.edu
  PSYCHOANALYSIS OF A CASE OF ACNE VULGARIS                              *
                      By DR.    LOUIS MONTGOMERY
                             OF NEW YORK, N. Y.


    Because of the apparent psychological significance of the skin as
a means of intercommunication between the inner and the outer
worlds, skin diseases obviously deserve the attention of psycho-
analysts. Yet, the examination of the literature discloses little sys-
tematic application of psychoanalytic technique to skin manifesta-
tions. Barinbaum (1) has pointed out the significance of psycho-
analysis to dermatology. "In adjudging psychogenic skin diseases,"
he says, "psychoanalysis merits first place, because this method alone
among all methods of psychotherapy is able to reveal the sources of
the energy bound up in these diseases. It is only this knowledge
that mal{es possible a rational therapy. Every psychogenic skin
disease is a symptom of a psychoneurosis, specifically a conversion
hysteria, providing physical release of repressed impulses."
    Numerous writers since Kreibich and Doswald (2), to whom we
owe the first demonstration that skin blisters can be produced hyp-
notically, have established the existence of psychogenic skin diseases.
Dunbar (3) lists 120 communications bearing directly on the sub-
ject. Recently Schilder (4) reported quite extensively 011 the psy-
chology of the skin. However, the literature in general seems barren
of detailed psychoanalytic case histories of psychogenic skin diseases.
Jelliffe's early paper (1916) stands alone.
    Perhaps the primary reason for this may be, as Sack (5) points
out, that "without psychic analysis, the diagnosis 'psychogenic skin
disease' cannot be established. There are no skin manifestations that
can be recognized by inspection as psychogenic."
    In the same paper Sack stresses the point, that the skin affords
an especially favorable field for the study of psychosomatic relation-
ship, particularly since here all voluntary innervation seems to be
excluded. The same author, in an earlier communication (6),
stresses the importance of the skin as an organ of expression which
has a twofold significance: reflex, springing from the deep strata of
   * Read   before Psychoanalytic Study Group of Los Angeles, February 18,
1938.
                                    [155]
                                                                              i                      p
156                       LOUIS MONTGOMERY                                    \

the unconscious to alarm the conscious mind and attract the attention                  cause could'
of the individual; demonstrative, that is, directed towards the social                 ever since tl
environment to derive notice and attention. In speaking of the skin                    worse. Wh
as an organ of expression, Sack also reminds us (5) that it is impor-                  a dog, she ~
                                                                                       continue to '
tant to remember that the skin is not experienced as the system of
                                                                                       ably become
layers which we know from the histological section, but in terms of
                                                                                       of depressio
the total situation-sometimes as point of sensibility to various
                                                                                       eral days at
stimuli . . . and again from the esthetic point of view, as beautiful                  were also gl
or ugly, pure or impure, pale, red, smooth, etc.; then again as the                          The pati
 boundary of the body as related to the environment. These and                          quite nards
 innumerable other roles are played by the skin in terms of experience                  noted,-was
 of the individual.                                                                     lesions on 1
      Hazen and Whitmore (7) who claim no particular training or                        diagnosed ~
 experience in psychoanalysis and emphasize that they are far removed                   for a period
from the pure Freudian school, state: "That emotional disturbances                      and uncert~
 will cause such transitory cutaneous symptoms as blushing, pallor and                  afraid of dl
 excessive perspiration is well recognized by the laity but that lesions                years. In
 of long duration and considerable severity may result is frequently                     alone on th
 overlooked by the profession."                                                          and after ~
      Through psychoanalysis we know, that the sensations, funda-                        I'm alone, ]
                                                                                         "When shl
 mentally the genital sensations of hysterical symptoms may occur in
                                                                                              It must
 any organ and also that hysteria can imitate almost any disease. In                     evident to
 the case I present here, the patient's original complaint was not her                   psychogeni
 skin condition. It was only during analysis that the analyst was able                   apparently
 to sense the definitely psychogenic nature ,of the acne vulgaris with                   psychosis.
 which the patient was also afflicted. It forced itself to the foreground                 narcissistic
 as a symptom which made it imperative to treat it as such. For that                      be a psyd
 reason and in order to create a more comprehensive insight into the                      analysis a<
 various psychic phenomena that were present, various other aspects                            Stella's
  of the case aside from the skin condition must be presented. For the                    and a bro
  sake of clarity, the material which is the resnlt of an aggregate of 603                aggressive
  hours of analysis, spread over a period of 39 montbs, is being pre-                     religious, I
                                                                                          under any
  sented in a more connected chronological order than actually secured.
                                                                                          a failurei
  Also, since a full description of the intricate structure of this case                  necessities
  would far surpass the frame of this paper, we shall endeavor to trace                    read nor
  the main lines only.                                                                     had ever'
      The patient, whom we shall call Stella, was brought to the analyst by                mean to e'
 her husband. The immediate object of the consultation was, what her                       own rigid
 husband a physician, diagnosed as an expanding dog phobia. There were                     the time   I


  also periodic depressions, nausea accompanied by vomiting spells ancl                    cerned ab
. occasional severe, spasm-like pains in her breasts for which no organic                   remark, j

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    I
                    PSYCHOANALYSIS OF A CASE OF ACNE VULGARIS                    157
         cause could be found. The husband related, that for the past three years,
         ever since their marriage, his wife's condition had been gradually getting
         worse. Whenever he went out of the house with her and she would spy
         a dog, she would become terror stricken, rigid with fear, she could not
         continue to walk and had to be placed in a cab. There she would invari-
         ably become nauseous and have an attack of vomiting. Her periodic states
         of depression, which at first lasted but a day, gradually extended to sev-
         eral days at a time. Her complaints of spasm-like pains in the breasts
         were also getting more frequent.
             The patient was a charming, somewhat shy and reserved, evidently
         quite narcissistic woman of twenty-four. Her face,-and this should be
         noted,-was unusually pretty but she had a few, quite noticeable acne
         lesions on her chin. Her husband casually remarked that this condition,
         diagnosed as Acne Vulgaris, has resisted all sorts of medical treatment
         for a period of six years. Stella's recital of her fear of dogs was confused
         and uncertain as to details. She stated that she was always somewhat
         afraid of dogs, but was never actually terror stricken until the past few
         years. In reply to the analyst's question as to how she managed when
         alone on the street, she looked quite surprised, became noticeably uneasy
         and after a pause said: "Come to think of it I'm always lucky when
         I'm alone, I don't seem to run into any dogs," to which the husband added,
         " When she's with me she sees dogs even when I can't see any."
             It must be remarked here, that even at the first interview it seemed
         evident to the analyst that if the symptoms enumerated were at all
         psychogenic, he was dealing not with a phobia, but with a pathoneurosis,
         apparently a psychopathic reaction intermediate between hysteria and
         psychosis. The general cIinica.1 picture appeared to show a sufficient
         narcissistic regression to presuppose that the cause of the illness might
         be a psychogenic hypercathexis of the organs involved, which made an
         analysis advisable.
             Stella's family background consisted of her parents, a sister two years
         and a brother five years younger than herself. Her mother was an
         aggressive, mentally insignificant, compulsive person who had her rigid,
         religious, moral and social conceptions from which she would not deviate
         under any condition. Her father, evidently a masochistic individual, was
         a failure in life and often unable to provide his family with even bare
         necessities. In intelligence he was far above the mother who could neither
         read nor write and according to Stella was the most stupid person she
         had ever encountered. She was not only stupid and ignorant but also
         mean to every member of the family, attempting to enforce upon them her
         own rigid conceptions. The younger brother, nineteen years of age at
         the time of analysis, was the patient's favorite and she was much con~
         cerned about his future. The sister was practically dismissed with the
         remark, that "she is stupid just like my mother." Thus the family




h
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                                                                               1

