ON THE RIGHT TO SEPARATE FROM NEURASTHENIA A DEFINITE SYMPTOM-COMPLEX AS
“ANXIETY NEUROSIS”
(ANGSTNEUROSE).
It is difficult to assert anything of general validity concerning
neurasthenia as long as this term is allowed to express all that for
which Beard used it. I believe that neuropathology can only gain by an
attempt to separate from the actual neurosis all those neurotic
disturbances the symptoms of which are on the one hand more firmly
connected among themselves than to the typical neurasthenic symptoms,
such as headache, spinal irritation, dyspepsia with flatulence and
constipation, and which on the other hand show essential differences
from the typical neurasthenic neurosis in their etiology and mechanism.
If we accept this plan we will soon gain quite a uniform picture of
neurasthenia. We will soon be able to differentiate—sharper than we have
hitherto succeeded—from the real neurasthenia the different
pseudoneurasthenias, such as the organically determined nasal reflex
neurosis, the neurotic disturbances of cachexias and arteriosclerosis,
the early stages of progressive paralysis, and of some psychoses.
Furthermore, following the proposition of Moebius, some status nervosi
of hereditary degenerates will be set aside and we will also find
reasons for ascribing some of the neuroses which are now called
neurasthenia to melancholia, especially those of an intermittent or
periodic nature. But we force the way into the most marked changes if we
decide to separate from neurasthenia that symptom-complex which I shall
hereafter describe and which especially fulfills the conditions
formulated above. The symptoms of this complex are clinically more
related to one another than to the real neurasthenic symptoms, that is,
they frequently appear together and substitute one another in the course
of the disease, and both the etiology as well as the mechanism of this
neurosis differs basically from the etiology and the mechanism of the
real neurasthenia which remains after such a separation.
I call this symptom-complex “anxiety neurosis” (Angstneurose) because
the sum of its components can be grouped around the main symptom of
anxiety, because each individual symptom shows a definite relation to
anxiety. I believed that I was original in this conception of the
symptoms of anxiety neurosis until an interesting lecture by E.
Hecker[41] fell into my hands. In this lecture I found the description
of the same interpretation with all the desired clearness and
completeness. To be sure, Hecker does not separate the equivalents or
rudiments of the attack of anxiety from neurasthenia as I intend to do;
but this is apparently due to the fact that neither here nor there has
he taken into account the diversity of the etiological determinants.
With the knowledge of the latter difference every obligation to
designate the anxiety neurosis by the same name as the real neurasthenia
disappears, for the only object of arbitrary naming is to facilitate the
formulation of general assertions.
I. CLINICAL SYMPTOMATOLOGY OF ANXIETY NEUROSIS.
What I call “anxiety neurosis” can be observed in complete or
rudimentary development, either isolated or in combination with other
neuroses. The cases which are in a measure complete, and at the same
time isolated, are naturally those which especially corroborate the
impression that the anxiety neurosis possesses clinical independence. In
other cases we are confronted with the task of selecting and separating
from a symptom-complex which corresponds to a “mixed neurosis,” all
those symptoms which do not belong to neurasthenia, hysteria, etc., but
to the anxiety neurosis.
The clinical picture of the anxiety neurosis comprises the following
symptoms:
1. _General Irritability._—This is a frequent nervous symptom, common as
such to many nervous states. I mention it here because it constantly
occurs in the anxiety neurosis and is of theoretical significance. For
increased irritability always points to an accumulation of excitement or
to an inability to bear accumulation, hence to an absolute or relative
accumulation of excitement. The expression of this increased
irritability through an auditory hyperesthesia is especially worth
mentioning; it is an over sensitiveness for noises, which symptom is
certainly to be explained by the congenital intimate relationship
between auditory impressions and fright. Auditory hyperesthesia is
frequently found as a cause of insomnia, of which more than one form
belongs to anxiety neurosis.
2. _Anxious Expectation._—I can not better explain the condition that I
have in mind, than by this name and by some appended examples. A woman,
for example, who suffers from anxious expectation thinks of
influenza-pneumonia whenever her husband who is afflicted with a
catarrhal condition has a coughing spell; and in her mind she sees a
passing funeral procession. If on her way home she sees two persons
standing together in front of her house she can not refrain from the
thought that one of her children fell out of the window; if she hears
the bell ring she thinks that someone is bringing her mournful tidings,
etc.; yet in none of these cases is there any special reason for
exaggerating a mere possibility.
The anxious expectation naturally reflects itself constantly in the
normal, and embraces all that is designated as “uneasiness and a
tendency to a pessimistic conception of things,” but as often as
possible it goes beyond such a plausible uneasiness, and it is
frequently recognized as a part of constraint even by the patient
himself. For one form of anxious expectation, namely, that which refers
to one’s own health, we can reserve the old name of hypochondria.
Hypochondria does not always run parallel with the height of the general
anxious expectation; as a preliminary stipulation it requires the
existence of paresthesias and annoying somatic sensations. Hypochondria
is thus the form preferred by the genuine neurasthenics whenever they
merge into the anxiety neurosis, a thing which frequently happens.
