Conditions of Nervous Anxiety and their Treatment

FIRST PART

ANXIETY NEUROSIS

CHAPTER I

GENERAL POINTS OF VIEW

THIS book is written by a medical practitioner for the Profession. Its purpose is to describe the origin and treatment of nervous anxiety conditions as clearly, briefly and thoroughly as possible, and to instruct us in the understanding of the enormous power of psychological forces. It is intended as an introduction to psycho-therapy, that great art which forms the basis of all medical practice.

We have so long enjoyed the fruits of biological discoveries that we have entirely forgotten that man has also a soul. In the progress made in chemistry, physics, bacteriology and pathology we have left the psychic component of disease out of account, and have seriously neglected the investigation of the human psyche; but the amazing experiences of life lead us back into the domain of psychology, proving to us that a thorough knowledge of the human psyche is of supreme importance. A good doctor must be a good psychologist, he must have a thorough knowledge of men.

And now to our theme! What has been hitherto known about Anxiety? It passed for a feeling of displeasure, of expectation, a higher degree of fear. Fear and anxiety were regarded by doctors in the same sense. This was Löwenfeld’s view, to whom we are indebted for the most profound treatise on anxiety conditions.¹ According to the ordinary use of language, fear indicates a lesser degree, and anxiety a higher degree of the emotional condition of painful anticipation characterised by a feeling of dread. He speaks indiscriminately too of fear and anxiety conditions without giving any criterion of their intensity.

If, however, we wished to make accurate linguistic distinctions, we should differentiate between fear and anxiety. We should regard fear as an unpleasant emotion with a logical basis serving the instinct of self-preservation. Fear has always reference to some particular object. One is afraid of burglars, another of violence. The feeling of displeasure can always be traced to some particular cause. We dread the Unknown. Anxiety is the neurotic sister of fear. We awake in the night with a vague feeling of oppression and palpitation and we call this unpleasant feeling anxiety. Anxiety is by no means a higher degree of fear. A higher degree of fear is fright. Fear is the chronic, fright the acute, condition. Fright increases again to terror when it takes away the individual’s capacity for conscious action. Fear, fright and terror are all manifestations of one instinct—the instinct of self-preservation. In fact Möbius¹ describes Fear as the most important manifestation of the instinct of self-preservation. If, in pathological conditions, the instinct is weakened, the longing for death supervenes and the pale mists of twilight seem to cover all that was once bright and lovely.

Anxiety also is an expression of the instinct of self-preservation with this one difference: it manifests the presence of a "repressed. instinct. It is the product of so-called repression."

This brings us for the first time to the expressions suppression and repression, which are not familiar to every doctor. They are, however, easily comprehensible, especially when the impulsive is under consideration. All progress, all development, all civilisation, e.g., education, morality, good manners, etc., is based on repression. The impulsive life has been very little investigated, and one must agree with Möbius when he says, "The misapprehension of the human impulsive life is a veritable testimonium paupertatis for psychologists, and nothing is more pitiable than the theory about ‘ideas that act and fight like little mannikins in the soul.’"

The instinctive life explains a remarkable fact. We have previously spoken of the feeling of Anxiety as an unpleasant feeling. This is really not correct. Anxiety-feeling can be, under certain circumstances, a pleasurable feeling, e.g., the delicious trepidation with which children listen to a fairy-tale—the tale of Hans who went out into the world to learn to shiver and shake is a proof of this. And we gain a still deeper insight into this subject from the fact that feelings of anxiety can sometimes serve to inspire works of art. The remarkable discovery that feelings of anxiety are so often linked up with feelings of sexual pleasure provides food for reflection. Janet regards this type of sexual excitement as a deviation from fear. But this explanation is not satisfactory to us. We can already perceive the dawn of a realisation that between fear and the sexual impulse there must exist certain intimate connections.²

Freud, in his epoch-making investigations upon the Quellen der infantilen Sexualität (Drei Abhandlungen zur Sexualtheorie, Wien, 1905) points out that all intensive affects, even the excitement caused by fright, encroach on sexuality, a fact which may contribute to the understanding of the pathogenic functioning of such emotions. In the school child, he says, the anxiety due to examinations, the tension produced by some difficult problem, may have very serious consequences both as regards his relations to the school and to the outbreak of sexual manifestations, in so far as such conditions very often engender a feeling of excitement which leads to the manipulation of the sex organs or to something in the nature of an emission with all their disturbing consequences. The sexually exciting functioning of affects which are displeasurable in themselves: anxiety, trepidations, horror, very often persist in after life and this is possibly the explanation of the fact that so many people seek the opportunity for such sensations if only certain accompanying conditions, belonging to the phantasy life (reading, attending theatres) lessen the intensity of the unpleasant emotions.

This brings us into the realm of the psychopathology of Masochism and Sadism which would lead us too far away from our present theme. We shall have sufficient opportunity when quoting cases to trace the connection with this subject.

We only wish to indicate that the connection between Anxiety and Sexuality is very often apparent without any disguise. This is illustrated by the case of a patient suffering from examination anxiety who always had one, or even several, emissions during each examination. Löwenfeld (Sexualleben und Nervenleiden—Wiesbaden, J. F., Bergmann) records similar instances. They must be familiar to every experienced nerve-specialist. In some cases patients seek anxiety as a means to effect an orgasm. They arrange for artificial shocks, dangerous situations which stimulate their emotions. (Compare my essay "Der Neurotiker als Schauspieler." Zentralbl. I. Bd. I. Heft). Feré describes a very interesting case of a very similar character. A patient seeks dangerous situations in which he may be surprised, or discovered, for the purpose of obtaining a violent orgasm. (La peur et l’explosion sexuelle. Revue de médecine 1907, I. Heft).

It is, of course, obvious to the experienced that such cases are the repetition of infantile pleasurable experiences.

Anxiety and sex-impulse are intimately connected. The sex impulse, like various other impulses, makes its appearance in association with counter impulses. The sex-impulse is always accompanied by the instinct of self-preservation and its counter-impulse, the Death-impulse. In fact the sex-impulse may be directly identified with the instinct of self-preservation. Sich ausleben means in the language of the common folk, to live oneself out, to satisfy one’s sexual instinct. Furthermore, coitus, as the Viennese philosopher, Swoboda¹ aptly expresses it, is a partial death. The begetting of another being involves the surrender of our right to existence. Love and death are closely connected. The greater the development of the instinct of self-preservation, the more likely is the individual to become a prey to the feelings of fear. It is the suppression of this instinct of self-preservation, linked with the sex-impulse, which leads to anxiety. Anxiety is always the result of repression.

