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Drives do not cause symptoms. Their role in symptom-formation is twofold: they are propelling forces of the symptoms, responsible for their repetitive nature; and they create conflicts which in turn, under specific conditions, may lead to the formation of symptoms.
The most widely accepted current psychoanalytic theory of instincts postulates a duality of instinctual drives: sexual and aggressive. There can be no doubt about the presence and power of aggressive propensities in man, and with good reason aggression should be considered an instinctual drive as it has such characteristic qualities as innate origin and continuous force, although other qualities—such as origin from bodily sensations and rhythmicity so familiar in the sexual instinct—are missing.
It is futile to seek to assign a quantitative predominance of one of these instincts in symptom-formation. Both instincts are always involved in the genesis of symptoms. The question to ask then is which instinct is involved in which type of symptom. We can expect to find the aggressive instinct at work in those aspects of symptom-formation which relate to the superego because its functions always presuppose internalized aggression. The sexual instinct will be predominant in those aspects of symptom-formation in which the primary process, repression as withdrawal of cathexis, and the return of the repressed make their decisive contributions to the pathological process.
A distinction between sadomasochistic and aggressive drives is necessary. This is a differentiation which is especially important,