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ON THE GROUNDS FOR DETACHING A PARTICULAR SYNDROME FROM
NEURASTHENIA UNDER THE DESCRIPTION ‘ANXIETY NEUROSIS’
(1895)
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ON THE GROUNDS FOR DETACHING A PARTICULAR SYNDROME FROM
NEURASTHENIA UNDER THE DESCRIPTION ‘ANXIETY NEUROSIS’
It is difficult to make any statement of general validity about neurasthenia, so long as we use that name to cover all the things which Beard has included under it. In my opinion, it can be nothing but a gain to neuropathology if we make an attempt to separate from neurasthenia proper all those neurotic disturbances in which, on the one hand, the symptoms are more firmly linked to one another than to the typical symptoms of neurasthenia (such as intracranial pressure, spinal irritation, and dyspepsia with flatulence and constipation ); and which, on the other hand, exhibit essential differences in their aetiology and mechanism from the typical neurasthenic neurosis. If we accept this plan, we shall soon obtain a fairly uniform picture of neurasthenia. We shall then be in a position to differentiate from genuine neurasthenia more sharply than has hitherto been possible various pseudo-neurasthenias (such as the clinical picture of the organically determined nasal reflex neurosis, the nervous disorders of the cachexias and arterio-sclerosis, the preliminary stages of general paralysis of the insane, and of some psychoses). Further, it will be possible - as Möbius has proposed - to eliminate some of the status nervosi of hereditarily degenerate individuals; and we shall also discover reasons why a number of neuroses which are to-day described as neurasthenia - in particular, neuroses of an intermittent or periodical nature - ought rather to be included under melancholia. But the most marked change of all will be introduced if we decide to detach from neurasthenia the syndrome which I propose to describe in the following pages and which satisfies especially fully the conditions set out above. The symptoms of this syndrome are clinically much more closely related to one another than to those of genuine neurasthenia (that is, they frequently appear together and they replace one another in the course of the illness); and both the aetiology and the mechanism of this neurosis are fundamentally different from the aetiology and mechanism of genuine neurasthenia as it will be left after this separation has been effected.
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I call this syndrome ‘anxiety neurosis’, because all its components can be grouped round the chief symptom of anxiety, because each one of them has a definite relationship to anxiety. I thought that this view of the symptoms of anxiety neurosis had originated with me, until an interesting paper by E. Hecker (1893) came into my hands, in which I found the same interpretation expounded with all the clarity and completeness that could be desired.¹ Nevertheless, although Hecker recognizes certain symptoms as equivalents or rudiments of an anxiety attack, he does not separate them from the domain of neurasthenia, as I propose to do. But this is evidently due to his not having taken into account the difference between the aetiological determinants in the two cases. When this latter difference is recognized there is no longer any necessity for designating anxiety symptoms by the same name as genuine neurasthenic ones; for the principal purpose of giving what is otherwise an arbitrary name is to make it easier to lay down general statements.
¹ Anxiety is actually brought forward as one of the principal symptoms of neurasthenia in a work by Kaan (1893).
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I
THE CLINICAL SYMPTOMATOLOGY OF ANXIETY NEUROSIS
What I call ‘anxiety neurosis’ may be observed in a completely developed form or in a rudimentary one, in isolation or combined with other neuroses. It is of course the cases which are in some degree complete and at the same time isolated which give particular support to the impression that anxiety neurosis is a clinical entity. In other cases, where the syndrome corresponds to a ‘mixed neurosis’, we are faced with the task of picking out and separating those symptoms which belong, not to neurasthenia or hysteria, and so on, but to anxiety neurosis.
The clinical picture of anxiety neurosis comprises the following symptoms:
(1) General irritability. This is a common nervous symptom and as such belongs to many status nervosi. I mention it here because it invariably appears in anxiety neurosis and is important theoretically. Increased irritability always points to an accumulation of excitation or an inability to tolerate such an accumulation - that is, to an absolute or a relative accumulation of excitation. One manifestation of this increased irritability seems to me to deserve special mention; I refer to auditory hyperaesthesia, to an oversensitiveness to noise - a symptom which is undoubtedly to be explained by the innate intimate relationship between auditory impressions and fright. Auditory hyperaesthesia frequently turns out to be a cause of sleeplessness, of which more than one form belongs to anxiety neurosis.
(2) Anxious expectation. I cannot better describe the condition I have in mind than by this name and by adding a few examples. A woman, for instance, who suffers from anxious expectation will think of influenzal pneumonia every time her husband coughs when he has a cold, and, in her mind’s eye, will see his funeral go past; if, when she is coming towards the house, she sees two people standing by her front door, she cannot avoid thinking that one of her children has fallen out of the window; when she hears the bell ring, it is someone bringing news of a death, and so on - while on all these occasions there has been no particular ground for exaggerating a mere possibility.
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Anxious expectation, of course, shades off imperceptibly into normal anxiety, comprising all that is ordinarily spoken of as anxiousness - or a tendency to take a pessimistic view of things; but at every opportunity it goes beyond a plausible anxiousness of this kind, and it is frequently recognized by the patient himself as a kind of compulsion. For one form of anxious expectation - that relating to the subject’s own health - we may reserve the old term hypochondria. The height reached by the hypochondria is not always parallel with the general anxious expectation; it requires as a precondition the existence of paraesthesias and distressing bodily sensations. Thus hypochondria is the form favoured by genuine neurasthenics when, as often happens, they fall victims to anxiety neurosis.