Anxiety then is the reaction against the pressing forward of the death impulse engendered by the suppression of the sex or self-preservation instinct.

In short, all anxiety is ultimately the fear of annihilation of the ego—is, in fact, the fear of death.

Although I previously agreed with Freud that all anxiety was of sexual origin, the experiences of the World War have taught me that the instinct of self-preservation can produce anxiety without its sexual component. All those who tremble, tremble for their lives. The trembling of those frightened by the War is a motor fixation of anxiety—is fear of annihilation, is reaction of the instinct of self-preservation against the dangers which threaten the ego.¹

On the other hand the analysis of the various anxiety states reveals that every neurotic is afraid of himself.

Anxiety, therefore, can also be fear of oneself, i.e., fear of one’s own criminal impulses. The desire for death (the longing to commit suicide), is a manifestation of anxiety.²

I may claim the credit of having built up the real psychology of neurotic anxiety by the amplification and persistent application of Freud’s teaching and also by some modification to avoid certain of his errors, as I have demonstrated by my numerous clinical illustrations. I am certainly indebted to Freud for having paved the way. He drew a definite distinction between "Angstneurose" (Anxiety-neurosis) and other neuroses. Sexual etiology is clearly demonstrated in Anxiety-neurosis. But we will deal more fully with this subject later, and will now turn our attention to a few practical illustrations of the nature of repression. We shall thereby gain an insight into the foundations of modern psychotherapeutics.

¹ Die psychischen Zwangerscheinungen. Wiesbaden, 1899.

¹ Die Hoffnungslosigkeit aller Psychologie. Halle. a.d. S. 1906.

² In the wonderful tale of Hans, who went forth to learn to shiver and shake, he is taught this art for the first time by his wife. The fairy-tale therefore confirms the fact, discovered by Freud, of the connection between sexual excitement and anxiety.

¹ Die Perioden im menschlichen Organismus in ihrer psychologischen und biologischen Bedeutung. Wien 1904, Deuticke.

¹ The fixation of the trembling neurosis in favour of certain pretensions as a consequence of covetousness and for the purpose of personal aggrandisement is a secondary symptom.

² A lady who felt an imperative desire to throw herself from the top story on to the pavement below, was frightened to look down into the street even from the ground-floor window.

CHAPTER II

THE NATURE OF REPRESSION¹

OUR culture is built upon territory conquered inch by inch after laborious struggles. Foetid water had to be diverted; marshes drained; primeval forests cleared and mighty dykes constructed. Culture is repression—a well-functioning inhibition.

What applies to humanity in general applies equally to men. Repression enables us to live the life of a civilized man who is willing to comply with all the ethical and social demands of his age. It is also the key to that inner culture, the life on a higher plane, which distinguishes us from the common herd.

Repression is not always a desirable acquisition to our existence. On the contrary. He who is not able to trace his thoughts back to their most obscure origins, and their most minute associations will never be able to free himself from them. Repression without the aid of consciousness is the cause of countless diseases; it is not a relief but a burden. The matter that lies hidden beneath the threshold of consciousness may, when stirred up, shake us to the depths. We can only forget that which we have consciously known.

In the histories of innumerable patients we shall see what an important rôle repression plays in the etiology of neuroses. One must take care not to confuse the mere forgetting of indifferent impressions, with repression. Repression presupposes an affect, some painful, unpleasant emotion. Forgetfulness, which is the result of repression is a dynamic psychic activity—as distinct from ordinary forgetting.

In repression the affect remains undiminished. It has been merely diverted from the sphere of consciousness into the unconscious, or into the pre-conscious, or it has found a surrogate (Affect-displacement). This substitution by its concealment of the affect in the unconscious renders the affect unassailable. Forgetfulness on the contrary implies a diminution of the affect. Remembrance, like attention, is essentially an affective process (Bleuler). In repression the attention appears to be diverted from the object which is charged with affect to some other object. This Repression is an active process, an act of will, in contradistinction from forgetting. By repression we understand an apparent forgetting when from motives of displeasure we do not wish to think of a particular idea.

Repression is seldom entirely successful. Indeed, successful repression, the complete forgetting of an event, of an impulse, or of a phantasy can seldom be traced. Affect-toned events are the more difficult to repress in proportion to the strength of the affect. If, however, the attempt is successful, we speak of it as successful repression, as suppression. Neuroses are the result of unsuccessful repression, as we shall see. The affect is not insulated,¹ it is only diverted. The symptoms are then a compromise between affect and repression.

Suppression has, however, rendered the psychic material concerned entirely worthless. The suppression, the successful repression, can never give rise to a neurosis. Ineffective repression may be compared with hysterical amnesia. In hypnosis or in dreams apparently forgotten impressions reappear. We will not at present go into the question of whether or not that form of hysteria common to us all plays the leading part in repression.

Recent investigations have convinced me that Freud’s assumption that in repression there is a real amnesia is mistaken. It is a question of "Not wanting to see, while Freud interprets it as Incapacity to see." The idea concerned is not unconscious, but pre-conscious. It is relegated from the visual field of our attention, to the periphery, so that the result is a limitation of the mental field of vision. The neurotic is like a man suffering from torticollis, who must always look in one direction because he is unable to turn his head the other way. The neurotic also looks in a wrong direction which accounts for his incapacity to see, which is always shown by analysis to be a desire not to see. In the same way many a man does not want to see the infidelity of his wife. He represses all thoughts suggestive of her unfaithfulness. He is eventually able to convince himself that he believes her to be faithful.

An excellent example of repression is given by Janet: A young girl of nineteen is subject to attacks of somnambulism, in which she talks of money, thieves and fire, and calls a certain ‘Lucien’ to her assistance. When awake she has absolutely no idea of the meaning of it all, and maintains that she has had no experience in which fire, theft and ‘Lucien’ played a part. As she came to the hospital alone we have no means of verifying her statement and are forced to assume that it is a case of délire imaginaire." Six months later her parents came up from the country, called on us and related the dramatic incident which was the origin of the nervous attacks. She was in service at a castle which was one night burgled and set on fire; she was rescued by a gardener of the name of Lucien. Now how could this young person have forgotten such an important occurrence? Why did she never speak of it in giving an account of her life? How can such a remarkable lapse of memory be reconciled with the development of a secret remembrance which revived the experience during the attacks of somnambulism? That is the important question. (Les Nevroses, p. 4.)