                                                                               I
                                                                                                    PSYCI
158                       LOUIS MONTGOMERY
                                                                                            She felt happ
aligtlment was father, brother and Stella on one side, mother and sister
                                                                                        would sing and d
on the other. While Stella stood for a great deal of abuse from her
                                                                                        her for showing
brother, even minor dissensions on the part of her sister resulted in
                                                                                        women teachers
violent arguments. Her antagonism against the sister she attributed to
the latter's utter lack of vanity. She was fa~ and ungainly yet would do                disliked male teal
                                                                                        shocking other f
nothing about it. Stella was ashamed to be seen with her.
                                                                                        she was about s£
    Very much attached to her father, Stella attributed his failures in life
to her mother who would constantly nag at him, be the cause of almost                   not at all hurt. :
incessant arguments and extended periods when the two parents would                     excitedly told hil
not speak to one another. The patient's critical attitude extended also to              terribly excited,
her father but only insofar as she claimed that he lacked backbone. In                  It seemed that h
other respects she was most tenderly attached and felt extremely sorry                   her fa ther. She I
                                                                                         forms of tOl'menl
for him.
    Her childhood was spent on the East-side of New York in comparative                  whenever her pa
poverty. She never had anything other children in the neighborhood had.                  other for weeks.
Even asking for a penny to buy candy brought forth a tirade from her                     secretly hoped tIl
mother, who reproached her for daring to ask for it. "I'm no millionaire                     At the begini
who can afford to buy such luxuries as candy," or "Your father makes                     too willing pert
next to nothing and you want to play the lady," were some of her mother's                forth a mass 0
characteristic remarks, which Stella resented primarily because of the
slur they implied against her father. In all domestic arguments, and
there were many, Stella always took her father's side. Even after she
                                                                               1         experiences relal
                                                                                         merely to fill u~
                                                                                         definite struggle
left home, each visit to her parents' house ended in an argument either        j         from the anxiet.
with her mother or her sister. She frankly admitted hating her mother.                   remark here, tho
                                                                                )
At the same time she felt sorry for her because "she waS so ignorant            I         which lasted for
                                                                               .,
and because all her life she worked so hard without ever having any                       the analyst, takir
pleasure." As much as she criticized her mother mercilessly, so she                       She always wan
defended her father with equal ardor. She found an excuse for anything
                                                                               1          to be noticed an
that he may have done wrong. She always consoled him in his failures
and tried to please him in every possible way. "I was more of a wife
                                                                               I          able ways, becm
                                                                                          reactions to disa
to him than my mother. She never understood him and I can't for the                           At the end a
life of me understand how he could live with her at all."                      I          enced by the pati
                                                                                          would smile an<
    As far back as she remembered, she was always ashamed of her
~o:erty. As a young child, just starting school, she chose a little girl,
hVlllg in a better section of town, as her chum, because she had a nice
                                                                               l          or "Better luck
                                                                                           purposely hinder
apartment and her father had money. She would lie to her friends about                     his spoils. Pul
her. folks' financial condition, concocting some of the most impossible                    enti rely that slu;
stones. The center of these stories and lies invariably portrayed her                      of her general   a
father as a wealthy man and a hero. A characteristic story she told in                     associating freel
~chool was her father introducing her to President Harding. She O'loried                   analyst to succe
III the envy. and admiration this story brought her.     When her bfather                  developed, it be
heard ~bout It, he scolded her severely. She didn't mind the scolding and                  irrelevant mater
kept rIght on telling fantastic stories as a means of securing admiration                       After the na
and envy.                                                                                  hended, the pat



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                       PSYCHOANALYSIS OF A CASE OF ACNE VULGARIS                    159
                She felt happy when people would tell her that she was pretty; she
            would sing and dance for them. Her mother, however, always reproached
            her for showing off. She was an excellent student and well liked by her
            women teachers to whom she catered in various ingenious ways. She
            disliked male teachers and enjoyed shocking them. She would also enjoy
            shocking other people, particularly her father. On one occasion, when
            she was about seven years old, her brother was almost hit by a car but!
            not at all hurt. Stella, that evening, rushed ahead to meet her father and
            excitedly told him that her brother was run over by a car. He became
            terribly excited, ran into the house and she enjoyed his apparent agony.
            It seemed that her sadistic acts fell upon a fertile field in the person of
            her father. She evidently sensed this and even as a child arranged various
            forms of torments for him. One of her most vivid recollections was that
            whenever her parents had an argument they would refuse to talk to each
            other for weeks. Stella would often try to effect a reconciliation, but
            secretly hoped that her father would not resume speaking to her mother.
                At the beginning of the analysis, Stella was a very willing patient;
            too willing perhaps. Informed of the fundamental rule,she brought
            forth a mass of evidently forced, nonsensical material; trivial daily
    r
    ,       experiences related in greftt detail, in short, matters that were intended
            merely to fill up the analytic hour. This useless material served as a
    \
    !       definite struggle against the analysis and was characteristically a flight
            from the anxiety that lurked behind her narcissism. We might also
            remark here, though perhaps a bit prematurely,. that the patient's conduct,
            which lasted for over a month, indicated that she was in effect castrating
            the analyst, taking away from him that which he needed most to succeed.
    r       She always wanted to be in the limelight, wanted her own way, wanted
            to be noticed and admired. She was naturally disappointed in innumer-
            able ways, because her wishes were immoderate and unrealizable. Her
            reactions to disappointments were violent.
                At the end of such fruitless sessions, the definite satisfaction experi-
            enced by the patient at the expense of the analyst was quite apparent. She
I           would smile and remark: "Well, you didn't get anywhere today!"-
I
1'#1,       or "Better luck tomorrow, perhaps."-or-" I hope you don't think I'm
            purposely hindering you? "-Her smile was that of the victor who enjoys
r           his spoils. Putting the entire burden upon the analyst, overlooking
            entirely that she herself would profit from any success, was characteristic
            of her general attitude to her environment. She experienced difficulty in
            associating freely because supplying important material would assist the
            analyst to succeed, which in turn meant defeat for her. As things later
            developed, it became also clear that she was imitating her father. The
            irrelevant material was the equivalent of not speaking at all.
                After the nature of this attitude to the analyst was fairly well compre-
            hended, the patient went to another extreme. She produced an almost




