Freud - Complete Works (59 page)

   This question may be answered by
reference to the theory of the genesis of hysterical symptoms
developed by Breuer and myself.¹ Here I will only remark that,
by the very fact of the substitution, the disappearance of the
emotional state is rendered impossible.

  
¹
Cf. the German popular song:

               
Auf jedes weisse Blatt Papier möcht’ ich es
schreiben:

               
Dein ist mein Herz und soll es ewig, ewig bleiben.

Obsessions And Phobias

323

II

   In addition to these two groups
of true obsessions there is the class of ‘phobias’,
which must now be considered. I have already mentioned the great
difference between obsessions and phobias: that in the latter the
emotion is always one of anxiety, fear. I might add that obsessions
are varied and more specialized, phobias are more monotonous and
typical. But this distinction is not of capital importance.

   Among the phobias, also, two
groups may be differentiated, according to the nature of the object
feared: (1) common phobias, an exaggerated fear of things that
everyone detests or fears to some extent: such as night, solitude,
death, illnesses, dangers in general, snakes, etc. (2) contingent
phobias, the fear of special conditions that inspire no fear in the
normal man; for example, agoraphobia and the other phobias of
locomotion. It is interesting to note that these phobias have not
the obsessive feature that characterizes true obsessions and the
common phobias. The emotional state appears in their instance only
under special conditions which the patient carefully avoids.

   The mechanism of phobias is
entirely different from that of obsessions. Substitution is no
longer the predominant feature in the former; psychological
analysis reveals no incompatible, replaced idea in them. Nothing is
ever found but
the emotional state of anxiety
which, by a
kind of selective process, brings up all the ideas adapted to
become the subject of a phobia. In the case of agoraphobia, etc.,
we often find
the recollection of an anxiety attack
; and
what the patient actually fears is the occurrence of such an attack
under the special conditions in which he believes he cannot escape
it.

  
¹
‘On the Psychical Mechanism of
Hysterical Phenomena’ (1893
a
)

Obsessions And Phobias

324

   The anxiety belonging to this
emotional state, which underlies all phobias, is not derived from
any memory; we may well wonder what the source of this powerful
condition of the nervous system can be.

   I hope to be able to demonstrate,
on another occasion, that there is reason to distinguish a special
neurosis, the ‘anxiety neurosis’, of which the chief
symptom is this emotional state. I shall then enumerate its various
symptoms and insist on the necessity for differentiating this
neurosis from neurasthenia, with which it is now confused.
Phobias
, then,
are part of the anxiety neurosis
, and
are almost always accompanied by other symptoms of the same
group.

  
The anxiety neurosis
, too,
has a sexual origin
as far as I can see, but it does not
attach itself to ideas taken from sexual life; properly speaking,
it has no psychical mechanism. Its specific cause is the
accumulation of sexual tension, produced by abstinence or by
unconsummated sexual excitation (using the term as a general
formula for the effects of, of relative impotence in the husband,
of excitation without satisfaction in engaged couples, of enforced
abstinence, etc.).

   It is under such conditions,
extremely frequent in modern society, especially among women, that
anxiety neurosis (of which phobias are a psychical manifestation)
develops.

   In conclusion I may point out
that combinations of a phobia and an obsession proper may co-exist,
and that indeed this is a very frequent occurrence. We may find
that a phobia had developed at the beginning of the disease as a
symptom of anxiety neurosis. The idea which constitutes the phobia
and which is associated with the state of fear may be replaced by
another idea or rather by the
protective procedure
that
seemed to relieve the fear. Case 7 (obsessive speculating) presents
a neat example of this group: a
phobia along with a true
substitutive obsession
.

325

ON THE GROUNDS FOR DETACHING A PARTICULAR SYNDROME FROM

NEURASTHENIA UNDER THE DESCRIPTION ‘ANXIETY NEUROSIS’

(1895)

326

Intentionally left blank

327

ON THE GROUNDS FOR DETACHING A PARTICULAR SYNDROME FROM

NEURASTHENIA UNDER THE DESCRIPTION
‘ANXIETY NEUROSIS’

It is difficult to make any statement of
general validity about neurasthenia, so long as we use that name to
cover all the things which Beard has included under it. In my
opinion, it can be nothing but a gain to neuropathology if we make
an attempt to separate from neurasthenia proper all those neurotic
disturbances in which, on the one hand, the symptoms are more
firmly linked to one another than to the typical symptoms of
neurasthenia (such as intracranial pressure, spinal irritation, and
dyspepsia with flatulence and constipation ); and which, on the
other hand, exhibit essential differences in their aetiology and
mechanism from the typical neurasthenic neurosis. If we accept this
plan, we shall soon obtain a fairly uniform picture of
neurasthenia. We shall then be in a position to differentiate from
genuine neurasthenia more sharply than has hitherto been possible
various pseudo-neurasthenias (such as the clinical picture of the
organically determined nasal reflex neurosis, the nervous disorders
of the cachexias and arterio-sclerosis, the preliminary stages of
general paralysis of the insane, and of some psychoses). Further,
it will be possible - as Möbius has proposed - to eliminate
some of the
status nervosi
of hereditarily degenerate
individuals; and we shall also discover reasons why a number of
neuroses which are to-day described as neurasthenia - in
particular, neuroses of an intermittent or periodical nature -
ought rather to be included under melancholia. But the most marked
change of all will be introduced if we decide to detach from
neurasthenia the syndrome which I propose to describe in the
following pages and which satisfies especially fully the conditions
set out above. The symptoms of this syndrome are clinically much
more closely related to one another than to those of genuine
neurasthenia (that is, they frequently appear together and they
replace one another in the course of the illness); and both the
aetiology and the mechanism of this neurosis are fundamentally
different from the aetiology and mechanism of genuine neurasthenia
as it will be left after this separation has been effected.