A further expression of anxious expectation is no doubt to be found in the inclination to moral anxiety, to scrupulousness and pedantry - an inclination which is so often present in people with more than the usual amount of moral sensitiveness and which likewise varies from the normal to an exaggerated form in doubting mania.
Anxious expectation is the nuclear symptom of the neurosis. It openly reveals, too, a portion of the theory of the neurosis. We may perhaps say that here a quantum of anxiety in a freely floating state, which, where there is expectation, controls the choice of ideas and is always ready to link itself with any suitable ideational content.
(3) But anxiousness - which, though mostly latent as regards consciousness, is constantly lurking in the background - has other means of finding expression besides this. It can suddenly break through into consciousness without being aroused by a train of ideas, and thus provoke an anxiety attack. An anxiety attack of this sort may consist of the feeling of anxiety, alone, without any associated idea, or accompanied by the interpretation that is nearest to hand, such as ideas of the extinction of life, or of a stroke, or of a threat of madness; or else some kind of paraesthesia (similar to the hysterical aura) may be combined with the feeling of anxiety, or, finally, the feeling of anxiety may have linked to it a disturbance of one or more of the bodily functions - such as respiration, heart action, vasomotor innervation or glandular activity. From this combination the patient picks out in particular now one, now another, factor. He complains of ‘spasms of the heart’, ‘difficulty in breathing’, ‘outbreaks of sweating’, ‘ravenous hunger’, and such like; and, in his description, the feeling of anxiety often recedes into the background or is referred to quite unrecognizably as ‘being unwell’, ‘feeling uncomfortable’, and so on.
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(4) Now it is an interesting fact, and an important one from a diagnostic point of view, that the proportion in which these elements are mixed in an anxiety attack varies to a remarkable degree, and that almost every accompanying symptom alone can constitute the attack just as well as can the anxiety itself. There are consequently rudimentary anxiety attacks and equivalents of anxiety attacks, all probably having the same significance, which exhibit a great wealth of forms that has as yet been little appreciated. A closer study of these larval anxiety-states (as Hecker calls them) and their diagnostic differentiation from other attacks should soon become a necessary task for neuropathologists.
I append here a list which includes only those forms of anxiety attack which are known to me:-
(a) Anxiety attacks accompanied by disturbances of the heart action, such as palpitation, either with transitory arrhythmia or with tachycardia of longer duration which may end in serious weakness of the heart and which is not always easily differentiated from organic heart affection; and, again, pseudo-angina pectoris - diagnostically a delicate subject!
(b) Anxiety attacks accompanied by disturbances of respiration, several forms of nervous dyspnoea, attacks resembling asthma, and the like. I would emphasize that even these attacks are not always accompanied by recognizable anxiety.
(c) Attacks of sweating, often at night.
(d) Attacks of tremor and shivering which are only too easily confused with hysterical attacks.
(e) Attacks of ravenous hunger, often accompanied by vertigo.
(f) Diarrhoea coming on in attacks.
(g) Attacks of locomotor vertigo.
(h) Attacks of what are known as congestions, including practically everything that has been termed vasomotor neurasthenia.
(i) Attacks of paraesthesias. (But these seldom occur without anxiety or a similar feeling of discomfort.)
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(5) Waking up at night in a fright (the pavor nocturnus of adults), which is usually combined with anxiety, dyspnoea, sweating and so on, is very often nothing else than a variant of the anxiety attack. This disturbance is the determinant of a second form of sleeplessness within the field of anxiety neurosis. I have become convinced, moreover, that the pavor nocturnus of children, too, exhibits a form which belongs to anxiety neurosis. The streak of hysteria about it, the linking of the anxiety with the reproduction of an appropriate experience or a dream, causes the pavor nocturnus of children to appear as something special. But the pavor can also emerge in a pure form, without any dream or recurring hallucination.
(6) ‘Vertigo’ occupies a prominent place in the group of symptoms of anxiety neurosis. In its mildest form it is best described as ‘giddiness’; in its severer manifestations, as ‘attacks of vertigo’ (with or without anxiety), it must be classed among the gravest symptoms of the neurosis. The vertigo of anxiety neurosis is not rotatory nor does it especially affect certain planes or directions, like Meniere’s vertigo. It belongs to the class of locomotor or co-ordinatory vertigo, as does the vertigo in oculomotor paralysis. It consists in a specific state of discomfort, accompanied by sensations of the ground rocking, of the legs giving way and of its being impossible to stand up any more; while the legs feel as heavy as lead and tremble or the knees bend. This vertigo never leads to a fall. On the other hand, I should like to state that an attack of vertigo of this kind may have its place taken by a profound fainting fit. Other conditions in the nature of fainting occurring in anxiety neurosis appear to depend upon cardiac collapse.
Attacks of vertigo are not seldom accompanied by the worst sort of anxiety, often combined with cardiac and respiratory disturbances. According to my observations, vertigo produced by heights, mountains and precipices is also often present in anxiety neurosis. Furthermore, I am not sure whether it is not also right to recognize alongside of this a vertigo a stomacho laeso.
