Freud - Complete Works (63 page)

   As regards its intimate nature,
anxiety neurosis presents the most interesting agreements with, and
differences from, the other major neuroses, in particular
neurasthenia and hysteria. It shares with neurasthenia one main
characteristic - namely that the source of excitation, the
precipitating cause of the disturbance, lies in the somatic field
instead of the psychical one, as is the case in hysteria and
obsessional neurosis. In other respects we rather find a kind of
antithesis between the symptoms of anxiety neurosis and of
neurasthenia, which might be brought out by such labels as
‘accumulation of excitation’ and ‘impoverishment
of excitation’. This antithesis does not prevent the two
neuroses from being intermixed with each other; but it nevertheless
shows itself in the fact that the most extreme forms of each are in
both cases also the purest.

   The symptomatology of hysteria
and anxiety neurosis show many points in common which have not yet
been sufficiently considered. The appearance of symptoms either in
a chronic form or in attacks, the paraesthesias, grouped like
aurae, the hyperaesthesias and pressure-points which are found in
certain surrogates of an anxiety attack (in dyspnoea and
heart-attacks), the intensification, through conversion, of pains
which perhaps have an organic justification - these and other
features which the two illnesses have in common even allow of a
suspicion that not a little of what is attributed to hysteria might
with more justice be put to the account of anxiety neurosis. If one
goes into the mechanism of the two neuroses, so far as it has been
possible to discover it hitherto, aspects come to light which
suggest that anxiety neurosis is actually the somatic counterpart
to hysteria. In the latter just as in the former there is an
accumulation of excitation (which is perhaps the basis for the
similarity between their symptoms we have mentioned). In the latter
just as in the former we find a
psychical insufficiency, as a
consequence of which abnormal somatic processes arise
. In the
latter just as in the former, too, instead of a psychical
working-over of the excitation, a deflection of it occurs into the
somatic field; the difference is merely that in anxiety neurosis
the excitation, in whose displacement the neurosis expresses
itself, is purely somatic (somatic sexual excitation), whereas in
hysteria it is psychical (provoked by conflict). Thus it is not to
be wondered at that hysteria and anxiety neurosis regularly combine
with each other, as is seen in ‘virginal anxiety’ or in
‘sexual hysteria’, and that hysteria simply borrows a
number of its symptoms from anxiety neurosis, and so on. These
intimate relations which anxiety neurosis has with hysteria provide
a fresh argument, moreover, for insisting on the detachment of
anxiety neurosis from neurasthenia; for if this detachment is not
granted, we shall also be unable any longer to maintain the
distinction which has been acquired with so much labour and which
is so indispensable for the theory of the neuroses, between
neurasthenia and hysteria.

VIENNA
,
December
1894.

350

A REPLY TO CRITICISMS OF MY PAPER ON
ANXIETY NEUROSIS

(1895)

351

Intentionally left blank

352

A REPLY TO CRITICISMS OF MY PAPER ON ANXIETY NEUROSIS

In the second number of Mendel’s
Neurologisches Zentralblatt
for 1895, I published a short
paper in which I ventured an attempt to detach a number of nervous
states from neurasthenia and to establish them as an independent
entity under the name of ‘anxiety
neurosis’.¹  I was led to do so by the presence of
a constant conjunction of certain clinical features with certain
aetiological ones - a thing which, in general, should permit us to
make a separation of this kind. I found - and in this Hecker (1893)
had anticipated me - that the neurotic symptoms in question could
all be classed together as constituting expressions of anxiety;
and, from my study of the aetiology of the neuroses, I was able to
add that these portions of the complex of the ‘anxiety
neurosis’  exhibit special aetiological preconditions
which are almost the opposite of the aetiology of neurasthenia. My
observations had shown me that in the aetiology of the neuroses (at
all events of
acquire–d
cases and
acquirable
forms) sexual factors play a predominant part and one which has
been given far too little weight; so that a statement such as that
‘the aetiology of the neuroses lies in sexuality’, with
all its unavoidable incorrectness
per excessum et defectum
,
nevertheless comes nearer to the truth than do the other doctrines,
which hold the field at the present time. A further assertion which
my observations forced me to make was to the effect that the
various sexual noxae are not to be found in the aetiology of every
neurosis indifferently, but that unmistakable special relationships
hold between particular noxae and particular neuroses. Thus I could
assume that I had discovered the
specific
causes of the
various neuroses. I then sought to formulate shortly the special
character of the sexual noxae which constitute the aetiology of
anxiety neurosis, and, on the basis of my view of the sexual
process (p. 108), I arrived at the proposition: anxiety neurosis is
created by everything which keeps somatic sexual tension away from
the psychical sphere, which interferes with its being worked over
psychically. If we go back to the concrete circumstances in which
this factor becomes operative, we are led to assert that
abstinence, whether voluntary or involuntary, sexual intercourse
with incomplete satisfaction, coitus interruptus, deflection of
psychical interest from sexuality, and similar things, are the
specific aetiological factors of the states to which I have given
the name of anxiety neurosis.