On The Grounds For Detaching A Particular Syndrome From Neurasthenia

328

   I call this syndrome
‘anxiety neurosis’, because all its components can be
grouped round the chief symptom of anxiety, because each one of
them has a definite relationship to anxiety. I thought that this
view of the symptoms of anxiety neurosis had originated with me,
until an interesting paper by E. Hecker (1893) came into my hands,
in which I found the same interpretation expounded with all the
clarity and completeness that could be desired.¹ Nevertheless,
although Hecker recognizes certain symptoms as equivalents or
rudiments of an anxiety attack, he does not separate them from the
domain of neurasthenia, as I propose to do. But this is evidently
due to his not having taken into account the difference between the
aetiological determinants in the two cases. When this latter
difference is recognized there is no longer any necessity for
designating anxiety symptoms by the same name as genuine
neurasthenic ones; for the principal purpose of giving what is
otherwise an arbitrary name is to make it easier to lay down
general statements.

  
¹
Anxiety is actually brought forward as one
of the principal symptoms of neurasthenia in a work by Kaan
(1893).

On The Grounds For Detaching A Particular Syndrome From Neurasthenia

329

I

THE CLINICAL SYMPTOMATOLOGY OF ANXIETY
NEUROSIS

   What I call ‘anxiety
neurosis’ may be observed in a completely developed form or
in a rudimentary one, in isolation or combined with other neuroses.
It is of course the cases which are in some degree complete and at
the same time isolated which give particular support to the
impression that anxiety neurosis is a clinical entity. In other
cases, where the syndrome corresponds to a ‘mixed
neurosis’, we are faced with the task of picking out and
separating those symptoms which belong, not to neurasthenia or
hysteria, and so on, but to anxiety neurosis.

   The clinical picture of anxiety
neurosis comprises the following symptoms:

   (1)
General irritability
.
This is a common nervous symptom and as such belongs to many
status nervosi
. I mention it here because it invariably
appears in anxiety neurosis and is important theoretically.
Increased irritability always points to an accumulation of
excitation or an inability to tolerate such an accumulation - that
is, to an
absolute
or a
relative
accumulation of
excitation. One manifestation of this increased irritability seems
to me to deserve special mention; I refer to
auditory
hyperaesthesia
, to an oversensitiveness to noise - a symptom
which is undoubtedly to be explained by the innate intimate
relationship between auditory impressions and fright. Auditory
hyperaesthesia frequently turns out to be a cause of sleeplessness,
of which more than one form belongs to anxiety neurosis.

   (2)
Anxious expectation
. I
cannot better describe the condition I have in mind than by this
name and by adding a few examples. A woman, for instance, who
suffers from anxious expectation will think of influenzal pneumonia
every time her husband coughs when he has a cold, and, in her
mind’s eye, will see his funeral go past; if, when she is
coming towards the house, she sees two people standing by her front
door, she cannot avoid thinking that one of her children has fallen
out of the window; when she hears the bell ring, it is someone
bringing news of a death, and so on - while on all these occasions
there has been no particular ground for exaggerating a mere
possibility.

On The Grounds For Detaching A Particular Syndrome From Neurasthenia

330

   Anxious expectation, of course,
shades off imperceptibly into normal anxiety, comprising all that
is ordinarily spoken of as anxiousness - or a tendency to take a
pessimistic view of things; but at every opportunity it goes beyond
a plausible anxiousness of this kind, and it is frequently
recognized by the patient himself as a kind of compulsion. For one
form of anxious expectation - that relating to the subject’s
own health - we may reserve the old term
hypochondria
. The
height reached by the hypochondria is not always parallel with the
general anxious expectation; it requires as a precondition the
existence of paraesthesias and distressing bodily sensations. Thus
hypochondria is the form favoured by genuine neurasthenics when, as
often happens, they fall victims to anxiety neurosis.

   A further expression of anxious
expectation is no doubt to be found in the inclination to
moral
anxiety
, to scrupulousness and pedantry - an inclination which
is so often present in people with more than the usual amount of
moral sensitiveness and which likewise varies from the normal to an
exaggerated form in
doubting mania
.

   Anxious expectation is the
nuclear symptom of the neurosis. It openly reveals, too, a portion
of the theory of the neurosis. We may perhaps say that here a
quantum of anxiety in a freely floating state
, which, where
there is expectation, controls the choice of ideas and is always
ready to link itself with any suitable ideational content.