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(7) On the basis of chronic anxiousness (anxious expectation) on the one hand, and a tendency to anxiety attacks accompanied by vertigo on the other, two groups of typical phobias develop, the first relating to general physiological dangers, the second relating to locomotion. To the first group belong fear of snakes, thunderstorms, darkness, vermin, and so on, as well as the typical moral over-scrupulousness and forms of doubting mania. Here the available anxiety is simply employed to reinforce aversions which are instinctively implanted in everyone. But as a rule a phobia which acts in an obsessional manner is only formed if there is added to this the recollection of an experience in which the anxiety was able to find expression as, for instance, after the patient has experienced a thunderstorm in the open. It is a mistake to try to explain such cases as being simply a persistence of strong impressions; what makes these experiences significant and the memory of them lasting is, after all, only the anxiety which was able to emerge at the time and which can similarly emerge now. In other words, such impressions remain powerful only in people with ‘anxious expectation’.
The other group includes agoraphobia with all its accessory forms, the whole of them characterized by their relation to locomotion. We frequently find that this phobia is based on an attack of vertigo that has preceded it; but I do not think that one can postulate such an attack in every case. Occasionally we see that after a first attack of vertigo without anxiety, locomotion, although henceforward constantly accompanied by a sensation of vertigo, still continues to be possible without restriction; but that, under certain conditions - such as being alone or in a narrow street - when once anxiety is added to the attack of vertigo, locomotion breaks down.
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The relation of these phobias to the phobias of obsessional neurosis, whose mechanism I made clear in an earlier paper¹ in this periodical, is of the following kind. What they have in common is that in both an idea becomes obsessional as a result of being attached to an available affect. The mechanism of transposition of affect thus holds good for both kinds of phobia. But in the phobias of anxiety neurosis (1) this affect always has the same colour, which is that of anxiety; and (2) the affect does not originate in a repressed idea, but turns out to be not further reducible by psychological analysis, nor amenable to psychotherapy. The mechanism of substitution, therefore, does not hold good for the phobias of anxiety neurosis.
Both kinds of phobias (and also obsessions) often appear side by side; although the atypical phobias, which are based on obsessions, need not necessarily spring from the soil of anxiety neurosis. A very frequent and apparently complicated mechanism makes its appearance if, in what was originally a simple phobia belonging to an anxiety neurosis, the content of the phobia is replaced by another idea, so that the substitute is subsequent to the phobia. What are most often employed as substitutes are the ‘protective measures’ that were originally used to combat the phobia. Thus, for instance, ’brooding mania’ arises from the subject’s endeavours to disprove that he is mad, as his hypochondriacal phobia maintains; the hesitations and doubt, and still more the repetitions, of folie du doute arise from a justifiable doubt about the certainty of one’s own train of thought, since one is conscious of its persistent disturbance by ideas of an obsessional sort, and so on. We can therefore assert that many syndromes, too, of obsessional neurosis, such as folie du doute and the like, are also to be reckoned, clinically if not conceptually, as belonging to anxiety neurosis.²
¹ ‘The Neuro-Psychoses of Defence’ (1894a).
² See ‘Obsessions and Phobias’ (1895c).
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(8) The digestive activities undergo only a few disturbances in anxiety neurosis; but these are characteristic ones. Sensations such as an inclination to vomit and nausea are not rare, and the symptom of ravenous hunger may, by itself or in conjunction with other symptoms (such as congestions), give rise to a rudimentary anxiety attack. As a chronic change, analogous to anxious expectation, we find an inclination to diarrhoea, and this has been the occasion of the strangest diagnostic errors. Unless I am mistaken, it is this diarrhoea to which Möbius (1894) has drawn attention recently in a short paper. I suspect, further, that Peyer’s reflex diarrhoea, which he derives from disorders of the prostate (Peyer, 1893), is nothing else than this diarrhoea of anxiety neurosis. The illusion of a reflex relationship is created because the same factors come into play in the aetiology of anxiety neurosis as are at work in the setting up of such affections of the prostate and similar disorders.
The behaviour of the gastro-intestinal tract in anxiety neurosis presents a sharp contrast to the influence of neurasthenia on those functions. Mixed cases often show the familiar ‘alternation between diarrhoea and constipation’. Analogous to this diarrhoea is the need to urinate that occurs in anxiety neurosis.
(9) The paraethesias which may accompany attacks of vertigo or anxiety are interesting because they, like the sensations of the hysterical aura, become associated in a definite sequence; although I find that these associations, in contrast to the hysterical ones, are atypical and changing. A further similarity to hysteria is provided by the fact that in anxiety neurosis a kind of conversion¹ takes place on to bodily sensations, which may easily be overlooked - for instance, on to rheumatic muscles. A whole number of what are known as rheumatic individuals who, moreover, can be shown to be rheumatic - are in reality suffering from anxiety neurosis. Along with this increase of sensitivity to pain, I have also observed in a number of cases of anxiety neurosis a tendency to hallucinations; and these could not be interpreted as hysterical.
(10) Several of the symptoms I have mentioned, which accompany or take the place of an anxiety attack, also appear in a chronic form. In that case they are still less easy to recognize, since the anxious sensation which goes with them is less clear than in an anxiety attack. This is especially true of diarrhoea, vertigo and paraesthesias. Just as an attack of vertigo can be replaced by a fainting fit, so chronic vertigo can be replaced by a constant feeling of great feebleness, lassitude and so on.
¹ See ‘The Neuro-Psychoses of Defence’ (1894a).
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II
INCIDENCE AND AETIOLOGY OF ANXIETY NEUROSIS
In some cases of anxiety neurosis no aetiology at all is to be discovered. It is worth noting that in such cases there is seldom any difficulty in establishing evidence of a grave hereditary taint.