r
160                       LOUIS MONTGOMERY
                                                                                       as he did t
endless volume of dreams; three and four daily and all of them almost two
                                                                                       tion. Sue
or three pages long. The analyst did not find it timely or advisable to
                                                                                       seemed to
discuss any of these dreams which, in turn, greatly annoyed her. Dream
                                                                                       embrace, s
interpretation promised a new "game" for her and she clearly resented
                                                                                       said to wh
the fact that the analyst refused, so to speak, to IJlay "her game," but
                                                                                       to keep it
instead insisted on continuing what she termed" his game."
                                                                                       that.
    The following was the first short dream she presented: (( I am driving
                                                                                              Weknl
a car. Suddenly the red light is on. I put my foot on the brake very
                                                                                        it.(8) Tl
quickly and the car stops beyond the curb. I'm surprised that traffic
                                                                                        Stella was
going the other way can go without bunk1:ng into me. I'm having diffi-
culty getting the car started. It just won't go. Suddenly it goes back-       I         she herseL
wards and I hit a girl who screams, but instead of agony, I notice delight    "         safely say
in her scream."
    We shall not enter into detailed interpretation of dreams, but will       "         old, well d
                                                                                         in Stella's
                                                                                        infantile Ii
merely allude to such points as will further the subject matter. With
extreme reluctance, Stella admitted total frigidity. Intercourse, while not
                                                                                         will becom
obnoxious, was nevertheless an effort for her; particularly since under no                     Psycho
condition did she want her spouse to know about it, she had to simula'te                 sexuality,
a great deal of passion. Her extreme reluctance to admit frigidity was        I          the elitori:
also a direct expression of her general attitude to life. To her, being                   passive, fel
frigid meant being inferior tD others, particularly to men. She often         \'          this proce!
wondered whether she missed something in life that others had. She con-       >           may becorr
sidered being frigid a purely personal matter which must never be                              After tl
                                                                              1
admitted. It served her as a weapon against those who, ignorant of her                    to go out!
frigidity, considered her extremely passionate and she could look down                    her conditi
upon them as being ignorant. She thus turned a liability into an asset.                   not stand
Castration anxiety and penis envy were here apparent.                                     frantic rou
    Only upon repeated assurances that the analyst would keep all her                      numerous
confidences, did Stella discuss her past freely. When she was eighteen,                    and with
she developed a case of acne. Her face broke out in pimples, quite sig-                    embittered
nificantly, just at the time when she had her first love affair with a man
 ten years her senior. She loved that man very much because he was
 older than other boys she had met and because he earned $80 per week.
 Although the entire affair consisted of the man taking her to the movies
                                                                              r   \.
                                                                                           drew from
                                                                                           Her chief
                                                                                           forced her
                                                                                           Most of hI
 and kissing her once, she had already fantasied herself as married to                     continued·
 him, how all her friends would envy her as the first one to get married                   efforts to
 and also how through him she would be able to escape her oppressing                        of conside
 home atmosphere. However, after the first and only kiss, the man, for                      she was p
 no reason that Stella could see, suddenly stopped calling on her. She was                  10 tell her
 heartbroken, cried for hours and felt greatly humiliated. Her anger                        became.
 knew no bounds. She fantasied various ways of getting even with him.                       frame of
 To her chums she pretended that she was still keeping company with this                    in the bat
 man and for months would lock herself into her room night after night,                      idea of en
 refusing to see anyone. She continually asked herself why the man acted                     and coaxi

                                                                                   I
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,
I
                PSYCHOANALYSIS OF A CASE OF ACNE VULGARIS                      161
     as he did towards her. She could find no answer to this tormenting ques-
     tion. Suddenly, she recalled that the one and only kiss he gave her
     seemed to last an awfully long time and as he released her from his
     embrace, she murmured something or other. He asked her what she had
     said to which she replied: "I was wondering how long you were going
     to keep it up." He said good night and she never heard from him after
     that.
          We know that every neurosis has a precipitating cause which releases
     it. (8) Thus far the one outstanding traumatic experience related by
     Stella was the utterly incomprehensible jilting by her first beau. That
     she herself had prepared this jilting never occurred to her. vVe might
     safely say that it can hardly be considered normal for an eighteen-year-
     old, well developed girl to react to the first kiss from the man she loves,
     in Stella's manner. That she had to react that way in the light of her
     infantile fixation, castration fear and the danger of losing parental love,
     will become quite evident as we further unwind the patient's life history.
          Psychoanalysis has clearly shown that women, besides their female
     sexuality, have an active, we might say male sexuality which centers on
     the clitoris. This latter sexuality must be overcome in favor of the
     passive, female sexuality which is concentrated in the vagina. Frequently
     this process either fails to be completed or succeeds only partially. This
     may become the point of departure of various conflicts. (9)
          After the jilting by her first beau, Stella became very irritable, refused
     to go out and cried upon the least provocation. All this she attributed to
r    her condition of acne which made life miserable for her. She simply could
     not stand her face being marred by pimples. She embarked upon a
     frantic round of all sorts of cures, tried innumerable remedies and visited
     numerous physicians and specialists, all to no avail. The acne continued
     and with that her attitude against the world at large became one of
     embittered rage. She considered herself cursed. She quit college, with-
I-
     drew from all social activities much to her father's quite evident chagrin.
     Her chief topic was bemoaning her cruel fate. Circumstances, however,
     forced her to seek employment and she secured a position as bookkeeper.
     Most of her earnings she spent on futile attempts to cure her acne. This
     continued for about two years and her attitude did not change. Her
     efforts to rid herself of acne did not diminish. Her behavior was a source
     of considerable pain to her father who vainly tried to convince her that
     she was pretty in spite of a few pimples on her face. The more he tried
     to tell her tha.t the pimples were hardly noticeable, the more enraged she
     became. On one occasion when her father reproached her for her silly
     frame of mind, she dramatically grabbed a bottle of iodine, locked herself
     in the bathroom, making sure that she had clearly enough conveyed the
     idea of ending her misery. It took her father several hours of beggin~
     and coaxing to get her out of the bathroom. She admitted that she
                                                                                1

162                         LOUIS MONTGOMERY
                                                                                t
                                                                                I
 intended to impress her father as forcefully as possible how truly miser-          the ell
 able she was and that her pimples were not something to be taken lightly.          have
     At that time her employer's seventeen-year-old son was Stella's only           initial
 source of interest. She struck up a mild flirtation with him. They                 none I
 exchanged furtive kisses and on one occasion, when they were alone,                less a
 she took him around and kissed him passionately. Why she did that she              these
 couldn't say. "I just felt like it at the moment. I think I enjoyed being          throul
 able to arouse him." The boy became aroused, took out his penis, she               passic
 took it in her hand and he had an orgasm. She became terribly frightened           knew
 by the way he moaned and she asked him if he were in pain. At this point               Sl
 she suddenly switched to relating how that morning she spent about an              throul
 hour squeezing pimples and how painful this was. After a significant               each   I


 pause she added: "Tell me, is it painful when a penis is squeezed very             she e:
 hard?" We must note here the patient's associative connection between              feel g
 penis, pimples and pain. Asked for further associations brought forth              feel v
 the following:                                                                     condu
     When she was about four years old, her father took her bathing and             and tl
she undressed in the same cabin with him. She did not recall seeing her                 St
father's penis, but saw some other men naked under a shower. Then                   force(
she recalled that at the age of about five, she and a group of other girls          tratio
forcihly took hold of a little boy, undressed him and examined his penis.           "I   111
She was the instigator of the affair and recalled that the more the hoy         ~
                                                                                    cums!
screamed the more she squeezed his penis.                                       I   ing h
    In her frantic efforts to cure her acne, Stella was taken to a physician        had s
by a girl who had an affair with this doctor. Instantly it occurred to the          cure I
patient that since she had heard about intercourse heing a cure for acne,           fact 1
it would be nice if she could induce this doctor to have intercourse with           other1
her as well. This was the only form of cure she had not as yet tried.               exper
She calmly laid the plan before this physician who then and there dis-              man i
virgined her. It must be stressed here that in this entire matter the patient       campi
took the initiative. The first intercourse was very painful and she won-            this t
dered why she had no reaction whatever. The doctor told her it must                 whid
be due to the circumstances and the fact that she was too tense. He                 took
suggested that she visit him in his apartment instead. This she did and             maSCI
for months thereafter visited him weekly for the sole purpose of having             in th,
intercourse. She emphasized the fact that since she considered this purely          m\!n,
as medical treatment for her acne, she paid him a fee at each visit. After          men.
the third visit to this doctor, she decided that since she was not a virgin         elrean
any more she might as well augment the doctor's treatments. She                     and t
embarked upon a frantic round of affairs. She had intercourse practically               TI
daily with a different man. Among these were her sixty-year-old                     am si
employer, his eighteen-year-old son, two male cousins and dozens of                  says
others. There was a complete lack of selectivity. The man had to fulfill            Mont.
but one requirement, that of being a man. On occasions she would visit              datlgl


                                                                                ~
                                                                                    ...




