CHAPTER VI.

ON THE RIGHT To SEPARATE FROM NEURASTHENIA A DEFINITE
SYMPTOM-COMPLEX AS “ ANXIETY NEUROSIS.”

(ANGSTNEUROSE.)

It is difficult to assert anything of general validity concerning
neurasthenia as long as this term is allowed to express all that
for which Beard used it. I believe that neuropathology can only
gain by an attempt to separate from the actual neurosis all those
neurotic disturbances the symptoms of which are on the one hand
more firmly connected among themselves than to the typical
neurasthenic symptoms, such as headache, spinal irritation, dys-
pepsia with flatulence and constipation, and which on the other
hand show essential differences from the typical neurasthenic
neurosis in their etiology and mechanism. If we accept this plan
we will soon gain quite a uniform picture of neurasthenia. We
will soon be able to differentiate—sharper than we have hitherto
succeeded—from the real neurasthenia the different pseudo-
neurasthenias, such as the organically determined nasal reflex
neurosis, the neurotic disturbances of cachexias and arterio-
sclerosis, the early stages of progressive paralysis, and of some
psychoses. Furthermore, following the proposition of Moebius,
some status nervosi of hereditary degenerates will be set aside
and we will also find reasons for ascribing some of the neuroses
which are now called neurasthenia to melancholia, especially
those of an intermittent or periodic nature. But we force the
way into the most marked changes if we decide to separate from
neurasthenia that symptom-complex which I shall hereafter de-
scribe and which especially fulfills the conditions formulated
above. The symptoms of this complex are clinically more re-
lated to one another than to the real neurasthenic symptoms, that
is, they frequently appear together and substitute for one another
in the course of the disease, and both the etiology as well as the
mechanism of this neurosis differs basically from the etiology

133

134 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES.

and the mechanism of the real neurasthenia which remains after
such a separation.

I call this symptom-complex “anxiety neurosis” (Angstneurose)
because the sum of its components can be grouped around the
main symptom of anxiety, because each individual symptom
shows a definite relation to anxiety. I believed that I was orig-
inal in this conception of the symptoms of anxiety neurosis until
an interesting lecture by E. Hecker* fell into my hands. In this
lecture I found the description of the same interpretation with
all the desired clearness and completeness. To be sure, Hecker
does not separate the equivalents or rudiments of the attack of
anxiety from neurasthenia as I intend to do; but this is appar-
ently due to the fact that neither here nor there has he taken
into account the diversity of the etiological determinants. With
the knowledge of the latter difference every obligation to desig-
nate the anxiety neurosis by the same name as the real neuras-
thenia disappears, for the only object of arbitrary naming is to
facilitate the formulation of general assertions.

I. CLINICAL SYMPTOMATOLOGY OF ANXIETY NEUROSIS.

What I call “anxiety neurosis” can be observed in complete or
rudimentary development, either isolated or in combination with
other neuroses. The cases which are in a measure complete, and
at the same time isolated, are naturally those which especially
corroborate the impression that the anxiety neurosis possesses
clinical independence. In other cases we are confronted with
the task of selecting and separating from a symptom-complex
which corresponds to a “mixed neurosis,” all those symptoms
which do not belong to neurasthenia, hysteria, etc., but to the
anxiety neurosis.

The clinical picture of the anxiety neurosis comprises the fol-
lowing symptoms:

I. General Irritability. — This is a frequent nervous symptom,
common as such to many nervous states. I mentioned it here be-

1E. Hecker, Uber larvierte und abortive Angstzustinde bei Neuras-
thenie, Centralblatt fiir Nervenheilkunde, December, 1893.—Anxiety is
made particularly prominent among the chief symptoms of neurasthenia

by Kaan, Der neurasthenische Angstaffekt bei Zwangsvorstellungen und
der primordiale Griibelzwang, Wien, 1893.

“ ANXIETY NEUROSES.” 135

cause it constantly occurs in the anxiety neurosis and is of theo-
retical significance. For increased irritability always points to
an accumulation of excitement or to an inability to bear accumu-
lation, hence to an absolute or relative accumulation of excite-
ment. The expression of this increase irritability through an
auditory hyperesthesia is especially worth mentioning; it is an
over-sensitiveness for noises, which symptom is certainly to be
explained by the congenital intimate relationship between audi-
tory impressions and fright. Auditory hyperesthesia is fre-
quently found as a cause of insomnia, of which more than one
form belongs to anxiety neurosis.

2. Anxious Expectation.—I can not better explain the condi-
tion that I have in mind, than by this name and by some appended
examples. A woman, for example, who suffers from anxious
expectation thinks of influenza-pneumonia whenever her husband
who is afflicted with a catarrhal condition has a coughing spell;
and in her mind she sees a passing funeral procession. If on her
way home she sees two persons standing together in front of her
house she can not refrain from the thought that one of her chil-
dren fell out of the window ; if she hears the bell ring she thinks
that someone is bringing her mournful tidings, etc.; yet in none
of these cases is there any special reason for exaggerating a mere
possibility.

The anxious expectation naturally reflects itself constantly in
the normal, and embraces all that is designated as “uneasiness
and a tendency to a pessimistic conception of things,” but as often
as possible it goes beyond such a plausible uneasiness, and it is
frequently recognized as a part of constraint even by the patient
himself. For one form of anxious expectation, namely, that
which refers to one’s own health, we can reserve the old name of
hypochondria. Hypochondria does not always run parallel with
the height of the general anxious expectation; as a preliminary
stipulation it requires the existence of paresthesias and annoying
somatic sensations. Hypochondria is thus the form preferred by
the genuine neurasthenics whenever they merge into the anxiety
neurosis, a thing which frequently happens.