But where there are grounds for regarding the neurosis as an acquired one, careful enquiry directed to that end reveals that a set of noxae and influences from sexual life are the operative aetiological factors. These appear at first sight to be of a varied nature, but they soon disclose the common character which explains why they have a similar effect on the nervous system. Further, they are present either alone or together with other noxae of a ‘stock’ kind, to which we may ascribe a contributory effect. This sexual aetiology of anxiety neurosis can be demonstrated with such overwhelming frequency that I venture, for the purpose of this short paper, to disregard those cases where the aetiology is doubtful or different.
In order that the aetiological conditions under which anxiety neurosis makes its appearance may be presented with greater accuracy, it will be advisable to consider males and females separately. In females - disregarding for the moment their innate disposition - anxiety neurosis occurs in the following cases:
(a) As virginal anxiety or anxiety in adolescents. A number of unambiguous observations have shown me that anxiety neurosis can be produced in girls who are approaching maturity by their first encounter with the problem of sex, by any more or less sudden revelation of what had till then been hidden - for instance, by witnessing the sexual act, or being told or reading about these things. Such an anxiety neurosis is combined with hysteria in an almost typical fashion.
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(b) As anxiety in the newly married. Young married women who have remained anaesthetic during their first cohabitations not seldom fall ill of an anxiety neurosis, which disappears once more as soon as the anaesthesia gives place to normal sensitivity. Since most young wives remain healthy where there is initial anaesthesia of this kind, it follows that, in order that this kind of anxiety shall emerge, other determinants are required; and these I will mention later.
(c) As anxiety in women whose husbands suffer from ejaculatio praecox or from markedly impaired potency; and (d) whose husbands practise coitus interruptus or reservatus. These cases belong together, for on analysing a great number of instances it is easy to convince oneself that they depend simply on whether the woman obtains satisfaction in coitus or not. If not, the condition for the genesis of an anxiety neurosis is given. On the other hand, she is saved from the neurosis if the husband who is affected with ejaculatio praecox is able immediately to repeat coitus with better success. Coitus reservatus by means of condoms is not injurious to the woman, provided she is very quickly excitable and the husband very potent; otherwise, this kind of preventive intercourse is no less injurious than the others. Coitus interruptus is nearly always a noxa. But for the wife it is only so if the husband practises it regardlessly - that is to say, if he breaks off intercourse as soon as he is near emission, without troubling himself about the course of the excitation in her. If, on the other hand, the husband waits for his wife’s satisfaction, the coitus amounts to a normal one for her; but he will fall ill of an anxiety neurosis. I have collected and analysed a large number of observations, on which these assertions are based.
(e) Anxiety neurosis also occurs as anxiety in widows and intentionally abstinent women, not seldom in a typical combination with obsessional ideas; and
(f) As anxiety in the climacteric during the last major increase of sexual need.
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Cases (c) (d) and (e) comprise the conditions under which anxiety neurosis in the female sex arises most frequently and most readily, independently of hereditary disposition. It is in reference to these cases of anxiety neurosis - these curable acquired cases - that I shall try to show that the sexual noxae discovered in them are really the aetiological factor of the neurosis.
Before doing so, however, I will discuss the sexual determinants of anxiety neurosis in men. I propose to distinguish the following groups, all of which have their analogies in women:
(a) Anxiety of intentionally abstinent men, which is frequently combined with symptoms of defence (obsessional ideas, hysteria). The motives which are responsible for intentional abstinence imply that a number of people with a hereditary disposition, eccentrics, etc., enter into this category.
(b) Anxiety in men in a state of unconsummated excitation (e.g. during the period of engagement before marriage), or in those who (from fear of the consequences of sexual intercourse) content themselves with touching or looking at women. This group of determinants - which, incidentally, can be applied unaltered to the other sex (during engagements or relations in which sexual intercourse is avoided) - provides the purest cases of the neurosis.
(c) Anxiety in men who practise coitus interruptus. As has been said, coitus interruptus is injurious to the woman if it is practised without regard to her satisfaction; but it is injurious to the man if, in order to obtain satisfaction for her, he directs coitus voluntarily and postpones emission. In this way it becomes intelligible that when a married couple practise coitus interruptus, it is, as a rule, only one partner who falls ill. Moreover, in men coitus interruptus only rarely produces a pure anxiety neurosis; it usually produces a mixture of anxiety neurosis and neurasthenia.
(d) Anxiety in senescent men. There are men who have a climacteric like women, and who produce an anxiety neurosis at the time of their decreasing potency and increasing libido.
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Finally, I must add two other cases which apply to both sexes:
(a) People who, as a result of practising masturbation, have become neurasthenics, fall victims to anxiety neurosis as soon as they give up their form of sexual satisfaction. Such people have made themselves particularly incapable of tolerating abstinence.
I may note here, as being important for an understanding of anxiety neurosis, that any pronounced development of that affection only occurs among men who have remained potent and women who are not anaesthetic. Among neurotics whose potency has already been severely damaged by masturbation, the anxiety neurosis resulting from abstinence is very slight and is mostly restricted to hypochondria and mild chronic vertigo. The majority of women, indeed, are to be regarded as ‘potent’; a really impotent - i.e. a really anaesthetic - woman is in a similar way little susceptible to anxiety neurosis, and she tolerates the noxae I have described remarkably well.
How far, in addition to this, we are justified in postulating any constant relation between particular aetiological factors and particular symptoms in the complex of anxiety neurosis, I should not like to discuss as yet in this paper.