                  PSYCHOANALYSIS OF A CASE OF ACNE VULGARIS                   163
      the doctor in the morning, meet her employer at a hotel at noon and
      have intercourse with his son at night. In all instances she took the
      initiative, practically telling each man that she desired him sexually. In
      none of these relations did she experience even a slight stimulation, much
      less an orgasm. She accepted neither money nor presents from any of
      these men. As far as she knew, she only endeavored to cure her acne
      through intercourse. "I did enjoy the fact that men considered me
      passionate and I often thought to myself, you damned fool, if you only
      knew that I am merely using you to cure my face and nothing else."
           She was completely frigid, but not disgusted. Her pleasure came
      through the deceit she thought she was practicing on the man. With
      each one she was hoping that his semen would clear her acne and thus
      she excused her actions to herself. During each intercourse, she would
      feel greatly humiliated until the man had his orgasm. Then she would
      feel victorious. Frequently she would severely reproach herself for her
      conduct and suffered a great deal because of what she called her cruel fate
      and that she had to go through all this to rid herself of acne.
           Stella's promiscuity, which she so carefully rationalized as having been
      forced upon her by her acne condition, indicated an exclusive concen-
      tration upon men, as though she were possessed by the single thought
       « I must have a man!" Her ego, however, must be right under all cir-
       cumstances. Trying everything conceivable for the sole purpose of clear-
,It
       ing her pimples was how her ego viewed her conduct. It was as if she
      had said to her father: "I am not doing anything wrong hy trying to
       cure my face of pimples. It's not the man I want but a clear face. In
       fact I am only using these men for my own purposes and despise them
       otherwise. I am fooling them "-Her emphasis upon heterosexuai
       experiences indicated a neurotic overvaluation of it. Her feeling for a
       man in reality was so complicated that it might well have been an almost
       compulsive overvaluation of heterosexual relationships. At the root of
       this behavior was a strong and at the same time dreaded homosexuality
       which caused her pathological flight to men. Since in all instances she
       took the initiative, we might say a homosexuality in the sense of true
       masculine behavior. The characteristic looseness and lack of selectivity
       in the patient's relationship with men was not based upon a desire for
       men, but a partly compulsive necessity to have a man and partly a flight to
       men. Sexual impulses toward women she vehemently denied. In her
       dreams, however, we could perceive definite expressions of being a man
       and masculine patterns of behavior in various disguises.
           The following dream helped to shed some light on this subject: "I
      am sitting next to a girl and snuggle up to her. A man comes along and
      says about rne, ,. Who is she, I don't know her?' Thel~ I see D1',
      Montgomery come along and I quickly say-I'm Dr. Montgomery's
      daughter."
164                        LOUIS MONTGOMERY

     In connection with this dream she admitted with a great deal of diffi-
 culty that several times in the past, she has had sexual contacts with a'
 girl friend. She masturbated this girl, kissed her breasts, but was quick
 to add that she did it only because the girl was very much aroused and
 too ugly to attract a man; she herself revolted against the idea. The
 other girl insisted, so she thought, " What's the difference!" This dream
 also gives us a glimpse into the transference situation in which the analyst
 plays the father.
     Since a satisfactory relationship to a man was for internal reasons
 impossible, a quantity of free flowing libido existed which could be
 directed upon women. There was a destructive tendency toward women
 also present in abundance. She could not stand any woman in com-
 petition with herself. Her ire was aroused whenever she heard of a
 girl friend having a new beau. She instantly wondered how he would like
 her instead and whether she could induce him to give up the other girl
 in her favor. Any accomplishment, even to the extent of a friend secur-
 ing a job, was met with hostility. She wanted to have just that job. She
could not bear the thought of others having what she did not have, even
if she herself did not want it. This attitude became quite obvious in the
transference situation as well. An interpretation that clearly hit home
with regard to the patient's difficulties, invariably brought forth hostile
reactions. This hostility shown toward the analyst made its appearance
regardless of the content of the problem under discussion or the solution
offered. It became quite clear that this hostility did not express a resist-
ance against any particular interpretation or insight, but was a general
and characteristic mode of reaction. The patient constantly compared
herself· with everyone. Her sole standard of value with regard to herself
was that of being better or worse, more or less beautif nl, more or less
intelligent, more or less desirable than others; in short it was an automatic
competition. Horney (10) has described similar phenomena in connec-
tion with negative therapeutic reactions.
     This constant comparison naturally brought about frequent defeats
and hostility towards the defeating objects. While this attitude was
unconscious, the patient realized that she was oversensitive to criticism.
Her hostility to the analyst expressed her general hostility against the
environment and was directly traceable to the consequences which
developed out of her infantile experiences, that is, a modified revival of
her rivalry in early childhood for the affections of her father. "No one
but I shall have father." This attitude assured safety; anything that
endangered it resulted in anxiety and hostility. Her early childhood
atmosphere which lacked warmth, but was rife with frightening ele-
ments, particularly the frequent quarrels between her parents, meant
engendering hostility and anxiety to the child. It also meant an exag-




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       <if               PSYCHOANALYSIS OF A CASE OF ACNE VULGARIS                      165
"'J.• ',     gerated need for affection to reassure her against expression of her own
             lurking hostility and fear. (10)
                  The patient's promiscuity, which caused her so much distress and at
             the same time a degree of delight, may be viewed from several aspects.
             First we found the unconscious hate against the consciously beloved
             father,-the jilting father;· plus the hatred for the rival mother. The
             unconscious hatred for the father was not directed against the real father
   I         figure as he existed, but against the infantile idea of the cruel, heartless,
   i
             brute of a father who denied pleasures and inflicted pain. It was this


   l
   \
             idea that was retained as an unconscious formation and it was the cruel,
             sadistic conception of the father alongside of which was the sadistic
             attitude of the infant, that remained active and exerted its dynamic
             influence. It was against these primitive, immoral ideas and impulses
             that defensive measures had to be invoked by the ego. We could perceive
              in the patient's promiscuity the unconscious wish to show the hated
              parent, out of spite, that she can get a man. This, however, was possible
              only at the price of a bad conscience which, to a degree, was appeased
              by the conscious perception that it was her acne that drove her to it. It
              was evident that the condition of acne played a very important part in
              the patient's scheme of life. The purpose it served was clear enough
              and so was the necessity to reveal its unconscious meaning and signifi-
              cance to the total personality.
                   In childhood, Stella, like all little girls, had to come off second best
              in competition for the man. As her father's favorite from early childhood
              on, she was in a particularly bad position with regard to him. He encour-
              aged her love and at the same time continued living with the mother.
              Thus, throughout her childhood, she experienced an intensified rivalry
              for his attention. This, as always is the case, was hopeless from the
              beginning and ultimately had to result in defeat. For Stella it produced
              specific consequences, not only because of the intensification of rivalry,
              but also because of the unquestionable lack of intelligence on the part of
              the mother who, for instance, would at every possible occasion hold the
              child up to ridicule not only to the beloved father but to outsiders as well.
                   The patient also recalled her mother's fanatic opposition for her ever
              to appear before her father naked. Her mother would also punish her
               severely for looking at herself, saying that all people were dirty down
              below. Touching herself (masturbation) was strictly forbidden as being
               dirty. Whenever her face was dirty, she would be admonished in a
               similar manncr. Both the face and the genitalia were dirty. In addition,
               during arguments, the mother would call the father a dirty dog, which
               must be rcmembered in connection with her phobic fear of dogs. It was
               only natural that the little girl should blame the loss of the beloved father,
               who would not love her because she was dirty, upon the mother and also
166                       LOUIS MONTGOMERY

