Freud - Complete Works (61 page)

   (
d
) Anxiety in
senescent
men. There are men who have a climacteric like
women, and who produce an anxiety neurosis at the time of their
decreasing potency and increasing libido.

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339

   Finally, I must add two other
cases which apply to both sexes:

   (
a
) People who, as a result
of practising masturbation, have become neurasthenics, fall victims
to anxiety neurosis as soon as they give up their form of sexual
satisfaction. Such people have made themselves particularly
incapable of tolerating abstinence.

   I may note here, as being
important for an understanding of anxiety neurosis, that any
pronounced development of that affection only occurs among men who
have remained potent and women who are not anaesthetic. Among
neurotics whose potency has already been severely damaged by
masturbation, the anxiety neurosis resulting from abstinence is
very slight and is mostly restricted to hypochondria and mild
chronic vertigo. The majority of women, indeed, are to be regarded
as ‘potent’; a really impotent - i.e. a really
anaesthetic - woman is in a similar way little susceptible to
anxiety neurosis, and she tolerates the noxae I have described
remarkably well.

   How far, in addition to this, we
are justified in postulating any constant relation between
particular aetiological factors and particular symptoms in the
complex of anxiety neurosis, I should not like to discuss as yet in
this paper.

   (
b
) The last of the
aetiological conditions I have to bring forward appears at first
sight not to be of a sexual nature at all. Anxiety neurosis also
arises - and in both sexes - as a result of the factor of overwork
or exhausting exertion - as, for instance, after night-watching,
sick-nursing, or even after severe illness.

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   The main objection to my
postulate of a sexual aetiology for anxiety neurosis will probably
be to the following effect. Abnormal conditions in sexual life of
the kind I have described are found so extremely frequently that
they are bound to be forthcoming wherever one looks for them. Their
presence in the cases of anxiety neurosis which I have enumerated
does not, therefore, prove that we have unearthed in them the
aetiology of the neurosis. Moreover, the number of people who
practise coitus interruptus and the like is incomparably larger
than the number who are afflicted with anxiety neurosis, and the
great majority of the former tolerate this noxa very well.

   To this I must reply in the first
place that, considering the admittedly enormous frequency of the
neuroses and especially of anxiety neurosis, it would certainly not
be right to expect to find an aetiological factor for them that is
of
rare
occurrence; in the second place, that a postulate of
pathology is in fact satisfied, if in an aetiological investigation
it can be shown that the
presence
of an aetiological factor
is more frequent than its effects, since, in order for these latter
to occur, other conditions may have to exist in addition ( such as
disposition, summation of specific aetiological elements, or
reinforcement by other stock noxae); and further, that a detailed
dissection of suitable cases of anxiety neurosis proves beyond
question the importance of the sexual factor. I will confine myself
here, however, to the single aetiological factor of coitus
interruptus and to bringing out certain observations which confirm
it.

   (1) So long as an anxiety
neurosis in young married women is not yet established, but only
appears in bouts and disappears again spontaneously, it is possible
to demonstrate that each such bout of the neurosis is traceable to
a coitus which was deficient in satisfaction. Two days after this
experience - or, in the case of people with little resistance, the
day after - the attack of anxiety or vertigo regularly appears,
bringing in its train other symptoms of the neurosis. All this
vanishes once more, provided that marital intercourse is
comparatively rare. A chance absence of the husband from home, or a
holiday in the mountains which necessitates a separation of the
couple, has a good effect. The gynaecological treatment which is
usually resorted to in the first instance is beneficial because,
while it lasts, marital intercourse is stopped. Curiously enough
the success of local treatment is only transitory: the neurosis
sets in again in the mountains, as soon as the husband begins his
holiday too; and so on. If, as a physician who understands this
aetiology, one arranges, in a case in which the neurosis has not
yet been established, for coitus interruptus to be replaced by
normal intercourse, one obtains a
therapeutic
proof of the
assertion I have made. The anxiety is removed, and - unless there
is fresh cause for it of the same sort - it does not return.

   (2) In the anamneses of many
cases of anxiety neurosis we find, both in men and women, a
striking oscillation in the intensity of its manifestations, and,
indeed, in the coming and going of the whole condition. One year,
they will tell you, was almost entirely good, but the next one was
dreadful; on one occasion the improvement seemed to be due to a
particular treatment, which, however, turned out to be quite
useless at the next attack; and so on. If we enquire into the
number and sequence of the children and compare this record of the
marriage with the peculiar history of the neurosis, we arrive at
the simple solution that the periods of improvement or good health
coincided with the wife’s pregnancies, during which, of
course, the need for preventive intercourse was no longer present.
The husband benefited by the treatment after which he found his
wife pregnant - whether he received it from Pastor Kneipp or at a
hydropathic establishment.

   (3) The anamnesis of patients
often discloses that the symptoms of anxiety neurosis have at some
definite time succeeded the symptoms of some other neurosis -
neurasthenia, perhaps - and have taken their place. In these
instances it can quite regularly be shown that, shortly before this
change of the picture, a corresponding change has occurred in the
form of the sexual noxa.