As a further manifestation of anxious expectation we may
mention the frequent tendency observed in morally sensitive
persons to pangs of conscience, scrupulosity, and pedantry, which

136 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES.

varies, as it were, from the normal to its aggravation as doubting
mania.

Anxious expectation is the most essential symptom of the neu-
rosis; it also clearly shows a part of its theory. It can perhaps
be said that we have here a quantum of freely floating anxiety
which controls the choice of ideas by expectation and is forever
ready to unite itself with any suitable ideation.

3. This is not the only way in which the anxiousness, usually
latent but constantly lurking in consciousness, can manifest itself.
On the contrary it can also suddenly break into consciousness
without being aroused by the issue of an idea, and thus provoke
an attack of anxiety. Such an attack of anxiety consists of
either the anxious feeling alone without any associated idea, or
of the nearest interpretation of the termination of life, such as
the idea of "sudden death” or threatening insanity ; or the feeling
of anxiety becomes mixed with some paresthesia (similar to the
hysterical aura) ; or finally the anxious feeling may be combined
with a disturbance of one or many somatic functions, such as
respiration, cardiac activity, the vasomotor innervation, and the
glandular activity. From this combination the patient renders
especially prominent now this and now the other moment. He
complains of “heartspasms,” “heavy breathing,” “profuse per-
spiration,” “inordinate appetite,” etc., and in his description the
feeling of anxiety is put to the background or it is rather vaguely
described as “feeling badly,” “uncomfortably,” etc.

4. What is interesting and of diagnostic significance is the fact
that the amount of admixture of these elements in the attack of
anxiety varies extraordinarily, and that almost any accompanying
symptom can alone constitute the attack as well as the anxiety
itself. Accordingly, there are rudimentary attacks of anxiety,
and equivalents for the attack of anxiety, probably all of equal
significance in showing a profuse and hitherto little appreciated
richness in forms. A more thorough study of these larvated
states of anxiety (Hecker) and their diagnostic division from
other attacks ought soon to become the necessary work for the
neuropathologist.

I now add a list of those forms of attacks of anxiety with
which I am acquainted. There are attacks:

(a) With disturbances of heart action, such as palpitation with

“ ANXIETY NEUROSES.” 137

transitory arhythmia, with longer continued tachycardia up to
grave states of heart weakness, the differentiation of which from
organic heart affection is not always easy; among such we have
the pseudo-angina pectoris, a delicate diagnostic sphere!

(b) With disturbances of respiration, many forms of nervous
dyspnea, asthma-like attacks, etc. I assert that even these at-
tacks are not always accompanied by conscious anxiety ;

(c) Of profuse perspiration, often nocturnal;

(d) Of trembling and shaking which may readly be mistaken
for hysterical attacks;

(e) Of inordinate appetite, often combined with dizziness ;

(f) Of attack-like appearing diarrhea;

(g) Of locomotor dizziness;

(h) Of so-called congestions, embracing all that was called
vasomotor neurasthenia ; and,

(i) Of paresthesias (these are seldom without anxiety or a
similar discomfort).

5. Very frequently the nocturnal frights (pavor nocturnus of
adults) usually combined with anxiety, dyspnea, perspiration, etc.,
is nothing other than a variety of the attack of anxiety. This
disturbance determines a second form of insomnia in the sphere
of the anxiety neurosis. Moreover, I became convinced that
even the pavor nocturnus of children evinces a form belonging
to the anxiety neurosis. The hysterical tinge and the connection
of the fear with the reproduction of appropriate experience or
dream, makes the pavor nocturnus of children appear as some-
thing peculiar, but it also occurs alone without a dream or a re-
curring hallucination.

6. “ Vertigo."— This in its lightest forms is better designated
as “dizziness,” assumes a prominent place in the group of symp-
toms of anxiety neurosis. In its severer forms the “attack of
vertigo,” with or without fear, belongs to the gravest symptoms
of the neurosis. The vertigo of the anxiety neurosis is neither
a rotatory dizziness nor is it confined to certain planes or lines
like Menier’s vertigo. It belongs to the locomotor or coördinat-
ing vertigo, like the vertigo in paralysis of the ocular muscles;
it consists in a specific feeling of discomfort which is accom-
panied by sensations of a heaving ground, sinking legs, of the
impossibility to continue in an upright position, and at the same

138 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES.

time there is feeling that the legs are as heavy as lead, they
shake, or give way. This vertigo never leads to falling. On the
other hand, I would like to state that such an attack of vertigo
may also be substituted by a profound attack of syncope. Other
fainting-like states in the anxiety neurosis seem to depend on a
cardiac collapse.

The vertigo attack is frequently accompanied by the worst kind
of anxiety and is often combined with cardiac and respiratory
disturbances. Vertigo of elevations, mountains and precipices,
can also be frequently observed in anxiety neurosis; moreover, I
do not know whether we are still justified in recognizing a ver-
tigo “a stomacho laeso.”