react with hatred towards the unfaithful father. Some of the conse-                    "Why dl
quences of this situation were that dirt and genitals, face, disease, to               remark a
which later masturbation and intercourse were added, became closely                    without [
linked concepts. The unconscious equation between vagina, dirt and                     a great ,
disease has recently been discussed by Kubic. (11) Other consequences                  reminded
were the patient's feeling of being downtrodden, the feeling of insecurity             not wish
and a profound hostility toward more fortunate rivals. This, in turn,                  was quit<
brought about an inhibition with regard to rivalry which she termed a                  her from
definite premonition of failure in no matter what she undertook and an                 it but eXI
attitude of uselessness as well. She had, for instance, ambitious plans                in itself,
for a career on the stage but felt that it was useless even to try. This               attack tl1
attitude of "what's the use" was quite an outstanding one. The uncon-                  within it.
scious content of this, she soon perceived. "What chance have I to                     with a g
succeed if I couldn't succeed with father who loved me so much." Con-                  remembe
sciously, she sought the reason for her inability to succeed within herself.           masturba
Innumerable self-tormenting complaints arose therefrom, such as, that her              masturb1
face was ugly and disfigured, her legs not shapely enough, her hair too                 and besil
dark and countless other self-depreciating attitudes, all of which com-                 about m
bined with the sense of guilt that originated in the repressed hatred. The              the desir
necessity of proving that she could, in spite of everything, attract men                    The
could clearly be traced to the same source. To be without a man was a                  store a 11,
disgrace to her.
    Stella's overemphasis of the misery she suffered because of what she
herself admitted was a comparatively mild case of acne was a charac-
                                                                                ••     bulldog .
                                                                                       I had a
                                                                                       jumped
teristic falsification of reality values. It was quite evident that such an     I :.   to show
exaggerated reaction to a few pimples bore the earmarks of a psychosis-                finally k
like reaction. It was also clear that Stella, with a tendency to narcissistic              The
regressions, was predisposed to the development of a pathoneurosis which                patient',
as we know, is most likely to develop as a result of an illness in those                layers, I
very organs which are most highly charged narcissistically. The whole                   sioned f
clinical picture and the patient's dreams showed that her attitude toward               of whic
her illness, that is her acne, and her infantile attitude toward her father             stage of
coincided with each other even to the minutest detail.                                  would c
    It became more and more evident that her condition of acne required                 only aft
thorough working through. The one outstanding feature of this symptom                   and th~
was that during periods of positive transference her face would break                       SUtij
out to such an extent that she was actually hideously disfigured, while                 About:;
during periods of hostility towards the analyst her face would be prac-                 patient'
tically clear of lesions. That the condition of acne served a very definite             block a
purpose was clear enough and so was the defensive nature of it. When-                   induced
ever she consciously wanted a man to love her, unconscious defensive                    rneetin~
measures had to be invoked. When 110 such need was present, the                          escapin
defensive measure could be J·elaxed.                                                     quickl~
    The patient on various occasions during analysis would exclaim:                      she bee



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                                                                                 1




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                 PSYCHOANALYSIS OF A CASE OF ACNE VULGARIS                     167
     " Why do you rub me the wrong way?" Due to the frequency of this
     remark and her statement that it was merely a habitual figure of speech
     without any particular meaning, she was asked for associations. After
     a great deal of difficulty she final\y stated that the remark somehow
     reminded her of masturbation. She seemed very much ashamed and did
     not wish to discuss it. Her bashfulness on the subject of masturbation
     was quite evidently not simply a resistance in the sense that it barred
     her from discussing it freely; quite the contrary, she wanted to talk about
     it but experienced a distinct state of anxiety. The degree of bashfulness,
     in itself, had the structure of a symptom. Clearly the analytic task was to
     attack this symptom, as well, in order to solve the conflict concentrated
     within it. But this proved by no means an easy task. She finally admitted
     with a great deal of difficulty having masturbated as long as she could
     remember, at the rate of about two or three times a week. All her
     masturbation was centered on the clitoris. She had heard of vaginal
     masturbation but was afraid of it, fearing that she might hurt herself
     and besides she never had the desire for it. She always felt very guilty
     about masturbation, reproached herself severely, but could not suppress
     the desire for it.
          The next day she brought the following dream: "I'm in a grocery
     store and as I go to one of the shelves to get something to eat, I see a
      bulldog. I nln a'Way from that shelf. Then I see a big dog and it seems
      I had a date 'With him. I sd(j hello a;nd he was so glad to see me that he
      jumped 1~P on my shoulder with his two> paws. I was afraid bnt tried not
      to show it and gave him my chee'~ to kiss. He only wanted m,y lips so I
      finally kissed him on the lips. Then the dog turned out to be m:J! httsband."
          The interpretation of this dream brought about the abandonment of the
      patient's "so-called" dog phobia and a working through of its deepest
      layers, cessation of her vomiting spells. Interpretation of it also occa-
      sioned the first breaking through of her oral sadistic impul ses, the solution
      of which brought about a new regression, and a new cathexis of the anal
      stage of development occurred. The details of the analysis of these phases
      would carry us beyond the scope of this paper but it must be stated that
      only after these pregenital fixations had been solved did the genital phase
      and the <Edipus situation come properly into the analysis.
          Surface interpretation of the dream brought forth the following result:
      About a week after their return from a short trip to the seashore, the
      patient and her husband took a walk along Broadway. Suddenly about a
      block away, she spied one of her former lovers, the man who originally
       induced her to practice fellatio. The sudden possibility of her husband
       meeting this man frightened her. She tried frantically to find a way of
       escaping a meeting. She spied a clog, let out a subdued scream and
       quickly ran into the nearest doorway. She explained to her husband that
       she became frightened by the dog, watched for the dreaded man to pass,
168                       LOUIS MONTGOMERY

