Selected Papers on Hysteria and Other Psychoneuroses/Chapter 6

by Sigmund Freud

CHAPTER VI.
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 pseudo-neurasthenias, 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^[1] 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 is 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. Hyponchondria 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, dyspnea, 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.

5. "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 com.pulsively 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,^[2] 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.^[3]

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 combating 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 folic 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 folic du doute and similar ones, can clinically, if not notionally be attributed to anxiety neurosis.^

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^[4] has recently called attention in a small article. I believe, moreover, that Peyer's^[5] 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^[6] 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 numiber 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 wome —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 congressu 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 interrupts 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 he 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 note-worthy 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 reurosis 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 that 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 years 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.

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 reëstablish 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 sub-cortically 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 extends 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 fmds 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 fiancee 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.

1. E. Hecker, Über larvierte und abortive Angstzustände bei Neurasthenie, Centralblatt für Nervenheilkunde, December, 1893.—Anxiety is made particularly prominent among the chief symptoms of neurasthenia by Kaan, Der neurasthenische Angstafifekt bei Zwangsvorstellungen und der primordiale Grübelzwang, Wien, 1893.
2. Die Abwehr-Neuropsychosen, Neurol. Centralbl., 1894, Nr. 10 u. 11.
3. Obsession et phobies, Révue neurologique, 1895.
4. Moebius, Neuropathologische Beiträge, 1894, 2. Heft.
5. Peyer, Die nervösen Affektionen des Darmes, Wiener Klinik, Jänner, 1893.
6. Freud, Abwehr-Neuropsychosen.