  
¹
‘On the Grounds for Detaching a
Particular Syndrome from Neurasthenia under the Description
"Anxiety Neurosis"' (1895
b
).

A Reply To Criticisms Of My Paper On Anxiety Neurosis

353

   When I published the paper I have
mentioned, I was under no illusion as to its power to carry
conviction. In the first place, I was aware that the account I had
given was only a brief and incomplete one and even in places hard
to understand - just enough, perhaps, to arouse the reader’s
expectations. Then, too, I had scarcely brought forward any
examples and given no figures. Nor had I touched on the technique
of collecting anamneses or done anything to prevent
misunderstandings. I had not given consideration to any but the
most obvious objections; and, as regards the theory itself, I had
laid stress only on its main proposition and not on its
qualifications. Accordingly, each reader was in fact at liberty to
form his own opinion as to the binding force of the whole
hypothesis. I could, moreover, reckon upon another difficulty in
the way of its acceptance. I know very well that in putting forward
my ‘sexual aetiology’ of the neuroses, I have brought
up nothing new, and that undercurrents in medical literature taking
these facts into account have never been absent. I know, too, that
official academic medicine has in fact also been aware of them. But
it has acted as if it knew nothing about the matter. It has made no
use of its knowledge and has drawn no inferences from it. Such
behaviour must have a deep-seated cause, originating perhaps in a
kind of reluctance to look squarely at sexual matters r in a
reaction against older attempts at an explanation, which are
regarded as obsolete. At all events, one had to be prepared to meet
with resistance in venturing upon an attempt to make something
credible to other people which they could without any trouble have
discovered for themselves.

A Reply To Criticisms Of My Paper On Anxiety Neurosis

354

   In such circumstances it would
perhaps be more expedient not to answer critical objections until I
had myself expressed my views on this complicated subject in
greater detail and had made them more intelligible. Nevertheless, I
cannot resist the motives which prompt me to make an immediate
answer to a criticism of my theory of anxiety neurosis which has
appeared in recent days. I do so because its author, L.
Löwenfeld of Munich, the author of
Pathologie und Therapie
der Neurasthenia
, is a man whose judgement undoubtedly carries
great weight with the medical public; because of a mistaken view
which Löwenfeld’s account imputes to me; and finally
because I wish to combat at the very start the impression that my
theory can be refuted quite so easily by the first objections that
come to hand.

   With an unerring eye
Löwenfeld (1895) detects the essential feature of my paper -
namely, my assertion that anxiety-symptoms have a specific and
uniform aetiology of a sexual nature. If this cannot be established
as a fact, then the main reason for detaching an independent
anxiety neurosis from neurasthenia disappears as well. There
remains, it is true, one difficulty to which I called attention -
the fact that anxiety-symptoms also have such very unmistakable
connections with hysteria, so that a decision on
Löwenfeld’s lines would prejudice the separation between
hysteria and neurasthenia. This difficulty, however, is met by a
recourse to heredity as the common cause of all these neuroses (a
view which I will go into later).