then came out of her hiding place. Due to the severe fright, she felt
nauseous, was placed into a cab where she had a vomiting spell.
     Being married to a man who knew nothing of her past made any false
step a possible cause of being cast aside. While the encountering of a
former lover may be unpleasant to any woman, it meant a definite danger
situation for Stella. This can easily be understood in the light of her
husband's ignorance of her past, his, to her, well-known strict moral
conceptions and the fact that life without him seemed inconceivable to her.
The idea of his meeting any of her former lovers and the possibility of
her past thus being disclosed meant to her a certain repetition of the
traumatic experience at the age of eighteen when her first beau cast her
aside. On the deeper levels, all these are traceable to the CEdi pus situ-
ation, the first frustration and castration. "I wouldn't mind so much
 leaving him if I had someone else who loved me" was one of her char-
acteristic remarks. We could see that to be cast off would be the definite
equivalent of being castrated. She didn't mind castrating the man, but
being castrated was unbearable.
     Up to that time the possibility of running into any of her former lovers
had never occurred to Stella. Since then, however, the possibility took
on immense proportions. She stayed in the house for several days feign-
ing an illness, trying to figure out a way of escaping any similar
encounter. Under no condition did she want her husband ever to meet
any of her numerous former lovers. The succeeding days were filled
with bitter self-reproaches as to her past conduct and her cruel fate, "all
due to her acne condition." When next she went out with her husband
she had not as yet arrived at any satisfactory plan. She anxiously scanned
the faces of all passers-by and again thought that she saw one of the men
approaching. For want of a better plan, she repeated the first incident,
simulating a terrifying enough fear of a dog to be placed in a cab. Then
 it occured to her that, in order to make the fright seem real, she must
vomit which she promptly did. She slowly recalled that simulating a state
of terror at the sight of a dog seemed an excellent way out of her dilemma.
 She repeated it on subsequent occasions whenever she was out with her
husband. After a while the original reason for her state of terror was
forgotten although she was fully aware that it was not the sight of a dog
 that created the state of anxiety. Being terml' stricken whenever she
was out with her husband became a regular routine.

    We might rightfully ask why such an experience as the patient
related, that is, her chosen method of avoiding her former Javel's,
should or could be forgotten. Can we call this forgetting? Yes
and no! There is no doubt that here we were dealing, not so much
with an inability to recall, as an unWillingness to see the truth. It was
not" Nicht bewltsstes," that is, something she dic1not know, but rather
           PSYCHOANALYSIS OF A CASE OF ACNE VULGARIS               169
"Nicht gedachtes," that is, something she did not want to know.
The actual experience connected with infantile sado-masochistic
phantasies, a previous childhood animal phobia, which brought about
that particular type of forgetting. The experience in itself would
otherwise not have met this fate. (Isolation.)
    Analysis clearly showed that each component part of her attacks
was not chosen by mere accident. On the contrary, each was amply
preconditioned. Dogs, as a result of the previous animal phobia in
childhood, to her unconscious, represented father, husband, men. (In
the dream all of these were fused.) Her becoming rigid with fright
represented herself as a penis in erection and simultaneously served
as a form of sexual gratification. The vomiting was the psychic
equivalent of an orgasm. She had to vomit after each seizure and
after that felt better.
    Her periodic states of depression were not true states of depres-
sion, but merely served as periodic "one act plays" deliberately
directed against her spouse. She was fully aware of the play-acting
nature of these states of depression, but unaware that in fact they
arose out of the feeling of guilt attached to infantile sexual wishes.
These periods of depression served not as self-accusations, on the
contrary, they were a form of accusation and torment of others. She
would get these spells of depression invariably when her spouse was
in particularly good spirits and happy, or whenever he had planned
something he was quite eager to do. Thus she spoiled his plans as
well as his happy mood.
    Her nausea was the result of unconscious fellatio phantasies with
the father. Freud has pointed out that the phantasy of fellatio is
important in the formation of hysterical symptoms. It is an extraor-
dinarily frequent one in the unconscious of hysterical women and is
the expression of a more repulsive idea, that is, to bite off the penis.
In Stella's case this was abundantly overdetermined. It meant at
once a revenge on the man who possessed the envied penis and
identification with him.
    The pains in the breast were also conceived as an equivalent
coitus, permeated by male features. She would perceive these pains
as if something were trying to break through her breasts, like spasms.
The painful, spasmodic contractions portrayed the penis during
orgasm. When her boss's son had an orgasm and moaned so, she
recalled having felt a pain in her breasts at that time.
    The patient's hysterical identification with her father was quite
clear. This identification was the conclusion of that painful process
170                       LOUIS MONTGOMERY

during which her sexual wishes toward the father had broken down.                her intem
She was forced to relinquish the object of her love and made up the              represente
loss by identifying herself with him. Wittels' postulation (12) that             sian of he
" the masochist wishes to prove the futility of one part of his person           becoming
in order to live the more securely in the important other part" and              herself as
" derives pleasure from the pain felt by the other figure," may well             orgasm.
be applied here. It was quite obvious that unconsciously she was                     When
her father by incarnation-impersonation. This second figure which                clitoris wi
lived within her had to be rejected by the conscious personality, con-           had to Call
sequently it had to be harassed, debased, made to suffer. Viewing                brute of a
Stella's case from this standpoint, we can understand why this figure            The girl 1
existing within her was destined to meet with various defeats, painful           and hittin
experiences and why it had to be devaluated as much as possible.                 Simultanel
" I am giving you just what you gave me. It's tit for tat! If I can't            As far bal
have you, there is nothing left but to meet you with the same weapons            was alway
that hurt me so much."                                                               It is WI
     The still frequently recurring remark: (( Why do you rub me the             tasies and
wrong way?)j indicated considerably more than mere association with              mations al
masturbation. Its significance became more and more apparent and                 phantasies
indicated a deeper conflict than had thus far been uncovered. Each               symptom J
attempt to work through was met by anxiety and marked hostility.                 phantasies.
In the midst of one of these states and at the height of a tirade of             CEdipus w
accusations against the analyst, the patient suddenly became very                     It is al
quiet. Pressed to disclose her thoughts, she remembered a childhood              marily a p
 experience of accidentally witnessing what evidently was her father             the libido.
 in the act of masturbation. He was alone in the bathroom, rubbing               old, her p:
 his penis violently and letting out a shrill cry. The child became              Stella was
 very much frightened and hid herself in a closet. Afterwards, she               call1e out tl
 tried to find on herself that which father rubbed. The remark now               was told j
 took on a definite ideational content and with that many heretofore             scream. 1
 inexplicable matters became clear. « Rubbing the 'Wrong 'Way>J                  and gave 1-
 meant (( rubbing the penis which I haven't got." Wanting to rub as              ated. He
 father did, but lacking the penis to rub, might well have leel to the           father Into
 discovery of the clitoris, but surely did lead to a partial incorporation       into the ce:
 of the object, that is a corresponding identification of herself with the       This incre:
 father's penis. She wanted to be rubbed the right way, the same as              big argul11
 father rubbed his penis. « Father rubs his penis, I am father's penis,"         excited. ~
  which is the equivalent to (( now I have a penis." To be rubbed the            would star
 wrong way, therefore, was the equivalent of being castrated. Thus,              caressed 11
  « Why do you rub me the 'Wrong "way?)) translated itself into:                 For a long
  « Why do you castrate me?" We could also observe displacement of               pating thai