7. On the basis of the chronic anxiousness (anxious expecta-
tion) on the one hand, and the tendency to vertiginous attacks
of anxiety on the other, there develop two groups of typical
phobias; the first refers to the general physiological menaces,
while the second refers to locomotion. To the first group belong
the fear for snakes, thunderstorms, darkness, vermin, etc., as well
as the typical moral overscrupulousness, and the forms of doubt-
ing-mania. Here the available fear is merely used to strengthen
those aversions which are instinctively implanted in every man.
But usually a compulsively acting phobia is formed only after a
reminiscence is added to an experience in which this fear could
manifest itself ; as, for example, after the patient has experienced
a storm in the open air. To attempt to explain such cases as
mere continuations of strong impressions is incorrect. What
makes these experiences significant and their reminiscences dura-
ble is after all only the fear which could at that time appear and
can also appear today. In other words, such impressions remain
forceful only in persons with “anxious expectations.”

The other group contains agoraphobia with all its accessory
forms, all of which are characterized by their relation to loco-
motion. As a determination of the phobia we frequently find a
precedent attack of vertigo; I do not think that it can always
be postulated. Occasionally, after a first attack of vertigo with-
out fear, we see that though locomotion is always accompanied
by the sensation of vertigo, it remains possible without restric-
tions, but as soon as fear attaches itself to the attack of vertigo,

* ANXIETY NEUROSES.” 139

locomotion fails, under the conditions of being alone, narrow
streets, etc.

The relation of these phobias to the phobias of obsessions,
which mechanism I discussed above,? is as follows: The agree-
ment lies in the fact that here as there, an idea becomes obsessive
through its connection with an available affect. The mechanism
of transposition of the affect therefore holds true for both kinds
of phobias. But in phobias of the anxiety neurosis this affect is
(1) a monotonous one, it is always one of anxiety; (2) it does
not originate from a repressed idea, and on psychological analysis
it proves itself not further reducible, nor can it be attacked
through psychotherapy. The mechanism of substitution does
not therefore hold true for the phobias of anxiety neurosis.

Both kinds of phobias (or obsessions) often occur side by side,
though the atypical phobias which depend on obsessions need
not necessarily develop on the basis of anxiety neurosis. A very
frequent, ostensibly complicated mechanism appears if the con-
tent of an original simple phobia of anxiety neurosis is substi-
tuted by another idea, the substitution is then subsequently added
to the phobia. The “protective measures” originally employed
in combating the phobia are most frequently used as substitutions.
Thus, for example, from the effort to provide oneself with coun-
ter evidence that one is not crazy, contrary to the assertion of the
hypochondriacal phobia, there results a reasoning mania. The
hesitations, doubts, and the many repetitions of the folie du
doute originate from the justified doubt concerning the certainty
of one’s own stream of thoughts, for, through the compulsive-
like idea one is surely conscious of so obstinate a disturbance, etc.
It may therefore be claimed that many syndromes of compulsion
neurosis, like the folie du doute and similar ones, can clinically,
if not notionally, be attributed to anxiety neurosis.®

8. The digestive functions in anxiety neurosis are subject to -
very few but characteristic disturbances. Sensations like nausea
and sickly feeling are not rare, and the symptom of inordinate
appetite alone or with other congestions, may serve as a rudi-
mentary attack of anxiety. As a chronic alteration analogous to
the anxious expectations one finds a tendency to diarrhea which

2 Die Abwehr-Neuropsychosen, Neurol. Centralbl., 1894, Nr. 10 u. II.

8 Obsession et phobies, Révue neurologique, 1895.

10

140 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES,

has occasioned the queerest diagnostic mistakes. If I am not
mistaken it is this diarrhea to which Moebius* has recently called
attention in a small article. I believe, moreover, that Peyer's*
reflex diarrhea which he attributes to a disease of the prostate
is nothing other than the diarrhea of anxiety neurosis. The
deceptive reflex relation is due to the fact that the same factors
which are active in the origin of such prostatic affections also
come into play in the etiology anxiety neurosis.

The behavior of the gastro-intestinal function in anxiety neu-
rosis shows a sharp contrast to the influence of this same func-
tion in neurasthenia. Mixed cases often show the familiar
“fluctuations between diarrhea and constipation.” The desire
to urinate in anxiety neurosis is analogous to the diarrhea.

9. The paresthesias which accompany the attack of vertigo or
anxiety are interesting because they associate themselves into a
firm sequence, similar to the sensations of the hysterical aura.
But in contrast to the hysterical aura I find these associated sen-
sations atypical and changeable. Another similarity to hysteria
is shown by the fact that in anxiety neurosis a kind of conversion®
into bodily sensations, as, for example, into rheumatic muscles,
takes place which otherwise can be overlooked at one’s pleasure.
A large number of so-called rheumatics, who are, moreover,
demonstrable as such, really suffer from an anxiety neurosis.
Besides this aggravation of the sensation of pain I have observed
in a number of cases of anxiety neurosis a tendency towards hal-
lucinations which could not be explained as hysterical.

10. Many of the so-called symptoms which accompany or sub-
stitute the attack of anxiety also appear in a chronic manner.
They are then still less discernible, for the anxious feeling accom-
panying them appears more indistinct than in the attack of
anxiety. This especially holds true for the diarrhea, vertigo, and
paresthesias. Just as the attack of vertigo can be substituted by
an attack of syncope, so can the chronic vertigo be substituted
by the continuous feeling of feebleness, lassitude, etc.

4 Moebius, Neuropathologische Beiträge, 1804, 2. Heft.

5 Peyer, Die nervôsen Affektionen des Darmes, Wiener Klinik, Januar,
1893.

5 Freud, Abwehr-Neuropsychosen.

* ANXIETY NEUROSES,” 141

II. THE OCCURRENCE AND ETIOLOGY OF ANXIETY NEUROSIS.

In some cases of anxiety neurosis no etiology can readily be
ascertained. It is noteworthy that in such cases it is seldom
difficult to demonstrate a marked hereditary taint.