   What arguments, then, does
Löwenfeld use to support his objection to my theory?

   (1) I emphasized as a point
essential to an understanding of anxiety neurosis that the anxiety
appearing in it does not admit of a psychical derivation - that is
to say that the preparedness for anxiety, which constitutes the
nucleus of the neurosis, cannot be acquired by a single or repeated
affect of psychically justified fright. Fright, I maintained, might
result in hysteria or a traumatic neurosis, but not in an anxiety
neurosis. This denial, it is easy to see, is nothing else than the
counterpart to my contention, on the positive side, that the
anxiety appearing in my neurosis corresponds to a somatic sexual
tension which has been deflected from the psychical field - a
tension which would otherwise have made itself felt as libido.

A Reply To Criticisms Of My Paper On Anxiety Neurosis

355

   Against this, Löwenfeld
insists on the fact that in a number of cases ‘states of
anxiety appear immediately or shortly after a psychical shock
(fright alone, or accidents which were accompanied by fright), and
in such situations there are sometimes circumstances which make the
simultaneous operation of sexual noxae of the kind mentioned
extremely improbable.’ He gives, shortly, as a particularly
pregnant example, one clinical observation (to serve instead of
many). This example concerns a woman of thirty, with a hereditary
taint, who had been married for four years and who had had a first,
difficult, confinement a year before. A few weeks after this event
her husband had an attack of illness which frightened her, and in
her agitation she ran about the cold room in her chemise. From that
time on she was ill. First she had states of anxiety and
palpitations in the evening, then came attacks of convulsive
trembling, and after that phobias, and so on. It was the picture of
a fully-developed anxiety neurosis. ‘Here,’ concludes
Löwenfeld, ‘the anxiety states are obviously of
psychical origin, brought about by the single fright.’

   I do not doubt that my respected
critic can produce many similar cases. I myself can supply a long
list of analogous examples. Anyone who has not seen such cases -
and they are extremely common - of an outbreak of anxiety neurosis
after a psychical shock, ought not to regard himself as qualified
to take part in discussions about anxiety neurosis. I will only
remark in this connection that neither fright nor anxious
expectation need always be found in the aetiology of such cases;
any other emotion will do as well. If I hastily recall a few cases
from my memory, I think of a man of forty-five who had his first
attack of anxiety (with cardiac collapse) at the news of the death
of his father, who was an old man; from that time on he developed a
complete and typical anxiety neurosis with agoraphobia. Again, I
think of a young man who was overtaken by the same neurosis on
account of his agitation about the disagreements between his young
wife and his mother and who had a fresh onset of agoraphobia after
every domestic quarrel. Then, there was a student, something of an
idler, who produced his first anxiety attacks during a period in
which, under the spur of his father’s displeasure, he was
working hard for an examination. I recall, too, a woman, herself
childless, who fell ill as a result of anxiety about the health of
a small niece. And other similar instances. About the facts
themselves, which Löwenfeld uses against me, there is not the
slightest doubt.

A Reply To Criticisms Of My Paper On Anxiety Neurosis

356

   But there is doubt about their
interpretation. Are we to accept the
post hoc ergo propter
hoc
conclusion straight away and spare ourselves any critical
consideration of the raw material? There are examples enough in
which the final, releasing cause has not, in the face of critical
analysis, maintained its position as the
causa efficiens
.
One has only to think, for instance, of the relationship between
trauma and gout. The role of a trauma in provoking an attack of
gout in the injured limb is probably no different from the role it
plays in the aetiology of tabes and general paralysis of the
insane; only in the case of gout it is clear to the meanest
capacity that it is absurd to suppose that the trauma has
‘caused’ the gout instead of having merely provoked it.
It is bound to make us thoughtful when we come across aetiological
factors of this sort - ‘stock’ factors, as I should
like to call them - in the aetiology of the most varied forms of
illness. Emotion, fright, is also a stock factor of this kind.
Fright can provoke chorea, apoplexy, paralysis agitans and many
other things just as well as it can provoke anxiety neurosis. I
must not go on to argue, of course, that, because of their
ubiquity, the stock causes do not satisfy our requirements and that
there must be specific causes as well; to do so would be to beg the
question in favour of the proposition I want to prove. But I am
justified in drawing the following conclusion: if the same specific
cause can be shown to exist in the aetiology of all, or the great
majority, of cases of anxiety neurosis, our view of the matter need
not be shaken by the fact that the illness does not break out until
one or other stock factor, such as emotion, has come into
operation.