As a further manifestation of anxious expectation we may mention the
frequent tendency observed in morally sensitive persons to pangs of
conscience, scrupulosity, and pedantry, which varies as it were, from
the normal to its aggravation as doubting mania.
Anxious expectation is the most essential symptom of the neurosis; it
also clearly shows a part of its theory. It can perhaps be said that we
have here a quantum of freely floating anxiety which controls the choice
of ideas by expectation and is forever ready to unite itself with any
suitable ideation.
3. This is not the only way in which the anxiousness, usually latent but
constantly lurking in consciousness, can manifest itself. On the
contrary it can also suddenly break into consciousness without being
aroused by the issue of an idea, and thus provoke an attack of anxiety.
Such an attack of anxiety consists of either the anxious feeling alone
without any associated idea, or of the nearest interpretation of the
termination of life, such as the idea of “sudden death” or threatening
insanity; or the feeling of anxiety becomes mixed with some paresthesia
(similar to the hysterical aura); or finally the anxious feeling may be
combined with a disturbance of one or many somatic functions, such as
respiration, cardiac activity, the vasomotor innervation, and the
glandular activity. From this combination the patient renders especially
prominent now this and now the other moment. He complains of
“heartspasms,” “heavy breathing,” “profuse perspiration,” “inordinate
appetite,” etc., and in his description the feeling of anxiety is put to
the background or it is rather vaguely described as “feeling badly,”
“uncomfortably,” etc.
4. What is interesting and of diagnostic significance is the fact that
the amount of admixture of these elements in the attack of anxiety
varies extraordinarily, and that almost any accompanying symptom can
alone constitute the attack as well as the anxiety itself. Accordingly
there are rudimentary attacks of anxiety, and equivalents for the attack
of anxiety, probably all of equal significance in showing a profuse and
hitherto little appreciated richness in forms. A more thorough study of
these larvated states of anxiety (Hecker) and their diagnostic division
from other attacks ought soon to become the necessary work for the
neuropathologist.
I now add a list of those forms of attacks of anxiety with which I am
acquainted. There are attacks:
(_a_) With disturbances of heart action, such as palpitation with
transitory arrythmia, with longer continued tachycardia up to grave
states of heart weakness, the differentiation of which from organic
heart affection is not always easy; among such we have the pseudo-angina
pectoris, a delicate diagnostic sphere!
(_b_) With disturbances of respiration, many forms of nervous dyspnoea,
asthma-like attacks, etc. I assert that even these attacks are not
always accompanied by conscious anxiety;
(_c_) Of profuse perspiration, often nocturnal;
(_d_) Of trembling and shaking which may readily be mistaken for
hysterical attacks;
(_e_) Of inordinate appetite, often combined with dizziness;
(_f_) Of attack-like appearing diarrhoea;
(_g_) Of locomotor dizziness;
(_h_) Of so called congestions, embracing all that was called vasomotor
neurasthenia; and,
(_i_) Of paresthesias (These are seldom without anxiety or a similar
discomfort).
5. Very frequently the nocturnal frights (pavor nocturnus of adults)
usually combined with anxiety, dyspnoea, perspiration, etc., is nothing
other than a variety of the attack of anxiety. This disturbance
determines a second form of insomnia in the sphere of the anxiety
neurosis. Moreover I became convinced that even the pavor nocturnus of
children evinces a form belonging to the anxiety neurosis. The
hysterical tinge and the connection of the fear with the reproduction of
appropriate experience or dream, makes the pavor nocturnus of children
appear as something peculiar, but it also occurs alone without a dream
or a recurring hallucination.
6. “_Vertigo._”—This in its lightest forms is better designated as
“dizziness,” assumes a prominent place in the group of symptoms of
anxiety neurosis. In its severer forms the “attack of vertigo,” with or
without fear, belongs to the gravest symptoms of the neurosis. The
vertigo of the anxiety neurosis is neither a rotatory dizziness nor is
it confined to certain planes or lines like Menier’s vertigo. It belongs
to the locomotor or coordinating vertigo, like the vertigo in paralysis
of the ocular muscles; it consists in a specific feeling of discomfort
which is accompanied by sensations of a heaving ground, sinking legs, of
the impossibility to continue in an upright position, and at the same
time there is a feeling that the legs are as heavy as lead, they shake,
or give way. This vertigo never leads to falling. On the other hand, I
would like to state that such an attack of vertigo may also be
substituted by a profound attack of syncope. Other fainting-like states
in the anxiety neurosis seem to depend on a cardiac collapse.
The vertigo attack is frequently accompanied by the worst kind of
anxiety and is often combined with cardiac and respiratory disturbances.
Vertigo of elevations, mountains and precipices, can also be frequently
observed in anxiety neurosis; moreover, I do not know whether we are
still justified in recognizing a vertigo “a stomacho laeso.”
7. On the basis of the chronic anxiousness (anxious expectation) on the
one hand, and the tendency to vertiginous attacks of anxiety on the
other, there develop two groups of typical phobias; the first refers to
the general physiological menaces, while the second refers to
locomotion. To the first group belong the fear for snakes,
thunderstorms, darkness, vermin, etc., as well as the typical moral
overscrupulousness, and the forms of doubting mania. Here the available
fear is merely used to strengthen those aversions which are
instinctively implanted in every man. But usually a compulsively acting
phobia is formed only after a reminiscence is added to an experience in
which this fear could manifest itself; as, for example, after the
patient has experienced a storm in the open air. To attempt to explain
such cases as mere continuations of strong impressions is incorrect.