Modern psychotherapy has undertaken to trace the origin of these repressions, to release them and thereby cure the patient.

It is hidden thoughts that produce the various neurotic symptoms. The strong sense of guilt expresses itself in ill-humours which are only puzzling as long as the inner cause remains unknown. The most remarkable part about this condition is that the neurotic does not know himself where the shoe pinches. But that no longer surprises us when we realise that the unpleasant thoughts have been banished from his consciousness and repressed, and that he does not want to know the truth. The art of the physician consists in removing these repressions and in getting the patient to acknowledge the truth fearlessly. This is a difficult task and generally requires a long technical process which we call psychanalysis.¹

It seldom happens that we can take a patient unawares and thereby immediately relieve him of his repression. In fact, the modern doctor of the soul prefers not to practise this treatment, although some cases could undoubtedly be cured in one sitting. We shall meet with some examples of this. The following example of a case of this nature coming within my own experience, may serve as an introduction to psycho therapeutic methods. It deals with a patient suffering from Agoraphobia. (Platzangst).

No. 1.—A tall, well-built man, twenty years of age, came to my consulting-room to see me about his fear of open spaces. Various hydrotherapeutic and electrotherapeutic treatments had been tried without success. I asked him to describe his anxiety symptoms; they were typical. The patient stopped at every open place, began to shake, and no power on earth could induce him to cross alone. But he could manage it accompanied by another person. I questioned him in regard to all the circumstances that might have been conducive to the neurosis, and we came to his sex-life. I will take this opportunity of drawing the reader’s attention to an excellent remark of Freud’s. Freud had learned by experience that many doctors although ignorant of psycho-therapeutic methods, nevertheless seek the root of neuroses in the sex-life, and simply advise the patient to give free rein to his sex-impulses in the hope that this may effect a cure. But this is not the point, says Freud. "The sexual need and privation is only one factor in the mechanism of neurosis. If it were the only one, debauchery and not disease would be the result. The other indispensible factor, which is only too readily overlooked, is the sexual aversion of neurotics, their incapacity to love, that psychic condition which I have called ‘repression.’ The disease arises out of the conflict between the two tendencies and in consequence, any counsel to indulge in sexual activity in cases of psychoneurosis, can seldom be regarded as wise."

Let us, therefore, bear this fact in mind.² Our patient showed very little interest in women. He had never been in love in his life, and had never felt any need for it. On one or two occasions he had tried sexual intercourse, without experiencing any particular sensation. This admission involuntarily gave rise to the suspicion that this was a case of homosexuality. The patient emphatically denied this, although he was otherwise quite open in his confessions. He would not even admit partial homosexual tendencies, which so often find expression in erotic homosexual dreams. In such cases one is not far wrong in deducing some fixation of sexual life. And who could be more appropriate as the object of this fixation than some person in the immediate environment on whom the child has already fixed his love? I asked him innocently if he were fond of his parents.

Tremendously, he replied. His eyes lighted up and his whole face became animated. My mother rather more so than my father.

Are your parents poor?

Very poor. I support them.

What is your profession?

I am a cashier in a large Banking House.

Does much money pass through your hands?

Yes, millions of kronen every day.

The understanding of his anxiety neurosis flashed upon me. The man must have been playing with the idea of seizing a few millions and going off with them. I put the unexpected question: Have you never thought to yourself, here am I up to the arms in gold while my poor parents are in want?

Oh, yes, I’ve often thought that.

And have you never felt tempted to go off with the money so that your parents’ remaining years may be free from care?

The patient suddenly turned pale, considered a while, and then said frankly: Yes, the idea has occurred to me, but I always suppressed it immediately.

Naturally, I replied, as any honourable man would do. We chat a while longer and eventually he asks my advice. I tell him quite frankly that his malady has arisen from the repression of the desire to run away with a large sum of money. I can only see one means of curing you: you must exchange your position of cashier for another which may perhaps entail more work but less temptation. He declared that it was out of the question, that it would arouse suspicion, which I denied, in view of his neurotic condition that prohibited any occupation dealing with accounts and money.

Here we have the repressed desire as the cause of anxiety. The open place symbolises the great unknown future, the ocean across which he would flee to America. Every neurotic is an actor, playing a particular scene. Our neurotic acted at the open space the flight to America.¹

We see from this first example that anxiety is not directly connected with the sex-life. It is obvious in this instance that the patient is afraid of his own criminal impulses. The fact that he contemplates the theft for the benefit of the mother cannot be considered the primary factor in his anxiety. He acts the flight to America and trembles because in his imagination he is caught by the police. If he were confident of success he would probably not be afraid. By this example my definition The neurotic is a criminal without the courage to commit a crime may be more readily understood.

After six months I heard from his family that he had given up his position and was entirely cured of his trouble. I do not know whether I shall ever see him again. And that is the strange thing about psychic cures: whereas in other successful cures the patients praise the Doctor and are only too glad to recommend him to others, they preserve the strictest secrecy as regards their psychic cures, which they owe to the psychotherapist.

In the first place, he has penetrated into the secret places of their minds, and revealed the criminal within, that dwells in every one; secondly, they fear he may betray the unflattering picture thus exposed. So they make their revelations as in a confessional, look upon the Doctor as a Father-Confessor whom they will never see again, and after the cure is complete avoid him. I must, however, hasten to acknowledge that there are exceptional patients who visit the doctor from time to time to free themselves from some minor ailment.

Let us turn to another case:—

No. 2 concerns a lady who came to consult me about a remarkable peculiarity. She could not remain in a room without a second person being present, who also must not be a stranger but some near relative of her husband. The suggestion of employing psycho-analytical treatment met with opposition because the treatment must only be carried out in the presence of her husband. Now confession in the presence of a third party is an utter impossibility. I attempted, nevertheless, to gain a closer insight into the nature of the affliction.