(b) The last of the aetiological conditions I have to bring forward appears at first sight not to be of a sexual nature at all. Anxiety neurosis also arises - and in both sexes - as a result of the factor of overwork or exhausting exertion - as, for instance, after night-watching, sick-nursing, or even after severe illness.
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The main objection to my postulate of a sexual aetiology for anxiety neurosis will probably be to the following effect. Abnormal conditions in sexual life of the kind I have described are found so extremely frequently that they are bound to be forthcoming wherever one looks for them. Their presence in the cases of anxiety neurosis which I have enumerated does not, therefore, prove that we have unearthed in them the aetiology of the neurosis. Moreover, the number of people who practise coitus interruptus and the like is incomparably larger than the number who are afflicted with anxiety neurosis, and the great majority of the former tolerate this noxa very well.
To this I must reply in the first place that, considering the admittedly enormous frequency of the neuroses and especially of anxiety neurosis, it would certainly not be right to expect to find an aetiological factor for them that is of rare occurrence; in the second place, that a postulate of pathology is in fact satisfied, if in an aetiological investigation it can be shown that the presence of an aetiological factor is more frequent than its effects, since, in order for these latter to occur, other conditions may have to exist in addition ( such as disposition, summation of specific aetiological elements, or reinforcement by other stock noxae); and further, that a detailed dissection of suitable cases of anxiety neurosis proves beyond question the importance of the sexual factor. I will confine myself here, however, to the single aetiological factor of coitus interruptus and to bringing out certain observations which confirm it.
(1) So long as an anxiety neurosis in young married women is not yet established, but only appears in bouts and disappears again spontaneously, it is possible to demonstrate that each such bout of the neurosis is traceable to a coitus which was deficient in satisfaction. Two days after this experience - or, in the case of people with little resistance, the day after - the attack of anxiety or vertigo regularly appears, bringing in its train other symptoms of the neurosis. All this vanishes once more, provided that marital intercourse is comparatively rare. A chance absence of the husband from home, or a holiday in the mountains which necessitates a separation of the couple, has a good effect. The gynaecological treatment which is usually resorted to in the first instance is beneficial because, while it lasts, marital intercourse is stopped. Curiously enough the success of local treatment is only transitory: the neurosis sets in again in the mountains, as soon as the husband begins his holiday too; and so on. If, as a physician who understands this aetiology, one arranges, in a case in which the neurosis has not yet been established, for coitus interruptus to be replaced by normal intercourse, one obtains a therapeutic proof of the assertion I have made. The anxiety is removed, and - unless there is fresh cause for it of the same sort - it does not return.
(2) In the anamneses of many cases of anxiety neurosis we find, both in men and women, a striking oscillation in the intensity of its manifestations, and, indeed, in the coming and going of the whole condition. One year, they will tell you, was almost entirely good, but the next one was dreadful; on one occasion the improvement seemed to be due to a particular treatment, which, however, turned out to be quite useless at the next attack; and so on. If we enquire into the number and sequence of the children and compare this record of the marriage with the peculiar history of the neurosis, we arrive at the simple solution that the periods of improvement or good health coincided with the wife’s pregnancies, during which, of course, the need for preventive intercourse was no longer present. The husband benefited by the treatment after which he found his wife pregnant - whether he received it from Pastor Kneipp or at a hydropathic establishment.
(3) The anamnesis of patients often discloses that the symptoms of anxiety neurosis have at some definite time succeeded the symptoms of some other neurosis - neurasthenia, perhaps - and have taken their place. In these instances it can quite regularly be shown that, shortly before this change of the picture, a corresponding change has occurred in the form of the sexual noxa.
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Observations of this sort, which can be multiplied at will, positively thrust a sexual aetiology on the doctor for a certain category of cases. And other cases, which would otherwise remain unintelligible, can at least be understood and classified without inconsistency by employing that aetiology as a key. I have in mind those very numerous cases in which, it is true, everything is present that has been found in the previous category - on the one hand the manifestations of anxiety neurosis, and on the other the specific factor of coitus interruptus - but in which something else as well intrudes itself: namely, a long interval between the presumed aetiology and its effects, and also perhaps aetiological factors that are not of a sexual nature. Take, for instance, a man who, on receiving news of his father’s death, had a heart attack and from that moment fell a victim to an anxiety neurosis. The case is not comprehensible, for, till then, the man was not neurotic. The death of his father, who was well advanced in years, did not take place under in any way special circumstances, and it will be admitted that the normal and expected decease of an aged father is not one of those experiences which usually cause a healthy adult to fall ill. Perhaps the aetiological analysis will become clearer if I add that this man had been practising coitus interruptus for eleven years, with due consideration for his wife’s satisfaction. The clinical symptoms are, at least, exactly the same as those which appear in other people after only a short sexual noxa of the same kind, and without the interpolation of any other trauma. A similar assessment must be made of the case of a woman whose anxiety neurosis broke out after the loss of her child, or of the student whose preparatory studies for his final examination were interfered with by an anxiety neurosis. I think that in these instances, too, the effect is not explained by the ostensible aetiology. One is not necessarily ‘overworked’ by study, and a healthy mother as a rule reacts only with normal grief to the loss of a child. Above all, however, I should have expected the student, as a result of his overwork, to acquire cephalasthenia, and the mother, as a result of her bereavement, hysteria. That both should have been overtaken by anxiety neurosis leads me to attach importance to the fact that the mother had been living for eight years in conditions of marital coitus interruptus, and that the student had for three years had an ardent love affair with a ‘respectable’ girl whom he had to avoid making pregnant.