What makes these experiences significant and their reminiscences durable
is after all only the fear which could at that time appear and can also
appear today. In other words such impressions remain forceful only in
persons with “anxious expectations.”
The other group contains agoraphobia with all its accessory forms, all
of which are characterized by their relation to locomotion. As a
determination of the phobia we frequently find a precedent attack of
vertigo; I do not think that it can always be postulated. Occasionally,
after a first attack of vertigo without fear, we see that though
locomotion is always accompanied by the sensation of vertigo, it remains
possible without any restrictions, but as soon as fear attaches itself
to the attack of vertigo, locomotion fails, under the conditions of
being alone, narrow streets, etc.
The relation of these phobias to the phobias of obsessions, which
mechanism I discussed above,[42] is as follows: The agreement lies in
the fact that here as there, an idea becomes obsessive through its
connection with an available affect. The mechanism of transposition of
the affect therefore holds true for both kinds of phobias. But in
phobias of the anxiety neurosis this affect is (1) a monotonous one, it
is always one of anxiety; (2) it does not originate from a repressed
idea, and on psychological analysis it proves itself not further
reducible, nor can it be attacked through psychotherapy. The mechanism
of substitution does not therefore hold true for the phobias of anxiety
neurosis.
Both kinds of phobias (or obsessions) often occur side by side, though
the atypical phobias which depend on obsessions need not necessarily
develop on the basis of anxiety neurosis. A very frequent, ostensibly
complicated mechanism appears if the content of an original simple
phobia of anxiety neurosis is substituted by another idea, the
substitution is then subsequently added to the phobia. The “protective
measures” originally employed in combatting the phobia are most
frequently used as substitutions. Thus, for example, from the effort to
provide oneself with counter evidence that one is not crazy, contrary to
the assertion of the hypochondriacal phobia, there results a reasoning
mania. The hesitations, doubts, and the many repetitions of the folie du
doute originate from the justified doubt concerning the certainty of
one’s own stream of thoughts, for, through the compulsive like idea one
is surely conscious of so obstinate a disturbance, etc. It may therefore
be claimed that many syndromes of compulsion neurosis, like folie du
doute and similar ones, can clinically, if not notionally be attributed
to anxiety neurosis.[43]
8. The digestive functions in anxiety neurosis are subject to very few
but characteristic disturbances. Sensations like nausea and sickly
feeling are not rare, and the symptom of inordinate appetite alone or
with other congestions, may serve as a rudimentary attack of anxiety. As
a chronic alteration analogous to the anxious expectations one finds a
tendency to diarrhea which has occasioned the queerest diagnostic
mistakes. If I am not mistaken it is this diarrhea to which Moebius[44]
has recently called attention in a small article. I believe, moreover,
that Peyer’s[45] reflex diarrhea which he attributes to a disease of the
prostate is nothing other than the diarrhea of anxiety neurosis. The
deceptive reflex relation is due to the fact that the same factors which
are active in the origin of such prostatic affections also come into
play in the etiology of anxiety neurosis.
The behavior of the gastro-intestinal function in anxiety neurosis shows
a sharp contrast to the influence of this same function in neurasthenia.
Mixed cases often show the familiar “fluctuations between diarrhea and
constipation.” The desire to urinate in anxiety neurosis is analogous to
the diarrhea.
9. The paresthesias which accompany the attack of vertigo or anxiety are
interesting because they associate themselves into a firm sequence,
similar to the sensations of the hysterical aura. But in contrast to the
hysterical aura I find these associated sensations atypical and
changeable. Another similarity to hysteria is shown by the fact that in
anxiety neurosis a kind of conversion[46] into bodily sensations, as for
example into rheumatic muscles, takes place which otherwise can be
overlooked at one’s pleasure. A large number of so called rheumatics,
who are moreover demonstrable as such, really suffer from an anxiety
neurosis. Besides this aggravation of the sensation of pain I have
observed in a number of cases of anxiety neurosis a tendency towards
hallucinations which could not be explained as hysterical.
10. Many of the so called symptoms which accompany or substitute the
attack of anxiety also appear in a chronic manner. They are then still
less discernible, for the anxious feeling accompanying them appears more
indistinct than in the attack of anxiety. This especially holds true for
the diarrhea, vertigo, and paresthesias. Just as the attack of vertigo
can be substituted by an attack of syncope, so can the chronic vertigo
be substituted by the continuous feeling of feebleness, lassitude, etc.
II. THE OCCURRENCE AND ETIOLOGY OF ANXIETY NEUROSIS.
In some cases of anxiety neurosis no etiology can readily be
ascertained. It is noteworthy that in such cases it is seldom difficult
to demonstrate a marked hereditary taint.
Where we have reason to assume that the neurosis is acquired we can find
by careful and laborious examination that the etiologically effective
moments are based on a series of injuries and influences from the sexual
life. These at first appear to be of a varied nature but easily display
the common character which explains their homogeneous effect on the
nervous system. They are found either alone or with other banal injuries
to which a reinforcing effect can be attributed. This sexual etiology of
anxiety neurosis can be demonstrated so preponderately often that I
venture for the purpose of this brief communication to set aside all
cases of a doubtful or different etiology.