The patient had been quite healthy until her marriage eight years before. Then it transpired that her husband was impotent for several years after the marriage and could not perform the sexual function. His condition had now improved so that he was able to fulfil his marital duties, although only moderately, and she became the mother of a child. She was of a lively imaginative disposition, and had been fond, ever since her youth, of dreaming, reading novels, etc., and her ideal of manliness certainly did not coincide with her real husband. She was obviously sexually unsatisfied and was subject to frequent neurotic phantasies. The mechanism of the anxiety was now quite apparent. Her devotion and passionate love for her husband were struggling against her desire to be unfaithful to him. She may have felt an inward leaning to be unfaithful to him on the first occasion that she was left alone with some other man and the lack of strength to resist his wooing and as a reaction against this impulse—manifested in this case as anxiety—arose the dread of being left alone in a room. Her husband, or some relative had to be there to protect her honour. Anxiety as the guardian of honour.

This case proves that anxiety serves as a "self-protective" measure to save the moral ego from destruction. This self-protection increases with the insistence of the impulses. In this case first the servant girl was sufficient protection for her, then any female relative, then a female relative of the husband must be present; and lastly the poor woman seized her husband’s hand and implored him not to leave her and not to go to the office. She only felt safe when she held his hand. Imagine the struggles which must take place in this woman’s mind. On one side she is beset by impulses, by passionate desires and longings for love and complete satisfaction, which are vetoed on the other hand by moral inhibitions. The neurosis was the salvation of her moral ego.

This example clearly demonstrates how the conflict between sexual inclination and sexual aversion is capable of producing the neurotic symptoms.

These two cases may suffice to justify the great importance of psychotherapy for the practice of medicine. Psychic diseases can only be cured by psychic methods. The detailed analyses in these pages will demonstrate to the doctor what means must be employed in dealing with these complicated phenomena. I will mention another case which I cured with the assistance of a Father-Confessor and in which I myself did not play the part of father-confessor but left that rôle to the church:—

No. 3.—A lady consulted me in regard to attacks of trembling and fainting fits, from which she had suffered since her childhood. The attacks were preceded by excessive anxiety. The first attack took place on Christmas eve while she was at prayer.

I at once offered to tell her the place where the attacks started.

I wonder whether you can guess that?

"Forgive us our trespasses!—that might have been the place,"—and so it was.

The girl of fourteen was disgracefully treated by a music master. She had allowed him to do what he liked with her, except coitus, because she believed she was abnormally formed (a common form of anxiety among girls)! She was very devout and pious, and the conflict between piety and sin had given rise to the attack. The repetition of this attack during recent years pointed to a similar conflict. This proved to be so. She confessed that she had had a liaison with the husband of her greatest friend. Psychanalytic treatment was not possible as the lady could only remain in Vienna a few days.

I asked her if she was still religious. She replied, Yes, but said it was quite a year since she had been to Confession. I advised her to go, and expressed the hope that if she could find a wise, judicious father-confessor, the attacks would certainly disappear. But so much depends upon the priest. If he is also a doctor of the soul (unfortunately he is not always that) he can read the heart of the sufferer, and a reassuring word from him may remove the whole psychical burden and relieve the conflict. He strengthens the inhibitions either one way or the other. If he pictures terrifying prospects to her, if he threatens with hell and punishment, he will make the illness worse, and increase the conflict, so that at length it becomes almost incurable. But in this case all went as I hoped. The patient went to Confession, and the mysterious attacks, although they had resisted a three months’ stay at a well known Hydropathic Institution, disappeared after a single Confession. What my part was in this success, is not for me to say.

Perhaps a remark may not be out of place here, concerning the relationship of religion and neurosis. All neurotics are at heart religious. Their ideal is "Pleasure without guilt." Belief has been overcome by the intellect, but is deeply rooted in the emotions. Or more precisely: Faith is rooted in the infantile; and only through psychanalysis can the conflict be resolved. The patients can neither believe nor disbelieve. They must be brought to do one or the other.

A really religious man can become well merely through confession, that is, if he has faith, knows what is amiss, and what he desires. Unfortunately, this is not often the case; the neurotic is seldom conscious of his criminal desires.

What the Confessional of the Church is to the religious, so the confessional of the doctor must be to all those whose souls are suffering.

Karl Marhold (1907), rightly says, without passing sentence on the worth of confession, that in the Protestant countries of German nationality, suicide is more frequent than in the Roman Catholic countries. Yet how few men, modern men, can make use of the benefit of confession! For such the physician must become the sympathetic priest—the priest whom Nietzsche in the Fröhlichen Wissenschaft, so strikingly describes: "The people venerate an entirely different type of man. . . . namely, the serious, simple, chaste, priestly nature. . . . Before whom they can pour forth their hearts with impunity, by whom they can obtain release from their secrets, their cares, and from things that are even worse. Here there is a great need; also for spiritual sewers with thoroughly cleansing water; a need for powerful streams of love, pure, strong hearts prepared to sacrifice themselves in such service which is outside the department of public health."

The psychotherapist who investigates repressions, must be cf a like chaste and earnest nature. With such a mind we can speak of all things, even of things that other people would condemn as beastliness. We cannot choose the cause of a neurosis. We must accept it as bountiful Mother Nature gives it to us. But let us not wrong nature! Nature has nothing to do with neurosis. Civilisation is alone to blame, because it assumes that it can violate nature with impunity. All illnesses are at base nothing else than sins against nature.

I consider that the three former examples illustrate the relationship between repression and anxiety.

It is interesting that even great men, whose deeds fill us with admiration, could not prevent feelings of anxiety. Augustus Cæsar’s whole body trembled when it began to thunder. He fled to the deepest cellar in his palace, and covered his head with thick furs, so that he might not hear the thunder-claps. Erasmus was horrified if he saw a fish, and Pascal was afraid of a thousand and one things. Frederick the Great had an aversion for all new clothing, or new uniforms. He frequently nearly fainted when he had to put on a new coat. Bernardin de Saint-Pierre, the author of Paul and Virginia, Newton, and Paganini were frightened and sick on encountering water. Mozart ran away at the sound of a trumpet or hunting horn. Schopenhauer trembled at the sight of a razor. Carlyle never dared to set foot in a shop; although a keen critic of heroes and heroic deeds, he was afraid of an ordinary shopkeeper. Edgar Allan Poe, Musset, Schumann and Chopin were all afraid of the dark. Dostojewski all through his life trembled before a something incomprehensible, inconceivable, that would one day stand before him, as something real, loathsome, and full of horror. Finally, Maupassant had a fear and horror of open doors. Those who know the relationship between genius and neurosis, will not be surprised at this. Compare my writing, Dichtung und Neurose. Grenzfragen des Nerven und Seelenlebens. J. F. Bergmann, 1909.

