Freud - Complete Works (60 page)

On The Grounds For Detaching A Particular Syndrome From Neurasthenia

333

   (7) On the basis of chronic
anxiousness (anxious expectation) on the one hand, and a tendency
to anxiety attacks accompanied by vertigo on the other, two groups
of typical phobias develop, the first relating to general
physiological dangers, the second relating to locomotion. To the
first group belong fear of snakes, thunderstorms, darkness, vermin,
and so on, as well as the typical moral over-scrupulousness and
forms of doubting mania. Here the available anxiety is simply
employed to reinforce aversions which are instinctively implanted
in everyone. But as a rule a phobia which acts in an obsessional
manner is only formed if there is added to this the recollection of
an experience in which the anxiety was able to find expression as,
for instance, after the patient has experienced a thunderstorm in
the open. It is a mistake to try to explain such cases as being
simply a persistence of strong impressions; what makes these
experiences significant and the memory of them lasting is, after
all, only the anxiety which was able to emerge at the time and
which can similarly emerge now. In other words, such impressions
remain powerful only in people with ‘anxious
expectation’.

   The other group includes
agoraphobia
with all its accessory forms, the whole of them
characterized by their relation to locomotion. We frequently find
that this phobia is based on an attack of vertigo that has preceded
it; but I do not think that one can postulate such an attack in
every case. Occasionally we see that after a first attack of
vertigo without anxiety, locomotion, although henceforward
constantly accompanied by a sensation of vertigo, still continues
to be possible without restriction; but that, under certain
conditions - such as being alone or in a narrow street - when once
anxiety is added to the attack of vertigo, locomotion breaks
down.

On The Grounds For Detaching A Particular Syndrome From Neurasthenia

334

   The relation of these phobias to
the phobias of obsessional neurosis, whose mechanism I made clear
in an earlier paper¹ in this periodical, is of the following
kind. What they have in common is that in both an idea becomes
obsessional as a result of being attached to an available affect.
The mechanism of
transposition of affect
thus holds good for
both kinds of phobia. But in the phobias of anxiety neurosis (1)
this affect always has the same colour, which is that of anxiety;
and (2) the affect does not originate in a repressed idea, but
turns out to be
not further reducible by psychological analysis,
nor amenable to psychotherapy
. The mechanism of
substitution
, therefore, does not hold good for the phobias
of anxiety neurosis.

   Both kinds of phobias (and also
obsessions) often appear side by side; although the
atypical
phobias, which are based on obsessions, need not necessarily spring
from the soil of anxiety neurosis. A very frequent and apparently
complicated mechanism makes its appearance if, in what was
originally a simple phobia belonging to an anxiety neurosis, the
content of the phobia is replaced by another idea, so that the
substitute is
subsequent
to the phobia. What are most often
employed as substitutes are the ‘
protective
measures
’ that were originally used to combat the phobia.
Thus, for instance, ’brooding mania’ arises from the
subject’s endeavours to disprove that he is mad, as his
hypochondriacal phobia maintains; the hesitations and doubt, and
still more the repetitions, of
folie du doute
arise from a
justifiable doubt about the certainty of one’s own train of
thought, since one is conscious of its persistent disturbance by
ideas of an obsessional sort, and so on. We can therefore assert
that many syndromes, too, of obsessional neurosis, such as
folie
du doute
and the like, are also to be reckoned, clinically if
not conceptually, as belonging to anxiety neurosis.²

  
¹
‘The Neuro-Psychoses of
Defence’ (1894
a
).

  
²
See ‘Obsessions and Phobias’
(1895
c
).

On The Grounds For Detaching A Particular Syndrome From Neurasthenia

335

   (8) The digestive activities
undergo only a few disturbances in anxiety neurosis; but these are
characteristic ones. Sensations such as an inclination to vomit and
nausea are not rare, and the symptom of ravenous hunger may, by
itself or in conjunction with other symptoms (such as congestions),
give rise to a rudimentary anxiety attack. As a chronic change,
analogous to anxious expectation, we find an inclination to
diarrhoea, and this has been the occasion of the strangest
diagnostic errors. Unless I am mistaken, it is this diarrhoea to
which Möbius (1894) has drawn attention recently in a short
paper. I suspect, further, that Peyer’s reflex diarrhoea,
which he derives from disorders of the prostate (Peyer, 1893), is
nothing else than this diarrhoea of anxiety neurosis. The illusion
of a reflex relationship is created because the same factors come
into play in the aetiology of anxiety neurosis as are at work in
the setting up of such affections of the prostate and similar
disorders.

   The behaviour of the
gastro-intestinal tract in anxiety neurosis presents a sharp
contrast to the influence of neurasthenia on those functions. Mixed
cases often show the familiar ‘alternation between diarrhoea
and constipation’. Analogous to this diarrhoea is the need to
urinate that occurs in anxiety neurosis.

   (9) The
paraethesias
which
may accompany attacks of vertigo or anxiety are interesting because
they, like the sensations of the hysterical aura, become associated
in a definite sequence; although I find that these associations, in
contrast to the hysterical ones, are atypical and changing. A
further similarity to hysteria is provided by the fact that in
anxiety neurosis a kind of
conversion
¹ takes place on
to bodily sensations, which may easily be overlooked - for
instance, on to rheumatic muscles. A whole number of what are known
as rheumatic individuals who, moreover, can be shown to
be
rheumatic - are in reality suffering from anxiety neurosis. Along
with this increase of sensitivity to pain, I have also observed in
a number of cases of anxiety neurosis a tendency to
hallucinations
; and these could not be interpreted as
hysterical.