For the more precise description of the etiological determinations under
which anxiety neurosis occurs, it will be advisable to treat separately
those occurring in men and those occurring in women. Anxiety neurosis
appears in women—disregarding their predisposition—in the following
cases:
(_a_) As virginal fear or anxiety in adults. A number of unequivocal
observations showed me that an anxiety neurosis, which is almost
typically combined with hysteria, can be evoked in maturing girls, at
the first encounter with the sexual problem, that is at the sudden
revelation of the things hitherto veiled, by either seeing the sexual
act, or by hearing or reading something of that nature;
(_b_) As fear in the newly married. Young women who remain anesthetic
during the first cohabitation not seldom merge into an anxiety neurosis
which disappears after the anesthesia is displaced by the normal
sensation. As most young women remain undisturbed through such a
beginning anesthesia, the production of this fear requires determinants
which I will mention;
(_c_) As fear in women whose husbands suffer from ejaculatio precox or
from diminished potency; and,
(_d_) In those whose husbands practice coitus interruptus or reservatus.
These cases go together, for on analyzing a large number of examples one
can easily be convinced that they only depend on whether the woman
attained gratification during coitus or not. In the latter case one
finds the determinant for the origin of anxiety neurosis. On the other
hand the woman is spared from the neurosis if the husband afflicted by
ejaculatio precox can repeat the congress with better results
immediately thereafter. The congressus reservatus by means of the condom
is not injurious to the woman if she is quickly excited and the husband
is very potent; in other cases the noxiousness of this kind of
preventive measure is not inferior to the others. Coitus interruptus is
almost regularly injurious; but for the woman it is injurious only if
the husband practices it regardlessly, that is, if he interrupt coitus
as soon as he comes near ejaculating without concerning himself about
the determination of the excitement of his wife. On the other hand if
the husband waits until his wife is gratified, the coitus has the same
significance for the latter as a normal one; but then the husband
becomes afflicted with an anxiety neurosis. I have collected and
analyzed a number of cases which furnished the material for the above
statements.
(_e_) As fear in widows and intentional abstainers, not seldom in
typical combination with obsessions; and,
(_f_) As fear in the climacterium during the last marked enhancement of
the sexual desire.
The cases (_c_), (_d_), and (_e_), contain the determinants under which
the anxiety neurosis originates in the female sex, most frequently and
most independently, of hereditary predisposition. I will endeavor to
demonstrate in these—curable, acquired—cases of anxiety neurosis that
the discovered sexual injuries really represent the etiological moments
of the neurosis. But before proceeding I will mention the sexual
determinants of anxiety neurosis in men. I would like to formulate the
following groups, every one of which finds its analogy in women:
(_a_) Fear of the intentional abstainers; this is frequently combined
with symptoms of defense (obsessions, hysteria). The motives which are
decisive for intentional abstinence carry along with them the fact that
a number of hereditarily burdened eccentrics, etc., belong to this
category.
(_b_) Fear in men with frustrated excitement (during the engagement
period), persons who out of fear for the consequences of sexual
relations satisfy themselves with handling or looking at the woman. This
group of determinants which can moreover be transferred to the other
sex—engagement periods, relations with sexual forbearance—furnish the
purest cases of the neurosis.
(_c_) Fear in men who practice coitus interruptus. As observed above,
coitus interruptus injures the woman if it is practiced regardless of
the woman’s gratification; it becomes injurious to the man, if in order
to bring about the gratification in the woman be voluntarily controls
the coitus by delaying the ejaculation. In this manner we can understand
why it is that in couples who practice coitus interruptus it is usually
only one of them who becomes afflicted. Moreover the coitus interruptus
only rarely produces in man a pure anxiety neurosis, usually it is a
mixture of the same with neurasthenia.
(_d_) Fear in men in the senium. There are men who show a climacterium
like women, and merge into an anxiety neurosis at the time when their
potency diminishes and their libido increases.
Finally I must add two more cases holding true for both sexes:
(_e_) Neurasthenics merge into anxiety neurosis in consequence of
masturbation as soon as they refrain from this manner of sexual
gratification. These persons have especially made themselves unfit to
bear abstinence.
What is important for the understanding of the anxiety neurosis is the
fact that any noteworthy development of the same occurs only in men who
remain potent, and in non-anesthetic women. In neurasthenics, who on
account of masturbation have markedly injured their potency, anxiety
neurosis as a result of abstinence occurs but rarely and limits itself
usually to hypochondria and light chronic dizziness. The majority of
women are really to be considered as “potent”; a real impotent, that is,
a real anesthetic woman, is also inaccessible to anxiety neurosis, and
bears strikingly well the injuries cited.
How far we are perhaps justified in assuming constant relations between
individual etiological moments and individual symptoms from the complex
of anxiety neurosis, I do not care to discuss here.
(_f_) The last of the etiological determinants to be mentioned seems, in
the first place, really not to be of a sexual nature. Anxiety neurosis
originates in both sexes through the moment of overwork, exhaustive
exertion, as for instance, after sleepless nights, nursing the sick, and
even after serious illnesses.