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   Observations of this sort, which
can be multiplied at will, positively thrust a sexual aetiology on
the doctor for a certain category of cases. And other cases, which
would otherwise remain unintelligible, can at least be understood
and classified without inconsistency by employing that aetiology as
a key. I have in mind those very numerous cases in which, it is
true, everything is present that has been found in the previous
category - on the one hand the manifestations of anxiety neurosis,
and on the other the specific factor of coitus interruptus - but in
which something else as well intrudes itself: namely, a long
interval between the presumed aetiology and its effects, and also
perhaps aetiological factors that are not of a sexual nature. Take,
for instance, a man who, on receiving news of his father’s
death, had a heart attack and from that moment fell a victim to an
anxiety neurosis. The case is not comprehensible, for, till then,
the man was not neurotic. The death of his father, who was well
advanced in years, did not take place under in any way special
circumstances, and it will be admitted that the normal and expected
decease of an aged father is not one of those experiences which
usually cause a healthy adult to fall ill. Perhaps the aetiological
analysis will become clearer if I add that this man had been
practising coitus interruptus for eleven years, with due
consideration for his wife’s satisfaction. The clinical
symptoms are, at least, exactly the same as those which appear in
other people after only a short sexual noxa of the same kind, and
without the interpolation of any other trauma. A similar assessment
must be made of the case of a woman whose anxiety neurosis broke
out after the loss of her child, or of the student whose
preparatory studies for his final examination were interfered with
by an anxiety neurosis. I think that in these instances, too, the
effect is not explained by the ostensible aetiology. One is not
necessarily ‘overworked’ by study, and a healthy mother
as a rule reacts only with normal grief to the loss of a child.
Above all, however, I should have expected the student, as a result
of his overwork, to acquire cephalasthenia, and the mother, as a
result of her bereavement, hysteria. That both should have been
overtaken by anxiety neurosis leads me to attach importance to the
fact that the mother had been living for eight years in conditions
of marital coitus interruptus, and that the student had for three
years had an ardent love affair with a ‘respectable’
girl whom he had to avoid making pregnant.

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   These considerations lead us to
the conclusion that the specific sexual noxa of coitus interruptus,
even when it is not able on its own account to provoke an anxiety
neurosis in the subject, does at least
provoke
him to
acquire it. The anxiety neurosis breaks out as soon as there is
added to the latent effect of the specific factor the effect of
another, stock noxa. The latter can act in the sense of the
specific factor quantitatively but cannot replace it qualitatively.
The specific factor always remains decisive for the
form
taken by the neurosis. I hope to be able to prove this assertion
concerning the aetiology of the neuroses more comprehensively
too.

   In addition, these latter remarks
contain an assumption which is not in itself improbable, to the
effect that a sexual noxa like coitus interruptus comes into force
through summation. A shorter or longer time is needed - depending
on the individual’s disposition and any other inherited
weaknesses of his nervous system - before the effect of this
summation becomes visible. Those individuals who apparently
tolerate coitus interruptus without harm, in fact become disposed
by it to the disorders of anxiety neurosis, and these may break out
at some time or other, either spontaneously or after a stock trauma
which would not ordinarily suffice for this; just as, by the path
of summation, a chronic alcoholic will in the end develop a
cirrhosis or some other illness, or will, under the influence of a
fever, fall a victim to delirium.

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III

FIRST STEPS TOWARD A THEORY OF ANXIETY
NEUROSIS

   The following theoretical
discussion can only claim to have the value of a first, groping
attempt; criticism of it ought not to affect an acceptance of the
facts
which have been brought forward above. Moreover, an
assessment of this ‘theory of anxiety neurosis’ is made
the more difficult from being only a fragment of a more
comprehensive account of the neuroses.

   What we have so far said about
anxiety neurosis already provides a few starting points for gaining
an insight into the mechanism of this neurosis. In the first place
there was our suspicion that we had to do with an accumulation of
excitation; and then there was the extremely important fact that
the anxiety which underlies the clinical symptoms of the neurosis
can be traced to
no psychical origin
. Such an origin would
exist, for instance, if it was found that the anxiety neurosis was
based on a single or repeated justifiable fright, and that that
fright had since provided the source for the subject’s
readiness for anxiety. But this is not so. Hysteria or a traumatic
neurosis can be acquired from a single fright, but never anxiety
neurosis. Since coitus interruptus takes such a prominent place
among the causes of anxiety neurosis, I thought at first that the
source of the continuous anxiety might lie in the fear, recurring
every time the sexual act was performed, that the technique might
go wrong and conception consequently take place. But I have found
that this state of feeling, either in the man or the woman, during
coitus interruptus has no influence on the generation of anxiety
neurosis, that women who are basically indifferent about the
consequence of a possible conception are just as liable to the
neurosis as those who shudder at the possibility, and that
everything depends simply on which partner has forfeited
satisfaction in this sexual technique.

   A further point of departure is
furnished by the observation, not so far mentioned, that in whole
sets of cases anxiety neurosis is accompanied by a most noticeable
decrease of sexual libido or
psychical desire
, so that on
being told that their complaint results from ‘insufficient
satisfaction’, patients regularly reply that that is
impossible, for precisely now all sexual need has become
extinguished in them. From all these indications - that we have to
do with an accumulation of excitation; that the anxiety which
probably corresponds to this accumulated excitation is of somatic
origin, so that what is being accumulated is a
somatic
excitation; and, further, that this somatic excitation is of a
sexual nature and that a decrease of
psychical
participation
in the sexual processes goes along with it - all these indications,
I say, incline us to expect that
the mechanism of anxiety is to
be looked for in a deflection of somatic excitation from the
psychical sphere, and in a consequent abnormal employment of that
excitation
.