Where we have reason to assume that the neurosis is acquired
we can find by careful and laborious examination that the etio-
logically effective moments are based on a series of injuries and
influences from the sexual life. These at first appear to be of
a varied nature but easily display the common character which
explains their homogeneous effect on the nervous system. They
are found either alone or with other banal injuries to which a
reinforcing effect can be attributed. This sexual etiology of
anxiety neurosis can be demonstrated so preponderately often
that I venture for the purpose of this brief communication to set
aside all cases of a doubtful or different etiology.

For the more precise description of the etiological determina-
tions under which anxiety neurosis occurs, it will be advisable to
treat separately those occurring in men and those occurring in
women. Anxiety neurosis appears in women—disregarding their
predisposition—in the following cases:

(a) As virginal fear or anxiety in adults. A number of un-
equivocal observations showed me that an anxiety neurosis, which
is almost typically combined with hysteria, can be evoked in
maturing girls, at the first encounter with the sexual problem,
that is, at the sudden revelation of the things hitherto veiled, by
either seeing the sexual act, or by hearing or reading something
of that nature;

(b) As fear in the newly married. Young women who remain
anesthetic during the first cohabitation not seldom merge into an
anxiety neurosis which disappears after the anesthesia is dis-
placed by the normal sensation. As most young women remain
undisturbed through such a beginning anesthesia, the production
of this fear requires determinants which I will mention ;

(c) As fear in women whose husbands suffer from ejaculatio
precox or from diminished potency; and,

(d) In those whose husbands practice coitus interruptus or
reservatus. These cases go together, for on analyzing a large
number of examples one can easily be convinced that they only
depend on whether the woman attained gratification during coitus

142 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES.

or not. In the latter case one finds the determinant for the origin
of anxiety neurosis. On the other hand the woman is spared
from the neurosis if the husband afflicted by ejaculatio precox
can repeat the congress with better results immediately thereafter.
The congressu reservatus by means of the condom is not injurious
to the woman if she is quickly excited and the husband is very
potent ; in other cases the noxiousness of this kind of preventive
measure is not inferior to the others. Coitus interruptus is
almost regularly injurious; but for the woman it is injurious only
if the husband practices it regardlessly, that is, if he interrupts
coitus as soon as he comes near ejaculating without concerning
himself about the determination of the excitement of his wife.
On the other hand, if the husband waits until his wife is gratified,
the coitus has the same significance for the latter as a normal
one; but then the husband becomes afflicted with an anxiety
neurosis. I have collected and analyzed a number of cases which
furnished the material for the above statements.

(e) As fear in widows and intentional abstainers, not seldom
in typical combination with obsessions; and,

(f) As fear in the climacterium during the last marked en-
hancement of the sexual desire.

The cases (c), (d), and (e) contain the determinants under
which the anxiety neurosis originates in the female sex, most
frequently and most independently of hereditary predisposition.
I will endeavor to demonstrate in these—curable, acquired—cases
of anxiety neurosis that the discovered sexual injuries really rep-
resent the etiological moments of the neurosis. But before pro-
ceeding I will mention the sexual determinants of anxiety neu-
rosis in men. I would like to formulate the following groups,
every one of which finds its analogy in woman:

(a) Fear of the intentional abstainers; this is frequently com-
bined with symptoms of defense (obsessions, hysteria). The
motives which are decisive for intentional abstinence carry along
with them the fact that a number of hereditarily burdened eccen-
trics, etc., belong to this category.

(5) Fear in men with frustrated excitement (during the en-
gagement period), persons who out of fear for the consequences
of sexual relations satisfy themselves with handling or looking at
the woman. This group of determinants which can moreover be

* ANXIETY NEUROSES.” 143

transferred to the other sex—engagement periods, relations with
sexual forbearance—furnish the purest cases of the neurosis.

(c) Fear in men who practice coitus interruptus. As observed
above, coitus interruptus injures the woman if it is practiced
regardless of the woman's gratification; it becomes injurious to
the man if in order to bring about the gratification in the woman
he voluntarily controls the coitus by delaying the ejaculation. In
this manner we can understand why it is that in couples who
practice coitus interruptus it is usually only one of them who
becomes afflicted. Moreover the coitus interruptus only rarely
produces in man a pure anxiety neurosis, usually it is a mixture
of the same with neurasthenia.

(d) Fear in men in the senium. There are men who show a
climacterium like women, and merge into an anxiety neurosis at
the time when their potency diminishes and their libido increases.

Finally I must add two more cases holding true for both sexes:

(e) Neurasthenics merge into anxiety neurosis in consequence
of masturbation as soon as they refrain from this manner of
sexual gratification. These persons have especially made them-
selve unfit to bear abstinence.

What is important for the understanding of the anxiety neu-
rosis is the fact that any noteworthy development of the same
occurs only in men who remain potent, and in non-anesthetic
women. In neurasthenics, who on account of masturbation have
markedly injured their potency, anxiety neurosis as a result of
abstinence occurs but rarely and limits itself usually to hypo-
chondria and light chronic dizziness. The majority of women
are really to be considered as “potent”; a real impotent, that
is, a real anesthetic woman, is also inaccessible to anxiety neu-
rosus, and bears strikingly well the injuries cited.