The main objection against my formulation of a sexual etiology of the
anxiety neurosis will probably be to the purport that such abnormal
relations of the sexual life can be found so very often that wherever
one will look for them they will be found near at hand. Their
occurrence, therefore, in the cases cited of anxiety neurosis does not
prove that the etiology of the neurosis was revealed in them. Moreover,
the number of persons practicing coitus interruptus, etc., is
incomparably greater than the number of those who are burdened with
anxiety neurosis, and the overwhelming number of the first are quite
well in spite of this injury.
To this I can answer that we certainly ought not to expect a rarely
occurring etiological moment in the conceded enormous frequency of the
neurosis, and especially anxiety neurosis; furthermore, that it really
fulfills a postulate of pathology if on examining an etiology the
etiological moments can be more frequently demonstrated than their
effects, for, for the latter still other determinants (predisposition,
summation of the specific etiology, reinforcement through other banal
injuries) could be demanded; and furthermore, that the detailed analysis
of suitable cases of anxiety neurosis show quite unequivocally the
significance of the sexual moment. I shall, however, here confine myself
to the etiological moment of coitus interruptus, and I will render
prominent obvious individual experiences.
1. As long as the anxiety neurosis in young women is not yet constituted
but appears in fragments which again spontaneously disappear, it can be
shown that every such turn of the neurosis depends on a coitus with lack
of gratification. Two days after this influence, and in persons of
little resistance the day after, there regularly appears the attack of
anxiety or vertigo to which all the other symptoms of the neurosis
attach themselves, only to separate again on rarer marriage relations.
An unexpected journey of the husband, a sojourn in the mountains causing
a separation of the married couple, does good; the benefit from a course
of gynecological treatment is due to the fact that during its
continuation the marriage relations are stopped. It is noteworthy that
the success of a local treatment is only transitory, the neurosis
reappears while in the mountains if the husband joins his wife for his
own vacation, etc. If, in a not as yet constituted neurosis, a physician
aware of this etiology causes a substitution of the coitus interruptus
by normal relations there results a therapeutic proof of the assertion
here formulated. The anxiety is removed and does not return unless there
be a new or similar cause.
2. In the anamnesis of many cases of anxiety neurosis we find in both
men and women a striking fluctuation in the intensity of the appearances
in both the coming and going of the whole condition. This year was
almost wholly good, the following was terrible, etc.; on one occasion
the improvement occurred after a definite treatment which, however,
failed to produce a response at the next attack. If we inform ourselves
about the number and the sequence of the children, and compare this
marriage chronicle with the peculiar course of the neurosis, the result
of the simple solution shows that the periods of improvement or well
being corresponded with the pregnancies of the woman during which,
naturally, the occasions for preventive relations were unnecessary. The
treatment which benefited the husband, be it Father Kneip’s or the
hydrotherapeutic institute, was the one which he has taken after he
found his wife was pregnant.
3. From the anamnesis of the patients we often find that the symptoms of
the anxiety neurosis are relieved at a certain time by another neurosis,
perhaps a neurasthenia which has supplanted it. It can then be regularly
demonstrated that shortly before this change of the picture there
occurred a corresponding change in the form of a sexual injury.
Whereas such experiences, which can be augmented at pleasure, plainly
obtrude upon the physician the sexual etiology for a certain category of
cases, other cases which would have otherwise remained incomprehensible
can at least without gainsaying be solved and classified by the key of
the sexual etiology. We refer to those numerous cases in which
everything exists that has been found in the former category, such as
the appearance of anxiety neurosis on the one hand, and the specific
moment of the coitus interruptus on the other, but yet something else
slips in, namely, a long interval between the assumed etiology and its
effect, and perhaps other etiological moments of a non-sexual nature. We
have here, for example, a man who was seized with an attack of
palpitation on hearing of his father’s death, and who since that time
suffered from an anxiety neurosis. The case cannot be understood, for up
to that time this man was not nervous. The death of the father, well
advanced in years, did not occur under any peculiar circumstances, and
it must be admitted that the natural expected death of an aged father
does not belong to those experiences which are wont to make a healthy
adult sick. The etiological analysis will perhaps seem clearer if I add
that out of regard for his wife this man practiced coitus interruptus
for eleven years. At all events the manifestations are precisely the
same as those appearing in other persons after a short sexual injury of
this nature, and without the intervention of another trauma. The same
judgment may be pronounced in the case of a woman who merges into an
anxiety neurosis after the death of her child, or in the case of the
student who becomes disturbed by an anxiety neurosis while preparing for
his final state examination. I find that here, as there, the effect is
not explained by the reported etiology. One must not necessarily
“overwork” himself studying, and a healthy mother is wont to react to
the death of her child with normal grief. But, above all, I would expect
that the overworked student would acquire a cephalasthenia, and the
mother in our example a hysteria. That both became afflicted with
anxiety neurosis causes me to attach importance to the fact that the
mother lived for eight year in marital coitus interruptus, and that the
student entertained for three years a warm love affair with a
“respectable” girl whom he was not allowed to impregnate.