   (3) But anxiousness - which,
though mostly latent as regards consciousness, is constantly
lurking in the background - has other means of finding expression
besides this. It can suddenly break through into consciousness
without being aroused by a train of ideas, and thus provoke an
anxiety attack. An anxiety attack of this sort may consist of the
feeling of anxiety, alone, without any associated idea, or
accompanied by the interpretation that is nearest to hand, such as
ideas of the extinction of life, or of a stroke, or of a threat of
madness; or else some kind of paraesthesia (similar to the
hysterical aura) may be combined with the feeling of anxiety, or,
finally, the feeling of anxiety may have linked to it a disturbance
of one or more of the bodily functions - such as respiration, heart
action, vasomotor innervation or glandular activity. From this
combination the patient picks out in particular now one, now
another, factor. He complains of ‘spasms of the heart’,
‘difficulty in breathing’, ‘outbreaks of
sweating’, ‘ravenous hunger’, and such like; and,
in his description, the feeling of anxiety often recedes into the
background or is referred to quite unrecognizably as ‘being
unwell’, ‘feeling uncomfortable’, and so on.

On The Grounds For Detaching A Particular Syndrome From Neurasthenia

331

   (4) Now it is an interesting
fact, and an important one from a diagnostic point of view, that
the proportion in which these elements are mixed in an anxiety
attack varies to a remarkable degree, and that almost every
accompanying symptom alone can constitute the attack just as well
as can the anxiety itself. There are consequently
rudimentary
anxiety attacks
and
equivalents of anxiety attacks
, all
probably having the same significance, which exhibit a great wealth
of forms that has as yet been little appreciated. A closer study of
these larval anxiety-states (as Hecker calls them) and their
diagnostic differentiation from other attacks should soon become a
necessary task for neuropathologists.

   I append here a list which
includes only those forms of anxiety attack which are known to
me:-

   (
a
) Anxiety attacks
accompanied by disturbances of the
heart action
, such as
palpitation, either with transitory arrhythmia or with tachycardia
of longer duration which may end in serious weakness of the heart
and which is not always easily differentiated from organic heart
affection; and, again, pseudo-angina pectoris - diagnostically a
delicate subject!

   (
b
) Anxiety attacks
accompanied by
disturbances of respiration
, several forms of
nervous dyspnoea, attacks resembling asthma, and the like. I would
emphasize that even these attacks are not always accompanied by
recognizable anxiety.

   (
c
) Attacks of
sweating
, often at night.

   (
d
) Attacks of
tremor
and
shivering
which are only too easily
confused with hysterical attacks.

   (
e
) Attacks of
ravenous
hunger
, often accompanied by vertigo.

   (
f
) Diarrhoea coming on in
attacks.

   (
g
) Attacks of locomotor
vertigo
.

   (
h
) Attacks of what are
known as
congestions
, including practically everything that
has been termed vasomotor neurasthenia.

   (
i
) Attacks of
paraesthesias
. (But these seldom occur without anxiety or a
similar feeling of discomfort.)

On The Grounds For Detaching A Particular Syndrome From Neurasthenia

332

   (5)
Waking up at night in a
fright
(the
pavor nocturnus
of adults), which is usually
combined with anxiety, dyspnoea, sweating and so on, is very often
nothing else than a variant of the anxiety attack. This disturbance
is the determinant of a second form of sleeplessness within the
field of anxiety neurosis. I have become convinced, moreover, that
the
pavor nocturnus
of children, too, exhibits a form which
belongs to anxiety neurosis. The streak of hysteria about it, the
linking of the anxiety with the reproduction of an appropriate
experience or a dream, causes the
pavor nocturnus
of
children to appear as something special. But the
pavor
can
also emerge in a pure form, without any dream or recurring
hallucination.

   (6) ‘
Vertigo
’
occupies a prominent place in the group of symptoms of anxiety
neurosis. In its mildest form it is best described as
‘giddiness’; in its severer manifestations, as
‘attacks of vertigo’ (with or without anxiety), it must
be classed among the gravest symptoms of the neurosis. The vertigo
of anxiety neurosis is not rotatory nor does it especially affect
certain planes or directions, like Meniere’s vertigo. It
belongs to the class of locomotor or co-ordinatory vertigo, as does
the vertigo in oculomotor paralysis. It consists in a specific
state of discomfort, accompanied by sensations of the ground
rocking, of the legs giving way and of its being impossible to
stand up any more; while the legs feel as heavy as lead and tremble
or the knees bend. This vertigo never leads to a fall. On the other
hand, I should like to state that an attack of vertigo of this kind
may have its place taken by a profound fainting fit. Other
conditions in the nature of fainting occurring in anxiety neurosis
appear to depend upon cardiac collapse.

   Attacks of vertigo are not seldom
accompanied by the worst sort of anxiety, often combined with
cardiac and respiratory disturbances. According to my observations,
vertigo produced by heights, mountains and precipices is also often
present in anxiety neurosis. Furthermore, I am not sure whether it
is not also right to recognize alongside of this a
vertigo a
stomacho laeso
.