How far we are perhaps justified in assuming constant rela-
tions between individual etiological moments and individual
symptoms from the complex of anxiety neurosis, I do not care
to discuss here.

(f) The last of the etiological determinants to be mentioned
seems, in the first place, really not to be of a sexual nature.
Anxiety neurosis originates in both sexes through the moment of
overwork, exhaustive exertion, as, for instance, after sleepless
nights, nursing the sick, and even after serious illnesses.

144 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES.

The main objection against my formulation of a sexual etiology
of the anxiety neurosis will probably be to the purport that such
abnormal relations of the sexual life can be found so very often
that wherever one will look for them they will be found near at
hand. Their occurrence, therefore, in the cases cited of anxiety
neurosis does not prove that the etiology of the neurosis was
revealed in them. Moreover, the number of persons practicing
coitus interruptus, etc., is incomparably greater than the num-
ber of those who are burdened with anxiety neurosis, and the
overwhelming number of the first are quite well in spite of this
injury.

To this I can answer that we certainly ought not to expect a
rarely occurring etiological moment in the conceded enormous
frequency of the neurosis, and especially anxiety neurosis;
furthermore, that it really fulfills a postulate of pathology if on
examining an etiology the etiological moments can be more fre-
quently demonstrated than their effects, for, for the latter still
other determinants (predisposition, summation of the specific
etiology, reinforcement through other banal injuries) could be
demanded ; and furthermore, that the detailed analysis of suita-
ble cases of anxiety neurosis shows quite unequivocally the sig-
nificance of the sexual moment. I shall, however, here confine
myself to the etiological moment of coitus interruptus, and I will
render prominent obvious individual experiences.

1. As long as the anxiety neurosis in young women is not yet
constituted but appears in fragments which again spontaneously
disappear, it can be shown that every such turn of the neurosis
depends on a coitus. with lack of gratification. Two days after
this influence, and in persons of little resistance the day after,
there regularly appears the attack of anxiety or vertigo to which
all the other symptoms of the neurosis attach themselves, only
to separate again on rarer marriage relations. An unexpected
journey of the husband, a sojourn in the mountains causing a
separation of the married couple, does good; the benefit from a
course of gynecological treatment is due to the fact that during
its continuation the marriage relations are stopped. It is note-
worthy that the success of a local treatment is only transitory, the
neurosis reappears while in the mountains if the husband joins
his wife for his own vacation, etc. If,in a not as yet constituted

* ANXIETY NEUROSES.” 145

neurosis, a physician aware of this etiology causes a substitution
of the coitus interruptus by normal relations there results a
therapeutic proof of the assertion here formulated. The anxiety
is removed and does not return unless there be a new or similar
cause.

2. In the anamnesis of many cases of anxiety neurosis we find
in both men and women a striking fluctuation in the intensity of
the appearance in both the coming and going of the whole con-
dition. This year was almost wholly good, the following was
terrible, etc.; on one occasion the improvement occurred after a
definite treatment which, however, failed to produce a response
at the next attack. If we inform ourselves about the number
and the sequence of the children, and compare this marriage
chronicle with the peculiar course of the neurosis, the result of
the simple solution shows that the periods of improvement or
well being corresponded with the pregnancies of the woman
during which, naturally, the occasions for preventive relations
were unnecessary. The treatment which benefited the husband,
be it Father Kneip’s or the hydrotherapeutic institute, was the
one which he has taken after he found his wife was pregnant.

3. From the anamnesis of the patients we often find that the
symptoms of the anxiety neurosis are relieved at a certain time
by another neurosis, perhaps a neurasthenia which has supplanted
it. It can then be regularly demonstrated that shortly before
this change in the picture there occurred a corresponding change
in the form of a sexual injury.

Whereas such experiences, which can be augmented at pleasure,
plainly obtrude upon the physician the sexual etiology for a cer-
tain category of cases, other cases which would have otherwise
remained incomprehensible can at least without gainsaying be
solved and classified by the key of the sexual etiology. We refer
to those numerous cases in which everything exists that has been
found in the former category, such as the appearance of anxiety
neurosis on the one hand, and the specific moment of the coitus
interruptus on the other, but yet something else slips in, namely,
a long interval between the assumed etiology and its effect, and
perhaps other etiological moments of a non-sexual nature. We
have here, for example, a man who was seized with an attack
of palpitation on hearing of his father’s death, and who since

146 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES.

that time suffered from an anxiety neurosis. The case cannot
be understood, for up to that time this man was not nervous.
The death of the father, well advanced in years, did not occur
under any peculiar circumstances, and it must be admitted that
the natural expected death of an aged father does not belong to
those experiences which are wont to make a healthy adult sick.
The etiological analysis will perhaps seem clearer if I add that
out of regard for his wife this man practiced coitus interruptus
for eleven years. At all events the manifestations are precisely
the same as those appearing in other persons after a short sexual
injury of this nature, and without the intervention of another
trauma. The same judgment may be pronounced in the case of
a woman who merges into an anxiety neurosis after the death
of her child, or in the case of the student who becomes disturbed
by an anxiety neurosis while preparing for his final state examina-
tion. I find that here, as there, the effect is not explained by the
reported etiology. One must not necessarily “overwork” him-
self studying, and a healthy mother is wont to react to the death
of her child with normal grief. But, above all, I would expect
that the overworked student would acquire a cephalasthenia, and
that mother in our example a hysteria. That both became
afflicted with anxiety neurosis causes me to attach importance
to the fact that the mother lived for eight years in marital coitus
interruptus, and that the student entertained for three years a
warm love affair with a “ respectable ” girl whom he was not
allowed to impregnate.