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These considerations lead us to the conclusion that the specific sexual noxa of coitus interruptus, even when it is not able on its own account to provoke an anxiety neurosis in the subject, does at least provoke him to acquire it. The anxiety neurosis breaks out as soon as there is added to the latent effect of the specific factor the effect of another, stock noxa. The latter can act in the sense of the specific factor quantitatively but cannot replace it qualitatively. The specific factor always remains decisive for the form taken by the neurosis. I hope to be able to prove this assertion concerning the aetiology of the neuroses more comprehensively too.
In addition, these latter remarks contain an assumption which is not in itself improbable, to the effect that a sexual noxa like coitus interruptus comes into force through summation. A shorter or longer time is needed - depending on the individual’s disposition and any other inherited weaknesses of his nervous system - before the effect of this summation becomes visible. Those individuals who apparently tolerate coitus interruptus without harm, in fact become disposed by it to the disorders of anxiety neurosis, and these may break out at some time or other, either spontaneously or after a stock trauma which would not ordinarily suffice for this; just as, by the path of summation, a chronic alcoholic will in the end develop a cirrhosis or some other illness, or will, under the influence of a fever, fall a victim to delirium.
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III
FIRST STEPS TOWARD A THEORY OF ANXIETY NEUROSIS
The following theoretical discussion can only claim to have the value of a first, groping attempt; criticism of it ought not to affect an acceptance of the facts which have been brought forward above. Moreover, an assessment of this ‘theory of anxiety neurosis’ is made the more difficult from being only a fragment of a more comprehensive account of the neuroses.
What we have so far said about anxiety neurosis already provides a few starting points for gaining an insight into the mechanism of this neurosis. In the first place there was our suspicion that we had to do with an accumulation of excitation; and then there was the extremely important fact that the anxiety which underlies the clinical symptoms of the neurosis can be traced to no psychical origin. Such an origin would exist, for instance, if it was found that the anxiety neurosis was based on a single or repeated justifiable fright, and that that fright had since provided the source for the subject’s readiness for anxiety. But this is not so. Hysteria or a traumatic neurosis can be acquired from a single fright, but never anxiety neurosis. Since coitus interruptus takes such a prominent place among the causes of anxiety neurosis, I thought at first that the source of the continuous anxiety might lie in the fear, recurring every time the sexual act was performed, that the technique might go wrong and conception consequently take place. But I have found that this state of feeling, either in the man or the woman, during coitus interruptus has no influence on the generation of anxiety neurosis, that women who are basically indifferent about the consequence of a possible conception are just as liable to the neurosis as those who shudder at the possibility, and that everything depends simply on which partner has forfeited satisfaction in this sexual technique.
A further point of departure is furnished by the observation, not so far mentioned, that in whole sets of cases anxiety neurosis is accompanied by a most noticeable decrease of sexual libido or psychical desire, so that on being told that their complaint results from ‘insufficient satisfaction’, patients regularly reply that that is impossible, for precisely now all sexual need has become extinguished in them. From all these indications - that we have to do with an accumulation of excitation; that the anxiety which probably corresponds to this accumulated excitation is of somatic origin, so that what is being accumulated is a somatic excitation; and, further, that this somatic excitation is of a sexual nature and that a decrease of psychical participation in the sexual processes goes along with it - all these indications, I say, incline us to expect that the mechanism of anxiety is to be looked for in a deflection of somatic excitation from the psychical sphere, and in a consequent abnormal employment of that excitation.
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This concept of the mechanism of anxiety neurosis can be made clearer if one accepts the following view of the sexual process, which applies, in the first instance, to men. In the sexually mature male organism somatic sexual excitation is produced probably continuously - and periodically becomes a stimulus to the psyche. In order to make our ideas on this point firmer, I will add by way of interpolation that this somatic excitation is manifested as a pressure on the walls of the seminal vesicles, which are lined with nerve endings; thus this visceral excitation will develop continuously, but it will have to reach a certain height before it is able to overcome the resistance of the intervening path of conduction to the cerebral cortex and express itself as a psychical stimulus. When this has happened, however, the group of sexual ideas which is present in the psyche becomes supplied with energy and there comes into being the psychical state of libidinal tension which brings with it an urge to remove that tension. A psychical unloading of this kind is only possible by means of what I shall call specific or adequate action. This adequate action consists, for the male sexual instinct, in a complicated spinal reflex act which brings about the unloading of the nerve-endings, and in all the psychical preparations which have to be made in order to set off that reflex. Anything other than the adequate action would be fruitless, for once the somatic sexual excitation has reached threshold value it is turned continuously into psychical excitation, and something must positively take place which will free the nerve endings from the load of pressure on them - which will, accordingly, remove the whole of the existing somatic excitation and allow the subcortical path of conduction to re-establish its resistance.
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I shall refrain from describing more complicated instances of the sexual process in a similar way. I will only state that in essentials this formula is applicable to women as well, in spite of the confusion introduced into the problem by all the artificial retarding and stunting of the female sexual instinct. In women too we must postulate a somatic sexual excitation and a state in which this excitation becomes a psychical stimulus - libido - and provokes the urge to the specific action to which voluptuous feeling is attached. Where women are concerned, however, we are not in a position to say what the process analogous to the relaxation of tension of the seminal vesicles may be.