¹ Partly from my booklet, Die Ursachen der Nervosität. (Paul Knepler, Wien).

¹ Auschalten = insulate, electrical term.

¹ At the suggestion of Pfister the expression Psycho-analysis is altered to Psychanalysis in my works.

² How much harm is done by doctors because they are so prone to regard every neurotic symptom as the result of sexual needs! I have met women who were advised, in consequence of compulsion-neurosis to form a liaison. The result was the aggravation of the disease. For neurotics are excessively moral people, inwardly religious and reproach themselves for the bare thought of sin.

¹ Cp. my opinion: Der Neurotiker als Schauspieler. Zentralblatt für Psychoanalyse I. Jahrg. H.1, and the essay Schauspieler des Lebens in Nervöse Leute (Verlag Paul Knepler, Wien).

CHAPTER III

BASIC CONCEPTS OF ANXIETY NEUROSIS

UEBER die Berechtigung, von der Neurasthenie einen bestimmten Symptomenkomplex als Angstneurose abzutrennen is the work by Freud¹ which set out to prove that a great number of so-called neurasthenics indicate an illness different to the typical neurasthenic. This clinical picture Freud calls anxiety neurosis, after the chief symptom, anxiety, around which all the other symptoms are grouped, and holds that the clinical picture cannot always be clearly recognised nor easily diagnosed. There are, for instance, a great number of symptoms which appear as anxiety equivalents, without being accompanied by the affect of anxiety, a circumstance to which E. Hecker² has already called attention. Once we know the typical symptoms or anxiety equivalents of the anxiety neurosis, then it should not be difficult, with some experience, also to discover the less distinct cases of anxiety neurosis.

Freud names anxiety neurosis and neurasthenia, Actual Neuroses, because, in his view, they arise from some harmful form of sexual life. He takes neurasthenia to be the result of excessive masturbation; anxiety neurosis the result of frustrated excitation.

The separation of anxiety neurosis and neurasthenia contradicts actual psychotherapeutic experience. Freud’s anxiety neurosis cannot be separated from neurasthenia. More exact analysis points to the fact that every neurasthenia is interpenetrated by anxiety neurotic symptoms. Anxiety neurosis really embraces the complete picture of neurasthenia. There remains compulsion neurosis, psychopathic inferiority, and light psychosis (dementia præcox). I call all neuroses: Parapathias.

In this terminology one looks in vain for hysteria. This is the great truth: there is only one neurosis with different forms of expression. One can think of anxiety neurosis as hysteria, and of hysteria as anxiety neurosis. But we will return to this subject later on. It would perhaps be more reasonable to call these maladies after the French custom, psychasthenia, for this does justice to the fact, that without the co-operation of the psyche the neurosis would not occur. There is no actual neurosis, in the sense of Freud’s conception; there are only psycho-neuroses, and really only one psycho-neurosis with different forms of expression and degrees of intensity.

Nevertheless, on didactic grounds, it is advisable to retain Freud’s classification for the present.

I will here, first of all, sketch in outline the clinical picture, as Freud has determined it.

A never failing cardinal symptom is a general irritability, manifested by abnormal reaction to all stimuli without and within. This irritability is extended to all the sense-organs, especially, as Freud emphasizes, to the sense of hearing, so that such an auditory hyperæsthesia may arise, causing insomnia.

A further symptom is the great absence of mind and forgetfulnessof these patients. Most of them complain that they can neither concentrate nor remember names; they easily forget orders and resolutions, so that they become frightened at the decrease of their mental powers. They show the well-known symptom, fear of insanity.

In addition, these patients suffer from a state of "Anxious expectation." This condition is aptly described by Löwenfeld¹ as follows:—

"The most harmless undertaking, such as going for a walk or drive in unfavourable weather, leads to exaggerated fear for body and life; a passing pain in any part of the body brings thoughts of severe illness. The belated return of any relation calls up the worst forebodings. A noise in the house will immediately suggest thieves and murderers, a business transaction of small importance leads to extreme fear of complications and disaster. It is easy to understand, that with all these extreme anxieties, their lives can seldom be cheerful. They see, for the most part, how groundless and ridiculous their fears are, and often try, with all the energy of their rational ego, to defend themselves against the compulsive nature of their fears, generally, however, without much success.

The abnormal disposition to anxiety does not always show itself in the same way on those different occasions which generally produce fear and hesitation. Besides those cases in which, there being a very slight possibility of harm, fears of a lesser or more serious degree appear on many different occasions, e.g., general anxiety. we also meet other cases in which the anxiety disposition is principally or exclusively manifested in a single sphere of personal interest.

Löwenfeld distinguishes the following forms of anxiety conditions:—"(a) Anxiety which specially concerns one’s own health, hypochondriacal anxiety. This appears in peculiarities conditioned either by heredity or by educational influences of the environment. It can also develop as the result of psychic upheavals, and other experiences harmful to the nervous system. (b) Moral Anxiety, in which the most harmless action or omission forms the starting point for moral or religious scruples, which very frequently become an exceedingly fruitful source of compulsion ideas. A sub-species of this special anxiety is concerned with the standard of the social conventions, and leads to an immoderate fear of offence against politeness or morality, also to extreme pedantry in manners and in the whole conduct of life. (c) An abnormal anxiety in reference to the health of near relatives (children, parents, husband or wife). One notices this form especially after severe mental stress caused by illness or death in the family. Such are roused to a painful state of agitation over the most trifling illness in the family, while they pay insufficient attention to their own physical sufferings. (d) Abnormal anxiety concerning one’s affairs or profession. To these belong the pessimists and those who take a black view of things. They see loss or disadvantage everywhere, and out of insignificant difficulties, make for themselves endless troubles."