A Reply To Criticisms Of My Paper On Anxiety Neurosis

357

   So it was with my cases of
anxiety neurosis. Let us take the man who, after receiving the news
of his father’s death, fell ill so inexplicably.(I add
‘inexplicably’ because the death was not unexpected and
did not occur in unusual or shattering circumstances.) This man had
carried out coitus interruptus for eleven years with his wife, whom
he tried for the most part to satisfy. Again, the young man who was
not equal to the quarrels between his wife and his mother, had
practised withdrawal with his young wife from the first, in order
to spare himself the burden of children. Then we have the student
who acquired an anxiety neurosis from overwork, instead of the
cerebral neurasthenia that was to be expected: he had maintained a
relationship for three years with a girl whom it was not
permissible for him to make pregnant. Again, there was the woman
who, childless herself, was overtaken by an anxiety neurosis about
a niece’s illness: she was married to an impotent man and had
never been sexually satisfied. And so on. Not all these cases are
equally clear or equally good evidence for my thesis; but when I
add them to the very considerable number of cases in which the
aetiology shows nothing but the specific factor, they fit without
contradiction into the theory I have put forward and they allow of
an extension of our aetiological understanding beyond the
boundaries hitherto in force.

   If anyone wants to prove to me
that in these remarks I have unduly neglected the significance of
the stock aetiological factors, he must confront me with
observations in which my specific factor is missing - that is, with
cases in which anxiety neurosis has arisen after a psychical shock
although the subject has (on the whole) led
a normal vita
sexualis
. Let us see now whether Löwenfeld’s case
fulfils this condition. My respected opponent has evidently not
been clear about this necessity in his own mind, otherwise he would
not have left us so completely in the dark about his
patient’s
vita sexualis
. I will leave on one side the
fact that this case of a lady of thirty is obviously complicated by
a hysteria as to the psychical origin of which I have not the least
doubt; and I naturally admit without raising any objection the
presence of an anxiety neurosis alongside of this hysteria. But
before I turn a case to account for or against the theory of the
sexual aetiology of the neuroses, I must first have studied the
patient’s sexual behaviour more closely than Löwenfeld
has done here. I should not be content to conclude that, because
the time at which the lady received her psychical shock was shortly
after a confinement, coitus interruptus could not have played a
part during the previous year, and that therefore sexual noxae are
ruled out. I know cases of women who were made pregnant every year,
and who yet had anxiety neurosis, because - incredible as it may
seem - all sexual relations were stopped after the first
fertilizing coition, so that in spite of having many children they
suffered from sexual privation through all these years. No doctor
is ignorant of the fact that women conceive from men whose potency
is very slight and who are not able to give them satisfaction.
Finally (and this is a consideration which should be taken into
account precisely by the upholders of a hereditary aetiology),
there are plenty of women who are afflicted with congenital anxiety
neurosis - that is to say, who inherit, or who develop without any
demonstrable disturbance from outside, a
vita sexualis
which
is the same as the one usually acquired through coitus interruptus
and similar noxae. In a number of these women we are able to
discover a hysterical illness in their youth, since which their
vita sexualis
has been disturbed and a deflection of sexual
tension from the psychical sphere has been established. Women with
this kind of sexuality are incapable of obtaining real satisfaction
even from normal coitus, and they develop anxiety neurosis either
spontaneously or after further operative factors have supervened.
Which of all these elements were present in Löwenfeld’s
case? I do not know. But I repeat: this case is evidence against me
only if the lady who responded to a single fright with an anxiety
neurosis had before then enjoyed a normal
vita sexualis
.