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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 related
to one another than to the real neurasthenic symptoms, that is,
they frequently appear together and substitute one another in the
course of the disease, and both the etiology and the mech-
anism of this neurosis differs basically from the etiology and the

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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 original in
this conception of the symptoms of anxiety neurosis until an inter-
esting lecture by E. Hecker¹⁾ 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 apparently 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 designate the anxiety
neurosis by the same name as the real neurasthenia disappears,
for the only object of arbitrary naming is to facilitate the formu-
lation 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:

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

¹⁾E. Hecker, Über larvierte und abortive Angstzustände bei Neuras-
thenie. Centralblatt für Nervenheilkunde, December, 1893.—Anxiety is
made particularly prominent among the chief symptoms of neurasthenia
by Kaan, Der neurasthenische Angstaffekt bei Zwangsvorstellungen und
der primordiale Grübelzwang, Wien, 1893.

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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 accumula-
tion, hence to an absolute or relative accumulation of excitement.
The expression of this increased irritability through an auditory
hyperesthesia is especially worth mentioning; it is an over sensi-
tiveness for noises, which symptom is certainly to be explained
by the congenital intimate relationship between auditory impres-
sions and fright. Auditory hyperesthesia is frequently 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 condition
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
is afflicted with a catarrhal condition has a coughing spell;
and in her mind 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 hypo-
chondria. Hypochondria does not always run parallel with the
height of the general anxious expectation; as a preliminary stipu-
lation 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

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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

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transitory arrhythmia, 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
dyspnoea, 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 readily be mistaken
for hysterical attacks;
(e) Of inordinate appetite, often combined with dizziness;
(f) Of attack-like appearing diarrhoea;
(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, dyspnoea, 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 something pecu-
liar, but it also occurs alone without a dream or a recurring
hallucination.

5. “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

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time there is a 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 vertigo
“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 durable 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 without
fear, we see that though locomotion is always accompanied by the
sensation of vertigo, it remains possible without any restrictions,
but as soon as fear attaches itself to the attack of vertigo,
locomotion fails, under the conditions of being alone, narrow
streets, etc.