Dr. Wilhelm Strohmayer (Die Beziehungen Der Sexualität zu Angstzuständen, Journal für Psychologie und Neurologie, Band XII, Heft 2.3, 1908) emphasizes the disturbances of the ego-feelings. He says: "Of special interest to me, in these patients, were conditions which stand in the closest relation to anxiety; and which are characterized by a diminished ego-feeling in the association of ideas, or by a momentary inability to bring certain feelings or conceptions into normal associative relations with the ego-consciousness. The peculiar conditions like anxiety appear in the form of attacks. It is often difficult to decide which was prior, whether anxiety or disorder of the ego-feeling. The patients say they cannot feel their ego, or that on account of the attacks it no longer resembles their normal ego. Their orientation in time and place is quite correct; but for their own person they have a feeling of strangeness, as if someone else thinks, feels, or acts for them. Their own body, face, voice, appear strange to them. The same patients distinguish from these symptoms, a second: they become partially conscious of their own personality, or a disturbing inability to associate organic feeling with the ego-consciousness. They feel the head, the arms, the hands, but as something outside the accustomed feelings of the body, or as an isolated part in strange dimensions. Finally, there is yet another variety to be considered: a strange emptiness in the head; the ego-feeling remains unaltered, but the outer world has a changed aspect. Suddenly, all the surroundings become ‘so completely altered,’ ‘so strange,’ ‘so comical.’ In spite of complete orientation, the surroundings lack the quality of recognition. Sometimes there is connected with it a feeling of remoteness and diminution. These conditions were always accompanied in my patients by extreme anxiety, because they believed, that ‘madness stared them in the face.’"¹

"The most striking symptom of anxiety neurosis is the anxiety attack. The attacks can come on suddenly and unexpectedly with great psychical disturbance, or by the gradual increase of rudimentary attacks. The patients feel that their end is approaching, they fear a stroke, feel that something is entangled in their brain, ‘the head feels as if it would burst,’ they are going mad, the heart seems to stop, somebody is throttling them and interferes with their breathing; just as a dying man must feel. All the symptoms that usually accompany the affect of fear or horror may also accompany an anxiety attack. The patients pale, lose their balance, and must lie down. They fight in vain for words and breath (vox faucibus haesit!). The arms and legs shake as in fever. Many patients shake violently, sweat breaks out from the whole body, the hair bristles, and the back creeps with coldness (cutis anserina). An abnormal secretion of urine causes an involuntary emptying of the bladder, or a violent disturbance of the bowels expresses itself in tenesmus, passing of wind, spasms and diarrhœa; this also produces involuntary evacuation. The pupils of the eyes dilate (according to Fliess, usually the left). The secretion of saliva ceases to flow,¹ and the mouth becomes dry. Often there follows attacks of faintness, migraine, giddiness or tachicardia of great intensity, various pains occur in the heart, chest, head; neuralgia, stomach-ache, and so on. All these phenomena can appear in the simplest to the gravest form, isolated, or in manifold combinations and variations."²

Quite as important as the understanding of the acute anxiety attack in its pronounced form is a thorough knowledge of the rudimentary anxiety attack, the so-called "anxiety equivalents." There is quite a scale of such rudimentary attacks, from simple discomfort and sudden depression, from an attack of sudden tiredness right up to extreme faintness and sudden collapse, thereby alarming the whole household. The physician and those surrounding the patient have to work hard to relieve the disorder. The knowledge of the rudimentary anxiety attack is of great significance to the practitioner.

Freud mentions the following equivalents of the anxiety attacks: (a) Disorders of the heart, palpitation with short arhythmia, with longer lasting tachycardia, up to a condition of such severe weakness, that the distinction from organic affections of the heart is not always easy; pseudo angina pectoris (no light task for diagnosis!). (b) Disorders of the breathing, several forms of nervous dyspnœa, attacks like asthma, and so on. Freud mentions that even these attacks are not always accompanied by recognisable anxiety. (c) Attacks of excessive sweating, often at night. (d) Attacks of trembling and shaking, which may easily be mistaken for hysteria. (e) Attacks of bulimia, often combined with giddiness. (f) Sudden attacks of diarrhœa. (g) Attacks of locomotor giddiness. (h) Attacks of so-called congestion, practically all that was formerly called vasomotor neurasthenia. (i) Attacks of paræsthesia (these seldom without anxiety). (j) Sudden fright on awakening from sleep (as if falling from a mountain). (k) Sudden urge for micturition. (l) Muscular cramp.

I should like to add to this list some important further additions:—(m) Sudden deep sighs, the result of breathlessness, often amounting to air-hunger. (n) The sudden on-coming of a feeling of weariness, that can amount to faintness. (o) Vomiting and stomach-ache (very important symptoms!), also painful flatulency with the noisy passing of large quantities of wind. (p) The fingers suddenly becoming dead, or the whole hand, or arm. (q) Migrâine. (r) Great restlessness, aimless running about.

How do such anxiety equivalents originate? We can only say now that some symptoms manifestly obtrude and represent the whole picture of the anxiety neurosis. Certainly by a more careful examination, many other symptoms can be found (irritability, anxious expectation, and so on), thereby rapidly proving the typical picture of an anxiety neurosis.

For the cause of the anxiety neurosis there are several injurious developments of the sexual life to be considered. Freud (l.c.) treats the conditions of men and women separately. According to his experience the anxiety neurosis with women occurs in the following circumstances:—

"(a) As virginal anxiety or the anxiety of adolescence. A number of observations of undoubted significance have shown him, that a first meeting¹ with the sexual problem, or similarly, the sudden disclosure of that which was formerly concealed, the seeing a sexual act, sexually exciting information or a lecture, can produce an anxiety neurosis in a girl approaching maturity.

"(b) As anxiety of the newly married. Young women, who with the first cohabitation remain anæsthetic, often develop anxiety neurosis, which disappears when it gives place to the normal feeling.

"(c) As anxiety of women whose husbands suffer from ejaculatio præcox, or very reduced potency; and

"(d) Of women whose husbands practice coitus interruptus or reservatus. These cases go together, for we can be assured by the analysis of a great number of examples that it all depends upon whether the woman obtains satisfaction in coitus or not: in the latter case the conditions for an anxiety neurosis are present; on the other hand, the woman escapes the neurosis if the man who is troubled with ejaculatio præcox can repeat the congress immediately afterwards with better results. The congressus reservatus with the condom does not harm the woman if she is easily aroused and the man very potent; otherwise, this sort of preventive intercourse is no less harmful. Coitus interruptus is almost always harmful; but for the woman it is only harmful if the man is thoughtless, that is, if he interrupts as soon as the ejaculation approaches, without troubling about the state of the woman. If on the contrary, the man waits for the satisfaction of the woman, then such a coitus has for her the same significance as a normal one: but in that case, the man is the victim of an anxiety neurosis.