We can include within the framework of this description of the sexual process not only the aetiology of anxiety neurosis but that of genuine neurasthenia. Neurasthenia develops whenever the adequate unloading ( the adequate action) is replaced by a less adequate one - thus, when normal coition, carried out in the most favourable conditions, is replaced by masturbation or spontaneous emission. Anxiety neurosis, on the other hand, is the product of all those factors which prevent the somatic sexual excitation from being worked over psychically. The manifestations of anxiety neurosis appear when the somatic excitation which has been deflected from the psyche is expended subcortically in totally inadequate reactions.
I will now attempt to discover whether the aetiological conditions for anxiety neurosis which I set out above exhibit the common character that I have just attributed to them. The first aetiological factor I postulated for men was intentional abstinence. Abstinence consists in the withholding of the specific action which ordinarily follows upon libido. Such withholding may have two consequences. In the first place, the somatic excitation accumulates; it is then deflected into other paths, which hold out greater promise of discharge than does the path through the psyche. Thus the libido will in the end sink, and the excitation will manifest itself subcortically as anxiety. In the second place, if the libido is not diminished, or if the somatic excitation is expended, by a short cut, in emissions, or if, in consequence of being forced back, the excitation really ceases, then all kinds of things other than an anxiety neurosis will ensue. Abstinence, then, leads to anxiety neurosis in the manner described above. But it is also the operative agent in my second aetiological group, that of unconsummated excitation. My third group, that of coitus reservatus with consideration for the woman, operates by disturbing the man’s psychical preparedness for the sexual process, in that it introduces alongside of the task of mastering the sexual affect another psychical task, one of a deflecting sort. In consequence of this psychical deflection, once more, libido gradually disappears, and the further course of things is then the same as in the case of abstinence. Anxiety in senescence (the male climacteric) requires another explanation. Here there is no diminution of libido; but, as in the female climacteric, so great an increase occurs in the production of somatic excitation that the psyche proves relatively insufficient to master it.
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The aetiological conditions applying to women can be brought into the framework of my scheme with no greater difficulties than in the case of men. Virginal anxiety is a particularly clear example. For here the groups of ideas to which the somatic sexual excitation should become attached are not yet enough developed. In the newly-married woman who is anaesthetic, anxiety only appears if the first cohabitations arouse a sufficient amount of somatic excitation. When the local indications of such excitement (spontaneous sensations of stimulation, desire to micturate and so on) are lacking, anxiety is also absent. The case of ejaculatio praecox and of coitus interruptus can be explained on the same lines as in men, namely that the libidinal desire for the psychically unsatisfying act gradually disappears, while the excitation which has been aroused during the act is expended subcortically. The alienation between the somatic and the psychical sphere is established more readily and is more difficult to remove in women than in men. The cases of widowhood and of voluntary abstinence, and also that of the climacteric, are dealt with in the same way in both sexes; but where abstinence is concerned there is in the case of women no doubt the further matter of intentional repression of the sexual circle of ideas, to which an abstinent woman, in her struggle against temptation, must often make up her mind. The horror which, at the time of the menopause, an ageing woman feels at her unduly increased libido may act in a similar sense.
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The two last aetiological conditions on our list seem to fall into place without difficulty. The tendency to anxiety in masturbators who have become neurasthenic is explained by the fact that it is very easy for them to pass into a state of ‘abstinence’ after they have been accustomed for so long to discharging even the smallest quantity of somatic excitation, faulty though that discharge is. Finally, the last case, - the generation of anxiety neurosis through severe illness, overwork, exhausting sick-nursing, etc., - finds an easy interpretation when brought into relation with the effects of coitus interruptus. Here the psyche, on account of its deflection, would seem to be no longer capable of mastering the somatic excitation, a task on which, as we know, it is continuously engaged. We are aware to what a low level libido can sink under these conditions; and we have here a good example of a neurosis which, although it exhibits no sexual aetiology, nevertheless exhibits a sexual mechanism.
The view here developed depicts the symptoms of anxiety neurosis as being in a sense surrogates of the omitted specific action following on sexual excitation. In further support of this view, I may point out that in normal copulation too the excitation expends itself, among other things, in accelerated breathing, palpitation, sweating, congestion, and so on. In the corresponding anxiety attacks of our neurosis we have before us the dyspnoea, palpitations, etc. of copulation in an isolated and exaggerated form.
A further question may be asked. Why, under such conditions of psychical insufficiency in mastering sexual excitation, does the nervous system find itself in the peculiar affective state of anxiety? An answer may be suggested as follows. The psyche finds itself in the affect of anxiety if it feels unable to deal by appropriate reaction with a task (a danger) approaching from the outside; it finds itself in the neurosis of anxiety if it notices that it is unable to even out the (sexual) excitation originating from within - that is to say, it behaves as though it were projecting that excitation outwards. The affect and its corresponding neurosis are firmly related to each other. The first is a reaction to an exogenous excitation, the second a reaction to the analogous endogenous one. The affect is a state which passes rapidly, the neurosis is a chronic one; because, while exogenous excitation operates with a single impact, the endogenous excitation operates as a constant force. In the neurosis, the nervous system is reacting against a source of excitation which is internal, whereas in the corresponding affect it is reacting against an analogous source of excitation which is external.
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IV
RELATION TO OTHER NEUROSES
There are still a few words to be said about the relations of anxiety neurosis to the other neuroses as regards their onset and their internal connections.