   (10)  Several of the
symptoms I have mentioned, which accompany or take the place of an
anxiety attack, also appear in a chronic form. In that case they
are still less easy to recognize, since the anxious sensation which
goes with them is less clear than in an anxiety attack. This is
especially true of diarrhoea, vertigo and paraesthesias. Just as an
attack of vertigo can be replaced by a fainting fit, so chronic
vertigo can be replaced by a constant feeling of great feebleness,
lassitude and so on.

  
¹
See ‘The Neuro-Psychoses of
Defence’ (1894
a
).

On The Grounds For Detaching A Particular Syndrome From Neurasthenia

336

II

INCIDENCE AND AETIOLOGY OF ANXIETY
NEUROSIS

   In some cases of anxiety neurosis
no aetiology at all is to be discovered. It is worth noting that in
such cases there is seldom any difficulty in establishing evidence
of a grave hereditary taint.

   But where there are grounds for
regarding the neurosis as an
acquired
one, careful enquiry
directed to that end reveals that a set of noxae and influences
from
sexual life
are the operative aetiological factors.
These appear at first sight to be of a varied nature, but they soon
disclose the common character which explains why they have a
similar effect on the nervous system. Further, they are present
either alone or together with other noxae of a ‘stock’
kind, to which we may ascribe a contributory effect. This sexual
aetiology of anxiety neurosis can be demonstrated with such
overwhelming frequency that I venture,
for the purpose of this
short paper
, to disregard those cases where the aetiology is
doubtful or different.

   In order that the aetiological
conditions under which anxiety neurosis makes its appearance may be
presented with greater accuracy, it will be advisable to consider
males and females separately. In females - disregarding for the
moment their innate disposition - anxiety neurosis occurs in the
following cases:

   (
a
) As
virginal
anxiety
or
anxiety in adolescents
. A number of
unambiguous observations have shown me that anxiety neurosis can be
produced in girls who are approaching maturity by their first
encounter with the problem of sex, by any more or less sudden
revelation of what had till then been hidden - for instance, by
witnessing the sexual act, or being told or reading about these
things. Such an anxiety neurosis is combined with hysteria in an
almost typical fashion.

On The Grounds For Detaching A Particular Syndrome From Neurasthenia

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   (
b
) As
anxiety in the
newly married
. Young married women who have remained
anaesthetic during their first cohabitations not seldom fall ill of
an anxiety neurosis, which disappears once more as soon as the
anaesthesia gives place to normal sensitivity. Since most young
wives remain healthy where there is initial anaesthesia of this
kind, it follows that, in order that this kind of anxiety shall
emerge, other determinants are required; and these I will mention
later.

   (
c
) As anxiety in women
whose husbands suffer from ejaculatio praecox or from markedly
impaired potency; and (
d
) whose husbands practise coitus
interruptus or reservatus. These cases belong together, for on
analysing a great number of instances it is easy to convince
oneself that they depend simply on whether the woman obtains
satisfaction in coitus or not. If not, the condition for the
genesis of an anxiety neurosis is given. On the other hand, she is
saved from the neurosis if the husband who is affected with
ejaculatio praecox is able immediately to repeat coitus with better
success. Coitus reservatus
by means of condoms
is not
injurious to the woman, provided she is very quickly excitable and
the husband very potent; otherwise, this kind of preventive
intercourse is no less injurious than the others. Coitus
interruptus is nearly always a noxa. But for the wife it is only so
if the husband practises it regardlessly - that is to say, if he
breaks off intercourse as soon as
he
is near emission,
without troubling himself about the course of the excitation in
her
. If, on the other hand, the husband waits for his
wife’s satisfaction, the coitus amounts to a normal one for
her
; but
he
will fall ill of an anxiety neurosis. I
have collected and analysed a large number of observations, on
which these assertions are based.

   (
e
)  Anxiety neurosis
also occurs as anxiety in
widows
and intentionally
abstinent women
, not seldom in a typical combination with
obsessional ideas; and

   (
f
) As anxiety in the
climacteric
during the last major increase of sexual
need.

On The Grounds For Detaching A Particular Syndrome From Neurasthenia

338

   Cases (
c
) (
d
) and
(
e
) comprise the conditions under which anxiety neurosis in
the female sex arises most frequently and most readily,
independently of hereditary disposition. It is in reference to
these cases of anxiety neurosis - these curable acquired cases -
that I shall try to show that the sexual noxae discovered in them
are really the aetiological factor of the neurosis.

   Before doing so, however, I will
discuss the sexual determinants of anxiety neurosis in
men
.
I propose to distinguish the following groups, all of which have
their analogies in women:

   (
a
)  Anxiety of
intentionally
abstinent
men, which is frequently combined
with symptoms of
defence
(obsessional ideas, hysteria). The
motives which are responsible for intentional abstinence imply that
a number of people with a hereditary disposition, eccentrics, etc.,
enter into this category.

   (
b
) Anxiety in men in a
state of
unconsummated excitation
(e.g. during the period of
engagement before marriage), or in those who (from fear of the
consequences of sexual intercourse) content themselves with
touching or looking at women. This group of determinants - which,
incidentally, can be applied unaltered to the other sex (during
engagements or relations in which sexual intercourse is avoided) -
provides the purest cases of the neurosis.

   (
c
) Anxiety in men who
practise coitus interruptus. As has been said, coitus interruptus
is injurious to the
woman
if it is practised without regard
to her satisfaction; but it is injurious to the
man
if, in
order to obtain satisfaction for her, he directs coitus voluntarily
and postpones emission. In this way it becomes intelligible that
when a married couple practise coitus interruptus, it is, as a
rule, only
one
partner who falls ill. Moreover, in men
coitus interruptus only rarely produces a pure anxiety neurosis; it
usually produces a mixture of anxiety neurosis and
neurasthenia.