"(e) As anxiety of widows and those who abstain intentionally. Not seldom in typical combination with compulsory ideas.

"(f) As anxiety in climacterium during the last great increase of the sexual need."

Freud places men in the following groups which likewise have their analogies among women:—

"(a) Anxiety of the intentional abstainer, frequently combined with symptoms of defence (compulsory ideas, hysteria). The motives which could account for intentional abstinence would also account for a number of peculiarities, hereditary traits and so on of this category.

"(b) Anxiety of men with frustrated desires (during courtship). The men who (out of fear of the consequence of sexual intercourse) satisfy themselves with touching and looking at women. This group of conditions, which can likewise be transferred to the other sex unaltered, (courtship with sexual abstinence) supply the clearest cases of neurosis.

"(c) Anxiety neuroses of men who practice coitus interruptus. As already remarked, coitus interruptus is harmful to the woman if consideration is not shown for her satisfaction. It is also harmful for the man, if he, in order to satisfy the woman, manages by force of will, to delay the ejaculation. In this way we can understand why among married people given to this practice, usually only one of them suffer. Coitus interruptus seldom creates in men a pure anxiety neurosis, but usually a mixture with neurasthenia.

"(d) Anxiety of men in senium. There are men, who like women, show a climacterium, and at the time of their descending potency, and increasing libido, manifest anxiety neurosis."

"Finally "—Freud remarks—"I must include two cases that serve for both sexes:—

"(e) The neurasthenics, who practise masturbation, develop an anxiety neurosis as soon as they give up their mode of sexual satisfaction. These people have made themselves particularly incapable of bearing abstinence."

Freud emphasizes here as an important point in the anxiety neuroses, that any remarkable development of it can only arise with men who have remained still potent and with women who are not anæsthetic. With neurasthenics who have already seriously depreciated their potency, the anxiety neurosis in cases of abstinence, is very mild and is limited mainly to hypochondria and slight chronic giddiness. The majority of women must be considered as potent; a really impotent, that means, anæsthetic woman, is likewise not easily accessible to anxiety neurosis and bears the afore-mentioned disadvantages extremely well.¹

"(f) The last ætiological conditions to be mentioned do not appear to be of an especially sexual nature. The anxiety neurosis originates in both sexes through over-work, exhaustion and strain; for example, night-duty, tending the sick, and even after severe illness."

It will be seen from our material that the latter is only the releasing cause. An already exhausted body cannot withstand the attack of a neurosis that has already been preparing for a long time. For a single example will show us that the individual on such an occasion is brought into severe psychical conflict, sufficient to disturb the psychic equilibrium.

The deeper I penetrate into the nature of the so-called "neuroses so much the stronger becomes my conviction that it only concerns disorders of the feelings, thus, parapathia." Above all, one must never be satisfied with a superficial anamnesia, but must always employ profound analytic investigation to find the basic truth.

In earlier editions I have supplemented Freud’s statements:—

(g) There are a large number of variations in the practice of coitus prolongatus or of prolonging the orgasm. I am reminded of a case in which a man read a newspaper or a novel, thereby prolonging the act up to half-an-hour. Another counted up to a thousand. The third repeated the Roman Emperors. All these men suffered from an anxiety neurosis. In the same way women try to suppress the Libido, in order to prevent pregnancy and thereby become liable to a severe anxiety neurosis.

(h) Many men have the remarkable idea that the loss of the sperm is very harmful and robs the body of its best energy. Such men practise coitus sine ejaculatione, a particularly harmful form of cohabitation. Coitus interruptus sine ejaculatione is, more frequently than one would suppose, the cause of an anxiety neurosis.

(i) Also, "masturbatio interrupta and pollutio interrupta" play their part in originating an anxiety neurosis. Rohleder has been the first to call attention to this very important and frequent form of masturbatio interrupta (Zeitschrift für Sexualwissenschaft, 1908, Nr. 8, und, Vorlesungen über den Geschlechtstrieb und das gesamte Geschlechtsleben des Menschen). The pollutio interrupta was first described by P. Näcka (Einiges über Pollutionen. Neurol. Centralbl, 1909. Nr. 20, und Ueber die pollutio interrupta, Münch, med. Wochenschr, 1909, Nr. 34.)

(j) Masturbatio prolongata is another cause of anxiety neurosis. For instance, one of my patients could practise masturbation ten times in a night, without allowing an ejaculation. He showed symptoms of a severe anxiety neurosis. While on the other hand, I knew a young man of medium strength who could practise masturbation with ejaculation, five to ten times in an hour, without showing any neurotic symptoms. As soon as he ceased the practice of onanism, he developed severe neurotic symptoms. That is an experience that any physician can easily note.

(k) Further, an anxiety neurosis can originate, if a man or a woman imagines another person, during cohabitation, or uses phantasy in order to obtain the orgasm.

(l) One often meets men, who carry on a normal coitus, but nevertheless suffer from anxiety neurosis. If one investigates for any length of time—for these intimate things do not come up in the first hours of talk—one realises that one is treating persons whose sexual desires strive after some different kind of satisfaction. For instance, a married homosexual will, despite the so-called normal satisfaction, suffer from an anxiety neurosis: so to a pervert woman the normal coitus is an act of onanism. (Relative abstinence!)

How does Freud describe the etiology of anxiety neurosis? He believes that the libido is converted into anxiety in some mysterious (chemical or organic) manner. I have again and again been able to prove the relationship which Freud has described, and tempted by these facts, I accepted this libido theory.

After a more precise investigation of all the facts, I have completely abandoned it.

I do not believe that physical harm comes to the nervous system by means of frustrated excitation.

I have found in every anxiety neurosis a psychical cause.

I conveyed these facts to Freud and he proposed to distinguish two sorts of anxiety neuroses: one with a pure somatic basis, Freud’s genuine anxiety neurosis, and one with a psychical basis, which he terms anxiety hysteria. But in the second edition of this work (page 22) I wrote: "I may here, however, emphasize that the distinction between anxiety neurosis and anxiety hysteria is more clearly worked out in this book from a theoretical point of view than from practical experience. The sexual disorder contains within itself the germ of the psychic conflict. The unsatisfied man will long for other objects from which he expects full satisfaction; the same with the unsatisfied woman. This produces in marriage a series of traumatic wish-phantasies, which create a torturing sense of guilt.