These examples tend to show that where the specific sexual
injury of the coitus interruptus is in itself unable to provoke an
anxiety neurosis it at least predisposes to its acquisition. The
anxiety neurosis then comes to light as soon as the effect of
another banal injury enters into the latent effect of the specific
moment. The former can quantitatively substitute the specific
moment but not supplant it qualitatively. The specific moment
always remains that which determines the form of neurosis. I
hope to be able to prove to a greater extent this proposition for
the etiology of the neurosis.

Furthermore, the last discussions contain the, not in itself, im-
probable assumption that a sexual injury like coitus interruptus
asserts itself through summation. The time required before the

* ANXIETY NEUROSES.” 147

effect of this summation becomes visible depends upon the pre-
disposition of the individual and the former burdening of his
nervous system. The individuals who bear coitus interruptus
manifestly without disadvantage really become predisposed by it
to the disturbance—anxiety neurosis—which can at any time
burst forth spontaneously or after a banal, otherwise inadequate,
trauma, just as the chronic alcoholic finally develops a cirrhosis
or another disease by summation, or under the influence of a
fever he merges into a delirium.

III. ADDENDA TO THE THEORY OF ANXIETY NEUROSIS.

The following discussions claim nothing but the value of a first
tentative experiment, which judgment should not influence the
acceptance of the facts mentioned above. The estimation of this
“Theory of Anxiety Neurosis” is rendered still more difficult
by the fact that it merely corresponds to a fragment of a more
comprehensive representation of the neuroses.

The facts hitherto expressed concerning the anxiety neurosis
already contain some starting points for an insight into the mech-
anism of this neurosis. In the first place it contains the assump-
tion that we deal with an accumulation of excitement, and then
the very important fact that the anxiety underlying the mani-
festations of the neurosis is not of psychic derivation. Such, for
example, would exist if we found as a basis for the anxiety neu-
rosis a justified fright happening once or repeatedly which has
since supplied the source of the preparedness for the anxiety
neurosis. But this is not the case; a former fright can perhaps
cause a hysteria or a traumatic neurosis but never an anxiety
neurosis. As the coitus interruptus is rendered so prominent
among the causes of anxiety neurosis I have thought at first that
the source of the continuous anxiety was perhaps the repeated
fear during the sexual act lest the technique will fail and concep-
tion follow. But I have found that this state of mind of the man
or woman during the coitus interruptus plays no part in the
origin of anxiety neurosis, that the women who are really indif-
ferent to the possibilities of conception are just as exposed to the
neurosis as those who are trembling at the possibility of it, it all
depends on which persons suffers the loss of sexual gratification.

Another starting point presents itself in the as yet unmentioned

148 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES.

observation that in a whole series of cases the anxiety neurosis
goes along with the most distinct diminution of the sexual libido
or the psychic desire, so that on revealing to the patients that
their affliction depends on “insufficient gratification,” they regu-
larly reply that this is impossible as just now their whole desire is
extinguished. The indications that we deal with an accumulation
of excitement, that the anxiety which probably corresponds to
such accumulated excitement is of somatic origin, so that somatic
excitement becomes accumulated, and furthermore, that this
somatic excitement is of a sexual nature, and that it is accom-
panied by a decreased psychic participation in the sexual proc-
esses—all these indications, I say, favor the expectation that the
mechanism of the anxiety neurosis is to be found in the deviation
of the somatic sexual excitement from the psychic, and in the
abnormal utilization of this excitement.

This conception of the mechanism of anxiety neurosis will be-
come clearer if one accepts the following view concerning the
sexual process in man. In the sexually mature male organism,
the somatic sexual excitement is—probably continuously—pro-
duced, and this becomes a periodic stimulus for the psychic life.
To make our conceptions clearer we will add that this somatic
sexual excitement manifests itself as a pressure on the wall of
the seminal vesicle which is provided with nerve endings. This
visceral excitement thus becomes continuously increased, but not
before attaining a certain height is it able to overcome the resist-
ances of the intercalated conduction as far as the cortex, and
manifest itself as psychic excitement. Then the group of sexual
ideas existing in the psyche becomes endowed with energy and
results in a psychic state of libidinous tension which is accom-
panied by an impulse to remove this tension. Such psychic un-
burdening is possible only in one way which I wish to designate
as specific or adequate action. This adequate action for the
male sexual impulse consists of a complicated spinal reflex-act
which results in the unburdening of those nerve endings, and of
all psychically formed preparations for the liberation of this
reflex. Anything else except the adequate action would be of no
avail, for after the somatic sexual excitement has once reached
the liminal value, it continuously changes into psychic excite-
ment; that must by all means occur which frees the nerve end-

* ANXIETY NEUROSES,” 149

ings from their heavy pressure, and thus abolish the whole so-
matic excitement existing at the time and allow the subcortical
conduction to reéstablish its resistance.

I will desist from presenting in a similar manner more com-
plicated cases of the sexual process. I will merely formulate the
statement that this scheme can essentially be transferred to the
woman despite the problem of the perplexity, artificial retarda-
tion, and stunting of the female sexual impulse. In the woman,
too, it can be assumed that there is a somatic sexual excitement
and a state in which this excitement becomes psychic, evoking
libido and the impulse to specific action which is accompanied
by the sensual feeling. But we are unable to state what anal-
ogy there may be in the woman to the unburdening of the semi-
nal vesicles.