These examples tend to show that where the specific sexual injury of the
coitus interruptus is in itself unable to provoke an anxiety neurosis it
at least predisposes to its acquisition. The anxiety neurosis then comes
to light as soon as the effect of another banal injury enters into the
latent effect of the specific moment. The former can quantitatively
substitute the specific moment but not supplant it qualitatively. The
specific moment always remains that which determines the form of
neurosis. I hope to be able to prove to a greater extent this
proposition for the etiology of the neurosis.
Furthermore, the last discussions contain the, not in itself, improbable
assumption that a sexual injury like coitus interruptus asserts itself
through summation. The time required before the effect of this summation
becomes visible depends upon the predisposition of the individual and
the former burdening of his nervous system. The individuals who bear
coitus interruptus manifestly without disadvantage really become
predisposed by it to the disturbance—anxiety neurosis—which can at any
time burst forth spontaneously or after a banal, otherwise inadequate,
trauma, just as the chronic alcoholic finally develops a cirrhosis or
another disease by summation, or under the influence of a fever he
merges into a delirium.
III. ADDENDA TO THE THEORY OF ANXIETY NEUROSIS.
The following discussions claim nothing but the value of a first
tentative experiment, which judgment should not influence the acceptance
of the facts mentioned above. The estimation of this “Theory of Anxiety
Neurosis” is rendered still more difficult by the fact that it merely
corresponds to a fragment of a more comprehensive representation of the
neuroses.
The facts hitherto expressed concerning the anxiety neurosis already
contain some starting points for an insight into the mechanism of this
neurosis. In the first place it contains the assumption that we deal
with an accumulation of excitement, and then the very important fact
that the anxiety underlying the manifestations of the neurosis is not of
psychic derivation. Such, for example, would exist if we found as a
basis for the anxiety neurosis a justified fright happening once or
repeatedly which has since supplied the source of the preparedness for
the anxiety neurosis. But this is not the case; a former fright can
perhaps cause a hysteria or a traumatic neurosis but never an anxiety
neurosis. As the coitus interruptus is rendered so prominent among the
causes of anxiety neurosis I have thought at first that the source of
the continuous anxiety was perhaps the repeated fear during the sexual
act lest the technique will fail and conception follow. But I have found
that this state of mind of the man or woman during the coitus
interruptus plays no part in the origin of anxiety neurosis, that the
women who are really indifferent to the possibilities of conception are
just as exposed to the neurosis as those who are trembling at the
possibility of it, it all depends on which person suffers the loss of
sexual gratification.
Another starting point presents itself in the as yet unmentioned
observation that in a whole series of cases the anxiety neurosis goes
along with the most distinct diminution of the sexual libido or the
psychic desire, so that on revealing to the patients that their
affliction depends on “insufficient gratification,” they regularly reply
that this is impossible as just now their whole desire is extinguished.
The indications that we deal with an accumulation of excitement, that
the anxiety which probably corresponds to such accumulated excitement is
of somatic origin, so that somatic excitement becomes accumulated, and
furthermore, that this somatic excitement is of a sexual nature, and
that it is accompanied by a decreased psychic participation in the
sexual processes—all these indications, I say, favor the expectation
that the mechanism of the anxiety neurosis is to be found in the
deviation of the somatic sexual excitement from the psychic, and in the
abnormal utilization of this excitement occasioned by the former.
This conception of the mechanism of anxiety neurosis will become clearer
if one accepts the following view concerning the sexual process in man.
In the sexually mature male organism, the somatic sexual excitement
is—probably continuously—produced, and this becomes a periodic stimulus
for the psychic life. To make our conceptions clearer we will add that
this somatic sexual excitement manifests itself as a pressure on the
wall of the seminal vesicle which is provided with nerve endings. This
visceral excitement thus becomes continuously increased, but not before
attaining a certain height is it able to overcome the resistances of the
intercalated conduction as far as the cortex, and manifest itself as
psychic excitement. Then the group of sexual ideas existing in the
psyche becomes endowed with energy and results in a psychic state of
libidinous tension which is accompanied by an impulse to remove this
tension. Such psychic unburdening is possible only in one way which I
wish to designate as specific or adequate action. This adequate action
for the male sexual impulse consists of a complicated spinal reflex-act
which results in the unburdening of those nerve endings, and of all
psychically formed preparations for the liberation of this reflex.
Anything else except the adequate action would be of no avail, for after
the somatic sexual excitement has once reached the liminal value, it
continuously changes into psychic excitement; that must by all means
occur which frees the nerve endings from their heavy pressure, and thus
abolish the whole somatic excitement existing at the time and allow the
subcortical conduction to reestablish its resistance.
I will desist from presenting in a similar manner more complicated cases
of the sexual process. I will merely formulate the statement that this
scheme can essentially be transferred to the woman despite the problem
of the perplexity, artificial retardation, and stunting of the female
sexual impulse. In the woman, too, it can be assumed that there is a
somatic sexual excitement and a state in which this excitement becomes
psychic, evoking libido and the impulse to specific action which is
accompanied by the sensual feeling. But we are unable to state what
analogy there may be in the woman to the unburdening of the seminal
vesicles.