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          PSYCHOANALYSIS OF A CASE OF ACNE VULGARIS                 171
her intense oral greediness to an avid interest in those objects that
represented this penis. Her interest in men was the symbolic expres-
sion of her interest in the penis. Now we also understand that her
becoming rigid with fright was in fact a symbolic expression of
herself as a penis in erection and her vomiting the equivalent of an
orgasm.
    When masturbating, Stella had to accompany the titillating of the
clitoris with a specific phantasy, in order to reach an orgasm. She
had to conjure up the picture of a young girl being whipped by a tall
brute of a man, while a lot of people, including herself, were watching.
The girl ran up a staircase, exposing her anus, the man following
and hitting her while she ran. The girl let out a terrific scream.
Simultaneously with the girl's scream, Stella would have an orgasm.
As far back as she could remember, she claimed that the phantasy
was always the same.
    It is well known, however, that between the earliest ffidipns phan-
tasies and those of an adult, a host of all sorts of intermediary for-
mations are found. They all are derivatives of the earliest ffidipus
phantasies. The path from these early CEdipus phantasies to the
symptom is connected by means of masturbation and masturbatory
phantasies. However, the anxiety which is connected with the
CEdipus wishes is displaced upon the act of masturbation.
    It is also well known that masturbatory phantasies are not pri-
marily a psychic act but the product of an intricate development of
the libido. Stella remembered that when she was about four years
old, her parents took her to visit an aunt who had three children.
Stella was playing with these children on the street when her father
came out to go on a nearby beach. Stella wanted to go with him, but
was told that she could not. She refused to stay and started to
scream. Her father, in front of the other children, lifted her dress
and gave her a spanking. She was deeply mortified and felt humili-
ated. He had never hit her before. She had ideas of tearing her
father into pieces, of hitting him harder than he hit her. She ran
into the cellar ane! there cried. The other children poked fun at her.
This increased her anger and humiliation. That night there was a
big argument between the parents. Stella was very scaree! and
excited. She was willing to be spanked again if only her parents
would stop fighting. After a while her father came over to her,
caressed her and that night she was permitted to sleep with him.
For a long time after that, she would purposely be naughty antici-
pating that it would result in her being. spanked which in turn
          w




                                                                                                 PSY(
172                      LOUIS MONTGOMERY

meant being permitted to sleep with father. Sleeping with father                          Freud in b
was the most pleasant thing in Stella's childhood. Later this was                     such beating I
replaced by masturbation. Spanldng and sleeping with father became                    no means Slm~
synonymous.                                                                           respects more
     Slowly and with great effort, various phantasy formations were                   Freud's postu!
uncovered until quite suddenly what may well have been the earliest                   from "the fat
of these phantasies gradually took shape. In her second year, when                    earlier phanta:
her sister was born, Stella slept with her father for some time.                      replaced by "
Nightly she would watchfully wait for the other sibling to start to                   is stilI valid J
cry, which was a signal for her father to get out of bed. She would                   turning of sal
wonder what he was doing in the other room where her mother and                       father identifi
sister slept. Invariably while he was in the other room, she would                    showed only I
wet the bed and her father had to change her. Once, instead of                        the foregrouDi
changing her, he gave her a spanking. Thereafter, she controlled the                  girl is being t
bed-wetting, but felt very angry whenever he left her alone. In her                   father. "By
phantasy she followed him and fancied herself being punished for                       (punishes me:
going into the forbidden room. At that time, the phantasy was, (( I                   been repress!
 follow father and he punishes me for misbehaving." Whether this                      phantasy.
was a true experience or not, it becoming conscious meant for the                          Environm
analysis the possibility of disclosing the sadistic conception of coitus              then later, thl
and sexuality in general. (It is well known that bed-wetting in chil-                 forced the pa:
dren is one of the most frequent masturbatory equivalents.)                           conscious forr
     In Stella's case the phantasy of a girl is being beaten by a brute               of warding til
was the psychic equivalent or derivative of the earlier phantasy with                      The most
regard to " something is going on in the other room." That" some-                      Stella's frigid
thing" was conceived as cruel and mysterious, yet desirable because                    line identifica
it was exciting and thus pleasurable. This, however, could not                         connected wil
 remain for long. Genital excitement produced anxiety because it                       only vaginall:
 was connected with the fear that something terrible is going to hap-                  more than TIl
 pen. The wishes attached to the father had to be repressed and with                   haps respons
 it also the phantasy of " what is happening in the other room."                       served simul1
      The next phantasy, that is, herself being spanked by the father,                 as well as p,
 appeared several years later, perhaps after the incident when he                      of Helen De
 actually did spank her in front of the other children. This phantasy                  fuse her dire,
 was then replaced in adolescence by the phantasy of " a girl is being                 to women, if
 beaten by a brute while the patient is looking on."-This last phan-                   impulses, rei
 tasy, however, had a peculiar affective reaction. She said: "It is                    The clitoris:
 as if I did the beating and was an onlooker at the same time and as                   zone, becausl
 if I were screaming." This confirms the condensation of the father,                   to find an 0,
 herself and the brute into one and the final ideational content was:                  sive, femini
 " I am beating father, who beats me."                                                 Analysis of


                                                                           ~,\.., .
                                                                              "
                                                                             "




                                                                           I
          PSYCHOANALYSIS OF A CASE OF ACNE VULGARIS                173
    Freud in his classic "A Child is Being Beaten JJ has shown that
such beating phantasies have an historical development, which is by
no means simple and in the course of which they are changed in most
respects more than once. The case of StelIa seemingly contradicts
Freud's postulation of the path taken by the libidinal charge, that is,
from "the father beats the child," to "father is beating me." Her
earlier phantasy showed "father is beating me," but this ,,'as later
replaced by "I am beating father." Freud's formulation, however,
is still valid here, namely, that masochism represents a secondary
turning of sadistic impulses against the self. Stella with a strong
father identification phantasying (fA girl is being beaten" in fact
showed only half of the complete phantasy. The other half came to
the foreground in that" The girl is I, and I am father." Thus," a
girl is being beaten" at once served the sadistic impulses against the
father. "By beating father I am punishing him, but he beats me too
 (punishes me) because I am a bad girl." Both component parts have
been repressed but surrendered their cathexis to the conscious
phantasy.
    Environmental experiences; first, the mystery of the other room,
then later, the actual beating by her father at the age of four, rd!n-
forced the particular instinctual source and adapted it to serve in its
conscious form as a substitute for sadistic impulses as well as a means
of warding them off through a sense of guilt.
    The most important sexual phantasies which were connected with
Stella's frigidity were related to the CEdipus situation and the mascu-
line identification with the father. This masculine identification was
connected with another important point. She was not genitally but
only vaginally frigid. Her clitoris had preserved its normal, in fact
more than normal, excitability. Her masturbation, which was per-
haps responsible for the excitability of the clitoris becoming fixed,
served simultaneously as an outlet for masculine, sadistic, autoerotic
as well as passive, feminine, sexual phantasies. The point of view
of Helen Deutsch (13), that frigidity sets in if the woman fails to
fuse her direct instinctual aims with the masochism which is peculiar
to women, seemed to apply here. Stella's oral and anal sadistic
impulses, reinforced by environmental experiences, were repressed.
The clitoris refrained from turning over its primacy to the vaginal
zone, because of psychological determinants and as a result she failed
to find an outlet in the vaginal erotogenic zone for her normal, pas-
sive, feminine impulses with freedom from anxiety and guilt.
Analysis of her masturbatory phantasy indicated a partial preser-
  174                      LOUIS MONTGOMERY

 vation of her genital sexuality but all the energies of t:l~ sexual
 impulse were displaced on to the phantasy in order to facIbtate the
                  .,      JectlOna bl e WIS Iles, the CEdipus and the cas-
 control of rema1l1l11g ab"              .
 tration complex. The libidinal excitation attached to t~e phantasy
 found its outlet in masturbation and was at once the pun~shl11cnt f~r
 forbidden genital relations with the father and the s~bstitute for It.
     While working through the masturbatory phantasIes, .the a.nalyst
 found it advisable to limit all interpretations to matenal dIre~tly
 related to that subject. The patient, however, brough~ the fol1ow111~
 significant dream, the interpretation of which seemed Important as It
 apparently alluded to the skin condition.
      "A group of I(S are going 10 have our piles cut out. We go into a d~rty
  1'omn and as we enter a doctor says to me,-' The more water you dnnk,
  the bettcr '-A woman gives me a glass of colored, dirty water and as I
  drink it a dirty green salve spl"eads allover my face. I become frightened
 and the wmnan sa}'s,-' I only wanted to see the reaction on, Y01W face.'-
 Then the doctor comes ilt and says,-' I am yatW god, you shall have no
 other gods before me.'-He then cuts out my piles and as he does my green
 face becmnes beautiful again."