We can bring into the bounds of this representation of the
sexual process the etiology of actual neurasthenia as well as of
the anxiety neurosis. Neurasthenia always originates whenever
the adequate (action) unburdening is replaced by a less adequate
one, like the normal coitus under the most favorable conditions,
by a masturbation or spontaneous pollution; while anxiety neu-
rosis is produced by all moments which impede the psychic elabo-
ration of the somatic sexual excitement. The manifestations of
anxiety neurosis are brought about by the fact that the somatic
sexual excitement diverted from the psyche expends itself sub-
cortically in not at all adequate reactions.

Iwill now attempt to test the etiological determinants suggested
before in order to see whether they show the common character
formulated by me. As the first etiological moment for the man,
I have mentioned intentional abstinence. Abstinence consists in
foregoing the specific action which results from the libido. Such
foregoing may have two consequences, namely, that the somatic
excitement accumulates, and then, what is more important, is the
fact that it becomes diverted to another route where there is more
chance for discharge than through the psyche. It will then finally
diminish the libido and the excitement will manifest itself sub-
cortically as anxiety. Where the libido does not become dimin-
ished, or the somatic excitement is expended in pollutions, or
where it really becomes exhausted in consequence of repulsion,
everything else except anxiety neurosis is formed. In this man-

150 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES.

ner abstinence leads to anxiety neurosis. But abstinence is also
the active process in the second etiological group of frustrated
excitement. The third case, that of the considerate coitus reser-
vatus, acts through the fact that it disturbs the psychic prepared-
ness for the sexual discharge by establishing beside the subju-
gation of the sexual affect, another distracting psychic task.
Through this psychic distraction, too, the libido gradually dis-
appears and the further course is then the same as in the case of
abstinence. The anxiety in old age (climacterium of men) re-
quires another explanation. Here the libido does not diminish,
but just as in the climacterium of women, such an increase takes
place in the somatic excitement that the psyche shows itself rela-
tively insufficient for the subjugation of the same.

The subsummation of the etiological determinants in the wo-
man, under the aspect mentioned, does not afford any greater
difficulties. The case of the virginal fear is especially clear.
Here the group of ideas with which the somatic sexual excite-
ment should combine are not as yet sufficiently developed. In
anesthetically newly married the anxiety appears only if the first
cohabitations awakened a sufficient amount of somatic excite-
ment. Where the local signs of such excitability (like sponta-
neous feelings of excitement, desire to micturate, etc.) are lacking,
the anxiety, too, stays away. The case of ejaculatio precox or
coitus interruptus is explained similarly to that in the man by
the fact that the libido gradually disappears in the psychically
ungratified act, whereas the excitement thereby evoked is sub-
cortically expended. The formation of an estrangement be-
tween the somatic and psychic in the discharge of the sexual
excitement succeeds quicker in the woman than in the man and
is more difficult to remove. The case of widowhood or volun-
tary abstinence, as well as the case of climacterium, adjusts itself
in the woman as in the man, but in the case of abstinence there
surely is in addition the intentional repression of the sexual ideas,
for an abstinent woman struggling with temptation must often
decide to suppress it. The abhorrence perceived by an elderly
woman during her menopause against the immensely increased
libido can have a similar effect.

The two etiological determinants mentioned last can also be
classified without any difficulty.

* ANXIETY NEUROSES.” 151

The tendency to anxiety of the masturbator who becomes neu-
rasthenic is explained by the fact that these persons so easily
merge into the state of abstinence after they have for long been
accustomed to afford a discharge, to be sure an incorrect one, for
every little quantity of somatic excitement. Finally the last case,
the origin of anxiety neurosis through a severe illness, overwork,
exhaustive nursing, etc., in addition to the efficacy of coitus inter-
ruptus readily permits a free interpretation. Through deviation
the psyche becomes here insufficient for the subjugation of the
somatic sexual excitement, a task which continuously devolves
upon it. We know how deeply the libido can sink under the same
conditions, and we have here a nice example of a neurosis which
although not of a sexual etiology still evinces a sexual mechanism.

The conception here developed represents the symptoms of
anxiety neurosis in a measure as a substitute for the omitted spe-
cific action to the sexual excitement. As a further corroboration
of this I recall that also in normal coitus the excitement extends
itself in respiratory acceleration, palpitation, perspiration, con-
gestion, etc. In the corresponding attack of anxiety of our neu-
rosis we have before us the dyspnea, the palpitation, etc., of the
coitus in an isolated and aggravated manner.

It can still be asked why the nervous system merges into a
peculiar affective state of anxiety under the circumstances of
psychic inadequacy for the subjugation of the sexual excitement?
A hint to the answer is as follows: The psyche merges into the
affect of fear when it perceives itself unable to adjust an exter-
nally approaching task (danger) by corresponding reaction; it
merges into the neurosis of anxiety when it finds itself unable to
equalize the endogenously originated (sexual) excitement. The
psyche, therefore, behaves as if projecting this excitement exter-
nally. The affect and the neurosis corresponding to it stand in
close relationship to each other; the first is the reaction to an
exogenous, the latter the reaction to an analogous endogenous
excitement. The affect is a rapidly passing state, the neurosis is
chronic because the exogenous excitement acts like a stroke hap-
pening but once, while the endogenous acts like a constant force.
The nervous system reacts in the neurosis against an inner source
of excitement just as it does in the corresponding affect against
an analogous external one.