We can bring into the bounds of this representation of the sexual
process the etiology of actual neurasthenia as well as of the anxiety
neurosis. Neurasthenia always originates whenever the adequate (action)
unburdening is replaced by a less adequate one, like the normal coitus
under the most favorable conditions, by a masturbation or spontaneous
pollution; while anxiety neurosis is produced by all moments which
impede the psychic elaboration of the somatic sexual excitement. The
manifestations of anxiety neurosis are brought about by the fact that
the somatic sexual excitement diverted from the psyche expends itself
subcortically in not at all adequate reactions.
I will now attempt to test the etiological determinants suggested before
in order to see whether they show the common character formulated by me.
As the first etiological moment for the man, I have mentioned
intentional abstinence. Abstinence consists in foregoing the specific
action which results from the libido. Such foregoing may have two
consequences, namely that the somatic excitement accumulates, and then,
what is more important, is the fact that it becomes diverted to another
route where there is more chance for discharge than through the psyche.
It will then finally diminish the libido and the excitement will
manifest itself subcortically as anxiety. Where the libido does not
become diminished, or the somatic excitement is expended in pollutions,
or where it really becomes exhausted in consequence of repulsion,
everything else except anxiety neurosis is formed. In this manner
abstinence leads to anxiety neurosis. But abstinence is also the active
process in the second etiological group of frustrated excitement. The
third case, that of the considerate coitus reservatus, acts through the
fact that it disturbs the psychic preparedness for the sexual discharge
by establishing beside the subjugation of the sexual affect, another
distracting psychic task. Through this psychic distraction, too, the
libido gradually disappears and the further course is then the same as
in the case of abstinence. The anxiety in old age (climacterium of men)
requires another explanation. Here the libido does not diminish, but
just as in the climacterium of women, such an increase takes place in
the somatic excitement that the psyche shows itself relatively
insufficient for the subjugation of the same.
The subsummation of the etiological determinants in the woman, under the
aspect mentioned, does not afford any greater difficulties. The case of
the virginal fear is especially clear. Here the group of ideas with
which the somatic sexual excitement should combine are not as yet
sufficiently developed. In anesthetically newly married the anxiety
appears only if the first cohabitations awakened a sufficient amount of
somatic excitement. Where the local signs of such excitability (like
spontaneous feelings of excitement, desire to micturate, etc.) are
lacking, the anxiety, too, stays away. The case of ejaculatio precox or
coitus interruptus is explained similarly to that in the man by the fact
that the libido gradually disappears in the psychically ungratified act,
whereas the excitement thereby evoked is subcortically expended. The
formation of an estrangement between the somatic and psychic in the
discharge of the sexual excitement succeeds quicker in the woman than in
the man and is more difficult to remove. The case of widowhood or
voluntary abstinence, as well as the case of climacterium adjusts itself
in the woman as in the man, but in the case of abstinence there surely
is in addition the intentional repression of the sexual ideas, for an
abstinent woman struggling with temptation must often decide to suppress
it. The abhorrence perceived by an elderly woman during her menopause
against the immensely increased libido can have a similar effect.
The two etiological determinants mentioned last can also be classified
without any difficulty.
The tendency to anxiety of the masturbator who becomes neurasthenic is
explained by the fact that these persons so easily merge into the state
of abstinence after they have for long been accustomed to afford a
discharge, to be sure an incorrect one, for every little quantity of
somatic excitement. Finally the last case, the origin of anxiety
neurosis through a severe illness, overwork, exhaustive nursing, etc.,
in addition to the efficacy of coitus interruptus readily permits a free
interpretation. Through deviation the psyche becomes here insufficient
for the subjugation of the somatic sexual excitement, a task which
continuously devolves upon it. We know how deeply the libido can sink
under the same conditions, and we have here a nice example of a neurosis
which although not of a sexual etiology still evinces a sexual
mechanism.
The conception here developed represents the symptoms of anxiety
neurosis in a measure as a substitute for the omitted specific action to
the sexual excitement. As a further corroboration of this I recall that
also in normal coitus the excitement expends itself in respiratory
acceleration, palpitation, perspiration, congestion, etc. In the
corresponding attack of anxiety of our neurosis we have before us the
dyspnoea, the palpitation, etc., of the coitus in an isolated and
aggravated manner.
It can still be asked why the nervous system merges into a peculiar
affective state of anxiety under the circumstances of psychic inadequacy
for the subjugation of the sexual excitement? A hint to the answer is as
follows: The psyche merges into the affect of fear when it perceives
itself unable to adjust an externally approaching task (danger) by
corresponding reaction; it merges into the neurosis of anxiety when it
finds itself unable to equalize the endogenously originated (sexual)
excitement. The psyche, therefore, behaves as if projecting this
excitement externally. The affect and the neurosis corresponding to it
stand in close relationship to each other; the first is the reaction to
an exogenous, the latter the reaction to an analogous endogenous
excitement. The affect is a rapidly passing state, the neurosis is
chronic because the exogenous excitement acts like a stroke happening
but once, while the endogenous acts like a constant force. The nervous
system reacts in the neurosis against an inner source of excitement just
as it does in the corresponding affect against an analogous external
one.