"That is really the germ of the whole truth. There is no anxiety neurosis, only an anxiety hysteria. Or we will call anxiety neurosis every psychical suffering in which the effect of the anxiety is in any way somatically expressed. I retain the expression anxiety neurosis, not in Freud’s meaning of actual neurosis, but as psycho-neurosis. Illness in which the anxiety is expressed somatically (mostly mono-symptomatic) we will treat of as anxiety neurosis, while according to an old custom, we will treat the complicated psychical anxiety conditions as phobias.

All symptoms of an anxiety neurosis can be explained by a psychical conflict.

I return to the formula which I first used in my pamphlet of 1908, Die Ursachen der Nervosität: Every Neurosis originates through a psychical conflict!

This psychical conflict explains the great irritability of the anxiety neurotics. They are—as are all unsatisfied and unhappy people—in a continual ferment. They show an increased affectivity and sensitiveness, which are indicated by touchiness and irritability. Their absence of mind and forgetfulness can also be explained by psychic factors. People who are continually occupied with themselves, think inwardly, and those whose affectivity is focussed on their complexes, cannot turn their attention to anything except their complexes. Anxious expectation is the result of their inward distraction.

We must learn to understand truly the nature of anxiety. Anxiety is a wish of the inner man that is always censored and rejected by the moral self. When two wishes fight in a man’s breast, wishes that show a tendency to bipolarity—the one as a sign of social obedience in the service of culture, the other as a rebel in the power of the life of impulse—the stronger wish asserts itself, and the weaker appears in consciousness as anxiety. Anxiety is repressed desire. That distinguishes anxiety from fear. The anxiety is only apparently not attached to an object. The object is merely concealed from consciousness.

Anxious expectation corresponds to the unfulfilled wish. I have already in the second edition drawn attention to the psychical roots of anxiety after exhaustion (Point (f) of Freud’s thesis). I said there (page 12): This form of anxiety neurosis can according to the latest experience be traced back to psychical causes only.—Of course one must take into account that many of the people who act as nurse must live in a state of abstinence, for example, the wife who attends her sick husband, and so on. Very often in these cases there exists a repressed death-wish. The evil wish: ‘Oh, if only the patient would die, then I should be free and all possibilities open to me’ flashes for a second through the mind, and becomes the source of an extreme feeling of guilt. They atone for this by showing excessive anxiety and care for the patient, and in the case of death express it by a prolonged (unnaturally severe) grief.

The more precise and profound investigation of my material has convinced me that the anxiety neurosis is always caused by psychical factors, and that the so-called frustrated excitation, lacking such a conflict, has no harmful tendencies. I have observed men who have practised coitus interruptus for many years, and found satisfaction in it. They were exempt from all signs of anxiety neurosis. This also confirms the observations of Havelock Ellis which he expresses in his Geschlecht und Gesellschaft (II. Teil, Würzburg, Kurt Kabitsch, 1911). It treats of the so-called sect, Male continence, founded by Noyes. Every man was the husband of every woman, but he was only allowed to beget children by one. There were certainly two kinds of cohabitation, a propogative and non-propogative. It was the duty of the man to prolong the coitus for an hour, which was obtained by delaying the orgasm. Most of the members of the sect were perfectly healthy, only two, who had carried it to excess, showed slight signs of nervous disorder. This interesting observation shows, that excluding wishphantasies and the psychic conflict, coitus interruptus is, in and for itself, somatically an indifferent procedure.

I have known men who were able to extend coitus for an hour, and, finally, to accomplish coitus in anum, irrumatio or coitus inter mammas with ejaculation. I have not been able to find in these men more nervous symptoms, if they are free from psychic conflicts, than in other men who practise normal intercourse.

The basic condition is, that the man should find his sexual satisfaction from the woman he loves and desires. If this is not the case, then dissatisfaction and weariness result, and after coitus a variety of symptoms and pains will appear; these are, however, all psychically determined, as are the various troubles after masturbation.

Every unsatisfied man who is filled with wish-phantasies that his sexual partner cannot satisfy, becomes liable to an anxiety neurosis; also the successful repression of criminality leads to an anxiety neurosis, as shown by the example of the cashier, on page 8.

We come then to a single formula for the sexual etiology of anxiety neuroses: it runs as follows:—

Every individual who cannot find a form of sexual satisfaction adequate to himself, or is in severe psychical conflict between criminality and morality suffers from an anxiety neurosis.

An anxiety neurosis is the disease of a bad conscience. It might be a bad conscience arising from tabooed sexual impulses, or from a bad social conscience. It can always be proved that the ideal-self of the individual has come into conflict with his impulsive self.

Where the instinct of self-preservation and the conscience, i.e., the sum of all inhibitive ideas which interpose themselves between impulse and action, clash, the conditions for an anxiety neurosis have been established.

¹ Neurologisches Zentralblatt, 1895, und in den Beiträgen zur Neurosenlehre, Bd. I, Franz Deuticke. Wien und Leipzig, 1910.

² Uber larvierte und abortive Angstzustände bei Neurasthenie. Zentralblatt für Nervenheilkunde, 1893.

¹ Die Psychischen Zwangserscheinungen. J. F. Bergmann, Wiesbaden.

¹ A. Pick (Neurol. Zentralbl, 1903, Nr. 1) has explained similar conditions through an attack of agnosia. He has also had experience with patients who are epileptics and hysterical, who often without positive psychosensory anæsthesia or paræsthesia, complain of a feeling of strangeness in their surroundings. Löwenfeld (Die psychischen Zwangerscheinugen. Wiesbaden, 1904) classifies these symptoms under Zwangsgefül des Fremdartigen and Zwangspfindungen. In a new work, ( Uber traumartige und verwandte Zustände, Zentrabl, F. Nervenhlk. Psych., 1909. Bd. XX.) the same author draws attention to the importance of the affect underlying the phenomena. Cf. the Chapter The Feeling of Strangeness in Life and in the Dream in my book, Die Sprache des Traumes (The Language of Dreams) J. F. Bergmann, 1911.

¹ In India there is said to be a custom of discovering a thief. All the domestics are called together and some grains of rice are put into the mouth of each. The one whose rice remains dry is judged to be the thief, since anxiety stops the secretion of saliva. Alois Pick, Zur Kenntnis der Neurosen des Verdauungstraktes. (Med. Klinik, 1909, Nr. 40.)

² One of my patients, when shouted at,