152 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES,

IV. THE RELATIONS TO OTHER NEUROSES.

A few observations still remain to be mentioned on the rela-
tions of the anxiety neurosis to the other neuroses in reference
to occurrence and inner relationship.

The purest cases of anxiety neurosis are also usually the most
pronounced. They are found in potent young individuals with a
uniform etiology, and where the disease is not of long standing.

To be sure, the symptoms of anxiety are found more fre-
quently as a simultaneous and common occurrence with those
of neurasthenia, hysteria, compulsive ideas, and melancholia. If
on account of such clinical mixtures one hesitates in recogniz-
ing anxiety neurosis as an independent unity, he will also have
to abandon the laboriously acquired separation of hysteria and
neurasthenia.

For the analysis of the “ mixed neuroses” I can advocate the
following proposition: Where a mixed neurosis exists, an in-
volvement of many specific etiologies can be demonstrated.

Such a multiplicity of etiological moments determining a mixed
neurosis can only come about accidentally, if the activities of a
newly formed injury are added to those already existing. Thus,
for example, a woman who was at all times a hysteric begins to
practice coitus reservatus at a certain period of her married life,
and adds an anxiety neurosis to her hysteria; a man who had
masturbated and become neurasthenic, becomes engaged and
excites himself and his fiancée so that a fresh anxiety neurosis
allies itself to his neurasthenia.

The multiplicity of etiological moments in other cases is not
accidental, one of them has brought the other into activity. Thus,
a woman, with whom her husband practices coitus reservatus ış
without regard to her gratification, finds herself forced to finish
the tormenting excitement following such an act with mastur-
bation, as a result of which she shows an anxiety neurosis with
symptoms of neurasthenia. Under the same noxiousness another
woman has to contend with lewd pictures against which she
wishes to defend herself, and in this way the coitus interruptus
will cause her to acquire obsessions along with the anxiety neu-
rosis. Finally a third woman, as a result of coitus interruptus
loses her affection for her husband and forms another which she

“ ANXIETY NEUROSES.” 153

secretly guards, and as a result she evinces a mixture of hys-
teria and anxiety neurosis.

In a third category of mixed neuroses the connection of the
symptoms is of a still more intimate nature, as the same etio-
logical determinants regularly and simultaneously evoke both
neuroses. Thus, for example, the sudden sexual explanation
which we have found in virginal fear always produces hysteria,
too; most causes of intentional abstinence connect themselves in
the beginning with actual obsessions; and it seems to me that
the coitus interruptus of men can never provoke a pure anxiety
neurosis, but always a mixture of the same with neurasthenia,
etc.

It follows from this discussion that the etiological determinants
of the occurrence must moreover be distinguished from the spe-
cific etiological moments of neurasthenia. The first moments,
as for example the coitus interruptus, masturbation, and absti-
nence, are still ambiguous, and can each produce different neu-
roses; and it is only the etiological moments abstracted from
them, like the inadequate unburdening, psychic insufficiency, and
defense with substitution, that have an unambiguous and specific
relation to the etiology of the individual great neuroses.

In its intrinsic property, anxiety neurosis shows the most in-
teresting agreements and differences when compared with the
other great neuroses, particularly when compared with neuras-
thenia and hysteria. With neurasthenia it shares one main char-
acter, namely, that the source of excitement, the cause of the
disturbance, lies in the somatic rather than in the psychic sphere
as in the case of hysteria and compulsion neurosis. For the rest
we can recognize a kind of contrast between the symptoms of
neurasthenia and anxiety neurosis, which can be expressed in the
catchwords, accumulation and impoverishment of excitement.
This contrast does not hinder the two neuroses from combining
with each other, but shows itself in the fact that the most ex-
treme forms in both cases are also the purest.

When compared with hysteria anxiety neurosis shows in the
first place a number of agreements in the symptomatology
the valuation of which is still unsettled. The appearance of the
manifestations as persistent symptoms or attacks, the aura-like
grouped paresthesias, the hyperesthesias and pressure points can

154 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES.

be found in certain substitutes for the anxiety attack, as in dysp-
nea and palpitation, the aggravation of the perhaps organically
determined pains (by conversion)—these and other joint features
lead to the supposition that some things which are ascribed to
hysteria can with full authority be fastened to anxiety neurosis.
But if we enter into the mechanism of both neuroses, as far as
it can at present be penetrated, we find aspects which make it
appear that the anxiety neurosis is really the somatic counterpart
to hysteria. Here as there we have accumulation and excitement
—on which it perhaps based the similarity of the aforementioned
symptoms—; here as there we have a psychic insufficiency which
results from abnormal somatic processes; and here as there we
have instead of a psychic elaboration a deviation of the excite-
ment into the somatic. The difference only lies in the fact that
the excitement, in which displacement the neurosis manifests
itself, is purely somatic (somatic sexual excitement) in anxiety
neurosis, while in hysteria it is psychic (evoked through a con-
flict). Hence it is not surprising that hysteria and anxiety neu-
rosis lawfully combine with each other, as in the “ virginal fear”
or in the sexual hysteria, and that hysteria simply borrows a
number of symptoms from anxiety neurosis, etc. This intimate
relationship between anxiety neurosis and hysteria furnishes us
with a new argument for demanding the separation of anxiety
neurosis from hysteria, for if this be denied, one will also be
unable to maintain the so painstakingly acquired distinction be-
tween neurasthenia and hysteria, so indispensable for the theory
of the neuroses.