IV. THE RELATIONS TO OTHER NEUROSES.
A few observations still remain to be mentioned on the relations of the
anxiety neurosis to the other neuroses in reference to occurrence and
inner relationship.
The purest cases of anxiety neurosis are also usually the most
pronounced. They are found in potent young individuals with a uniform
etiology, and where the disease is not of long standing.
To be sure, the symptoms of anxiety are found more frequently as a
simultaneous and common occurrence with those of neurasthenia, hysteria,
compulsive ideas, and melancholia. If on account of such clinical
mixtures one hesitates in recognizing anxiety neurosis as an independent
unity, he will also have to abandon the laboriously acquired separation
of hysteria and neurasthenia.
For the analysis of the “mixed neuroses” I can advocate the following
proposition: Where a mixed neurosis exists, an involvement of many
specific etiologies can be demonstrated.
Such a multiplicity of etiological moments determining a mixed neurosis
can only come about accidentally, if the activities of a newly formed
injury are added to those already existing. Thus, for example, a woman
who was at all times a hysteric begins to practice coitus reservatus at
a certain period of her married life, and adds an anxiety neurosis to
her hysteria; a man who had masturbated and become neurasthenic, becomes
engaged and excites himself with his fiancée so that a fresh anxiety
neurosis allies itself to his neurasthenia.
The multiplicity of etiological moments in other cases is not
accidental, one of them has brought the other into activity. Thus a
woman, with whom her husband practices coitus reservatus without regard
to her gratification, finds herself forced to finish the tormenting
excitement following such an act with masturbation, as a result of which
she shows an anxiety neurosis with symptoms of neurasthenia. Under the
same noxiousness another woman has to contend with lewd pictures against
which she wishes to defend herself, and in this way the coitus
interruptus will cause her to acquire obsessions along with the anxiety
neurosis. Finally a third woman, as a result of coitus interruptus loses
her affection for her husband and forms another which she secretly
guards, and as a result she evinces a mixture of hysteria and anxiety
neurosis.
In a third category of mixed neuroses the connection of the symptoms is
of a still more intimate nature, as the same etiological determinants
regularly and simultaneously evoke both neuroses. Thus, for example, the
sudden sexual explanation which we have found in virginal fear always
produces hysteria, too; most causes of intentional abstinence connect
themselves in the beginning with actual obsessions; and it seems to me
that the coitus interruptus of men can never provoke a pure anxiety
neurosis, but always a mixture of the same with neurasthenia, etc.
It follows from this discussion that the etiological determinants of the
occurrence must moreover be distinguished from the specific etiological
moments of neurasthenia. The first moments, as for example the coitus
interruptus, masturbation, and abstinence, are still ambiguous, and can
each produce different neuroses; and it is only the etiological moments
abstracted from them, like the inadequate unburdening, psychic
insufficiency, and defense with substitution, that have an unambiguous
and specific relation to the etiology of the individual great neuroses.
In its intrinsic property, anxiety neurosis shows the most interesting
agreements and differences when compared with the other great neuroses,
particularly when compared with neurasthenia and hysteria. With
neurasthenia it shares one main character, namely, that the source of
excitement, the cause of the disturbance, lies in the somatic rather
than in the psychic sphere as in the case of hysteria and compulsion
neurosis. For the rest we can recognize a kind of contrast between the
symptoms of neurasthenia and anxiety neurosis, which can be expressed in
the catchwords, accumulation and impoverishment of excitement. This
contrast does not hinder the two neuroses from combining with each
other, but shows itself in the fact that the most extreme forms in both
cases are also the purest.
When compared with hysteria anxiety neurosis shows in the first place a
number of agreements in the symptomatology the valuation of which is
still unsettled. The appearance of the manifestations as persistent
symptoms or attacks, the aura-like grouped paresthesias, the
hyperesthesias and pressure points can be found in certain substitutes
for the anxiety attack, as in dyspnoea and palpitation, the aggravation
of the perhaps organically determined pains (by conversion)—these and
other joint features lead to the supposition that some things which are
ascribed to hysteria can with full authority be fastened to anxiety
neurosis. But if we enter into the mechanism of both neuroses, as far as
it can at present be penetrated, we find aspects which make it appear
that the anxiety neurosis is really the somatic counterpart to hysteria.
Here as there we have accumulation and excitement—on which is perhaps
based the similarity of the aforementioned symptoms—; here as there we
have a psychic insufficiency which results from abnormal somatic
processes; and here as there we have instead of a psychic elaboration a
deviation of the excitement into the somatic. The difference only lies
in the fact that the excitement, in which displacement the neurosis
manifests itself, is purely somatic (somatic sexual excitement) in
anxiety neurosis, while in hysteria it is psychic (evoked through a
conflict). Hence it is not surprising that hysteria and anxiety neurosis
lawfully combine with each other, as in the “virginal fear” or in the
“sexual hysteria,” and that hysteria simply borrows a number of symptoms
from anxiety neurosis, etc. This intimate relationship between anxiety
neurosis and hysteria furnishes us with a new argument for demanding the
separation of anxiety neurosis from hysteria, for if this be denied, one
will also be unable to maintain the so painstakingly acquired
distinction between neurasthenia and hysteria, so indispensable for the
theory of the neuroses.