The purest cases of anxiety neurosis are usually the most marked. They are found in sexually potent youthful individuals, with an undivided aetiology, and an illness that is not of too long standing.
More often, however, symptoms of anxiety occur at the same time as, and in combination with, symptoms of neurasthenia, hysteria, obsessions or melancholia. If we were to allow ourselves to be restrained by a clinical intermixture like this from acknowledging anxiety neurosis as an independent entity, we ought, logically, also to abandon once more the separation which has been so laboriously achieved between hysteria and neurasthenia.
For the purposes of analysing ‘mixed neuroses’ I can state this important truth: Wherever a mixed neurosis is present, it will be possible to discover an intermixture of several specific aetiologies.
A multiplicity of aetiological factors such as this, which determine a mixed neurosis, may occur purely fortuitously. For instance, a fresh noxa may add its effects to those of an already existing one. Thus, a woman who has always been hysterical may begin at a certain point in her marriage to experience coitus reservatus; she will then acquire an anxiety neurosis in addition to her hysteria. Or again, a man who has hitherto masturbated and has become neurasthenic, may get engaged and become sexually excited by his fiancée; his neurasthenia will now be joined by a new anxiety neurosis.
In other cases the multiplicity of aetiological factors is by no means fortuitous: one of the factors has brought the other into operation. For example, a woman with whom her husband practises coitus reservatus without regard to her satisfaction may find herself compelled to masturbate in order to put an end to the distressing excitation that follows such an act; as a result, she will produce, not an anxiety neurosis pure and simple, but an anxiety neurosis accompanied by symptoms of neurasthenia. Another woman suffering from the same noxa may have to fight against lascivious images against which she tries to defend herself; and in this way she will, through the coitus interruptus, acquire obsessions as well as an anxiety neurosis. Finally, as a result of coitus interruptus, a third woman may lose her affection for her husband and feel an attraction for another man, which she carefully keeps secret; in consequence, she will exhibit a mixture of anxiety neurosis and hysteria.
In a third category of mixed neuroses the interconnection between the symptoms is still more intimate, in that the same aetiological determinant regularly and simultaneously provokes both neuroses. Thus, for instance, the sudden sexual enlightenment, which we have found present in virginal anxiety, always gives rise to hysteria as well; by far the majority of cases of intentional abstinence become linked from the beginning with true obsessional ideas; coitus interruptus in men never seems to me to be able to provoke a pure anxiety neurosis, but always a mixture of it with neurasthenia.
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From these considerations it appears that we must further distinguish the aetiological conditions for the onset of the neuroses from their specific aetiological factors. The former - for example, coitus interruptus, masturbation or abstinence - are still ambiguous, and each of them can produce different neuroses. Only the aetiological factors which can be picked out in them, such as inadequate disburdening, psychical insufficiency or defence accompanied by substitution, have an unambiguous and specific relation to the aetiology of the individual major neuroses.
As regards its intimate nature, anxiety neurosis presents the most interesting agreements with, and differences from, the other major neuroses, in particular neurasthenia and hysteria. It shares with neurasthenia one main characteristic - namely that the source of excitation, the precipitating cause of the disturbance, lies in the somatic field instead of the psychical one, as is the case in hysteria and obsessional neurosis. In other respects we rather find a kind of antithesis between the symptoms of anxiety neurosis and of neurasthenia, which might be brought out by such labels as ‘accumulation of excitation’ and ‘impoverishment of excitation’. This antithesis does not prevent the two neuroses from being intermixed with each other; but it nevertheless shows itself in the fact that the most extreme forms of each are in both cases also the purest.
The symptomatology of hysteria and anxiety neurosis show many points in common which have not yet been sufficiently considered. The appearance of symptoms either in a chronic form or in attacks, the paraesthesias, grouped like aurae, the hyperaesthesias and pressure-points which are found in certain surrogates of an anxiety attack (in dyspnoea and heart-attacks), the intensification, through conversion, of pains which perhaps have an organic justification - these and other features which the two illnesses have in common even allow of a suspicion that not a little of what is attributed to hysteria might with more justice be put to the account of anxiety neurosis. If one goes into the mechanism of the two neuroses, so far as it has been possible to discover it hitherto, aspects come to light which suggest that anxiety neurosis is actually the somatic counterpart to hysteria. In the latter just as in the former there is an accumulation of excitation (which is perhaps the basis for the similarity between their symptoms we have mentioned). In the latter just as in the former we find a psychical insufficiency, as a consequence of which abnormal somatic processes arise. In the latter just as in the former, too, instead of a psychical working-over of the excitation, a deflection of it occurs into the somatic field; the difference is merely that in anxiety neurosis the excitation, in whose displacement the neurosis expresses itself, is purely somatic (somatic sexual excitation), whereas in hysteria it is psychical (provoked by conflict). Thus it is not to be wondered at that hysteria and anxiety neurosis regularly combine with each other, as is seen in ‘virginal anxiety’ or in ‘sexual hysteria’, and that hysteria simply borrows a number of its symptoms from anxiety neurosis, and so on. These intimate relations which anxiety neurosis has with hysteria provide a fresh argument, moreover, for insisting on the detachment of anxiety neurosis from neurasthenia; for if this detachment is not granted, we shall also be unable any longer to maintain the distinction which has been acquired with so much labour and which is so indispensable for the theory of the neuroses, between neurasthenia and hysteria.
VIENNA, December 1894.