    (We hardly need to comment on the ingenious reference to the
analysis. )
   When Stella was a small child her father would frequently
admonish her by saying;

_" If you are a bad girl, you won't be beautiful when you grow up.
You'll be ugly like Aunt Clara and never get a husband:" Aunt Clara was
an old maid and her face was marred by ugly growths, evidently moles.
The patient liked this aunt, but was afraid of her.

      Bearing in mind what is already known about the patient, the
 manifold meaning of this dream is apparent without much further
 comment. We must point, however, to the ingeniously recurring
 s~nonymo~s conception of face and vagina; as well as penis, pain,
 clIrt and dIsease. We must also point out, that the patient's first
association to " green salve" was" semen and penis." "Green salve
spreading over the face" symbolized pimples (many penises) on the
face. Again face and the genitals are one. Pimples as penis and
f~ce as geni~als ,are synonymous. The distorted sexual gratification,
lIke the patIent s masturbatory phantasies, represented at once the
erotized need for punishment for forbidden genital relations with the
father and the substitute for it. The libidinal excitation which fonnd
            PSYCHOANALYSIS OF A CASE OF ACNE VULGARIS                  175
  an outlet in her suffering served to ward off more objectionable wishes
   connected with the CEdipus and castration complex.
       The purpose which the acne served is quite clear. Any con-
   sciolls desire to be loved by a man was opposed by the unconscious.
  Defensive measures in the form of pimples on the face, which assured
  against being loved, were invoked. While the acne condition was a
  source of intense suffering to the conscious personality, it admirably
  satisfied the unconscious father figure dwelling within. (" I am
  your god; you shall have no other gods before me! ")
       The meaning of the acne symptom was a double one. A wish
  significance and a punishment significance both found expression in
  it. We might formulate it as follows: "I want father, I want a penis.
  I am father, I have a penis. I am a man. As punishment my genitals
  are dirty, my face is dirty, no man loves me."
       Ferenczi speaks of " hysterical materialization" (14) pointing out
 that all phantasy, as all ideation and thinking, is constantly accom-
 pnied by appropriate bodily changes; hence thinking, which takes
 the place of action, is still action or, so to speak, an " action sample."
 He also speaks of a « genitalization of organs." It may be said that
 Stella's phantasies found plastic expression in a real alteration of
 physical function.
      When, as a little girl, Stella was threatened by her father, that if
 she misbehaved she won't get a man, it was just what she wanted.
 But this also meant fear of castration and the danger of losing love.
 The turning fr0111 reality to phantasy, a process made necessary by
 the repression of the CEdipus complex and the replacement of the
 real sexual object by phantasied representatives of infantile objects,
and the prerequisite for development of a conversion were clearly
present. Alloplastic reactions 'Were substituted by a~ttoplastic ones
as soon as the potential lover appeared who threatenecl the patient's
psychic equilibrium. Her acne condition started at that time. The
more frantic her efforts to cure her acne were, the more did the
lesions increase, as was also the case during analysis whenever she
consciously desired the love of a man. The remarkable absence of
lesions during periods of negative transference and their spontaneous
recurrence with each change in attitude made for an impressive spec-
tacle. It was also significant to note how her general pattern of
behavior conformed with the demands of the unconscious. Her
deliberate choice of intercourse to cure her acne, her frigidity, her
emphasis upon heterosexual relationships, her Eight to men, her
masturbatory phantasies, as well as her other symptoms; the pseudo-
rr
                                                                                      3
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"




     176                       LOUIS MONTGOMERY

     phobia, nausea and vomiting, like her acne, were abundantly expres-
     sive of the demands of the unconscious second figure harbored within.
      (It must also be remembered that cutaneous processes, with their
     cosmetic, esthetic and social disadvantages, constitute a psychic
     trauma for the sufferer, which in turn perhaps favors these processes.)
         Long before Wittels' postulation (12) that "personalities, par-
     ticularly two who must be protected against each other and accorded
     different treatment, the one because he cannot tolerate the gruesome
     light of reality, the other because he is hated," Simmel (15) has
     pointed out (although not exactly in the same sense) this unconscious
     equation between the pathologically affected organ and the introjected
     object. He said: ({ The introjected parental substitute becomes the
     morbid material which must be eliminated if the patient is to recovC'r."
          In Stella's case, as the unconscious figure gradually emerged in
     its complete aliveness and was slowly with much difficulty inserted          f
                                                                                  !
     into her reality, the morbid material was gradually eliminated and her
     acne cleared completely. At this writing, nineteen months after the
     analysis, the patient reports no recurrence of acne lesions nor any of
     the other symptoms.
         We might postulate that at least certain psychosomatic symptoms
     run a chronic course precisely because they satisfy a definite need of
     the unknown second figure that dwells within.
         Further study along this line may disclose that the specific form
     which somatic symptoms take is determined by the specific form of
     satisfaction the unconscious figure demands, that is, the psychosomatic
     interrelationship might lie between the two personalities existing
     within the total personality. The one, the unconscious figure in its
     relationship to the inner physiological functions; the other, the con-
     scious figure in its relationship to the environment.

                                BIBLIOGRAPHY

      1. Barinbaum, M. "Eine vorlaufige Mitteilung nber die Bedeutung der
           Freudschen Psychoanalyse fur Dermatologie." Dermal. Woch., 95, 1932.
      2. Doswald, D. c., und K. Kreibich. "2ur Frage der posthypnotischen Haut-
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      3. Dunbar, H. F. "Emotions and Bodily Changes." II Edit. New York, 1938.
      4. Schilder, P. "Remarks on the Psychology of the Skin." PSYCHOANA-
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      5. Sack, W. Th. "Psychotherapie und Hautkrankheiten." Dermal. W oell.,
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              PSYCHOANALYSIS OF A CASE OF ACNE VULGARIS
                                                                              177
  6. Sack, W. Th. "Die Haut als Ausdl'uc!csorgan."         Arch.   f.   Dermat. u.
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  7. Hazen, R. R., and E. R. Whitmore. "Skin Diseases Due to Emotional
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  8. Freud, S. "'Ober neurotische Er!crankungstypen." Ges. Seh. V.
  9. Fenichel, O.   "Outline of Clinical Psychoanalysis." New York, 1934.
 to. Horney, K. "The Overvaluation of Love," Psy. Qllart. III, 4, 1934, also
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 11. Kubie, L. "The Phantasy of Dirt." Psy. Quart. VI, 4, 1937.
 12. Wittels, F. "The Mystery of Masochism." PSY. REv., 2'4, 2, 1937.
 13. Deutsch, H. "Del' feminine Masochismus und seine Beziehung zUr Frigidi-
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15. Simmel, E. "Dolctorspiel, Kranksein und Arzberuf," Int. Ztsehr. f. Psa.
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16. Jelliffe, S. E., Psoriasis as an Hysterical Conversion Syndrome, N. Y.
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       Nervous System; also Jelliffe, S. E., Skin, the Nervous System and the
       Bath, Medical Record, 145, 93, 1937.

								
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