Obsessions and phobias their psychical mechanism and their aetiology 2 страница

(7) On the basis of chronic anxiousness (anxious expectation) on the one hand, and a tendency to anxiety attacks accompanied by vertigo on the other, two groups of typical phobias develop, the first relating to general physiological dangers, the second relating to locomotion. To the first group belong fear of snakes, thunderstorms, darkness, vermin, and so on, as well as the typical moral over-scrupulousness and forms of doubting mania. Here the available anxiety is simply employed to reinforce aversions which are instinctively implanted in everyone. But as a rule a phobia which acts in an obsessional manner is only formed if there is added to this the recollection of an experience in which the anxiety was able to find expression as, for instance, after the patient has experienced a thunderstorm in the open. It is a mistake to try to explain such cases as being simply a persistence of strong impressions; what makes these experiences significant and the memory of them lasting is, after all, only the anxiety which was able to emerge at the time and which can similarly emerge now. In other words, such impressions remain powerful only in people with ‘anxious expectation’.

The other group includes agoraphobia with all its accessory forms, the whole of them characterized by their relation to locomotion. We frequently find that this phobia is based on an attack of vertigo that has preceded it; but I do not think that one can postulate such an attack in every case. Occasionally we see that after a first attack of vertigo without anxiety, locomotion, although henceforward constantly accompanied by a sensation of vertigo, still continues to be possible without restriction; but that, under certain conditions - such as being alone or in a narrow street - when once anxiety is added to the attack of vertigo, locomotion breaks down.

The relation of these phobias to the phobias of obsessional neurosis, whose mechanism I made clear in an earlier paper¹ in this periodical, is of the following kind. What they have in common is that in both an idea becomes obsessional as a result of being attached to an available affect. The mechanism of transposition of affect thus holds good for both kinds of phobia. But in the phobias of anxiety neurosis (1) this affect always has the same colour, which is that of anxiety; and (2) the affect does not originate in a repressed idea, but turns out to be not further reducible by psychological analysis, nor amenable to psychotherapy. The mechanism of substitution, therefore, does not hold good for the phobias of anxiety neurosis.

Both kinds of phobias (and also obsessions) often appear side by side; although the atypical phobias, which are based on obsessions, need not necessarily spring from the soil of anxiety neurosis. A very frequent and apparently complicated mechanism makes its appearance if, in what was originally a simple phobia belonging to an anxiety neurosis, the content of the phobia is replaced by another idea, so that the substitute is subsequent to the phobia. What are most often employed as substitutes are the ‘protective measures’ that were originally used to combat the phobia. Thus, for instance, ’brooding mania’ arises from the subject’s endeavours to disprove that he is mad, as his hypochondriacal phobia maintains; the hesitations and doubt, and still more the repetitions, of folie du doute arise from a justifiable doubt about the certainty of one’s own train of thought, since one is conscious of its persistent disturbance by ideas of an obsessional sort, and so on. We can therefore assert that many syndromes, too, of obsessional neurosis, such as folie du doute and the like, are also to be reckoned, clinically if not conceptually, as belonging to anxiety neurosis.²

¹ ‘The Neuro-Psychoses of Defence’ (1894a).

² See ‘Obsessions and Phobias’ (1895c).

(8) The digestive activities undergo only a few disturbances in anxiety neurosis; but these are characteristic ones. Sensations such as an inclination to vomit and nausea are not rare, and the symptom of ravenous hunger may, by itself or in conjunction with other symptoms (such as congestions), give rise to a rudimentary anxiety attack. As a chronic change, analogous to anxious expectation, we find an inclination to diarrhoea, and this has been the occasion of the strangest diagnostic errors. Unless I am mistaken, it is this diarrhoea to which Möbius (1894) has drawn attention recently in a short paper. I suspect, further, that Peyer’s reflex diarrhoea, which he derives from disorders of the prostate (Peyer, 1893), is nothing else than this diarrhoea of anxiety neurosis. The illusion of a reflex relationship is created because the same factors come into play in the aetiology of anxiety neurosis as are at work in the setting up of such affections of the prostate and similar disorders.

The behaviour of the gastro-intestinal tract in anxiety neurosis presents a sharp contrast to the influence of neurasthenia on those functions. Mixed cases often show the familiar ‘alternation between diarrhoea and constipation’. Analogous to this diarrhoea is the need to urinate that occurs in anxiety neurosis.

(9) The paraethesias which may accompany attacks of vertigo or anxiety are interesting because they, like the sensations of the hysterical aura, become associated in a definite sequence; although I find that these associations, in contrast to the hysterical ones, are atypical and changing. A further similarity to hysteria is provided by the fact that in anxiety neurosis a kind of conversion¹ takes place on to bodily sensations, which may easily be overlooked - for instance, on to rheumatic muscles. A whole number of what are known as rheumatic individuals who, moreover, can be shown to be rheumatic - are in reality suffering from anxiety neurosis. Along with this increase of sensitivity to pain, I have also observed in a number of cases of anxiety neurosis a tendency to hallucinations; and these could not be interpreted as hysterical.

(10) Several of the symptoms I have mentioned, which accompany or take the place of an anxiety attack, also appear in a chronic form. In that case they are still less easy to recognize, since the anxious sensation which goes with them is less clear than in an anxiety attack. This is especially true of diarrhoea, vertigo and paraesthesias. Just as an attack of vertigo can be replaced by a fainting fit, so chronic vertigo can be replaced by a constant feeling of great feebleness, lassitude and so on.

¹ See ‘The Neuro-Psychoses of Defence’ (1894a).

IIINCIDENCE AND AETIOLOGY OF ANXIETY NEUROSIS

In some cases of anxiety neurosis no aetiology at all is to be discovered. It is worth noting that in such cases there is seldom any difficulty in establishing evidence of a grave hereditary taint.

But where there are grounds for regarding the neurosis as an acquired one, careful enquiry directed to that end reveals that a set of noxae and influences from sexual life are the operative aetiological factors. These appear at first sight to be of a varied nature, but they soon disclose the common character which explains why they have a similar effect on the nervous system. Further, they are present either alone or together with other noxae of a ‘stock’ kind, to which we may ascribe a contributory effect. This sexual aetiology of anxiety neurosis can be demonstrated with such overwhelming frequency that I venture, for the purpose of this short paper, to disregard those cases where the aetiology is doubtful or different.

In order that the aetiological conditions under which anxiety neurosis makes its appearance may be presented with greater accuracy, it will be advisable to consider males and females separately. In females - disregarding for the moment their innate disposition - anxiety neurosis occurs in the following cases:

(a) As virginal anxiety or anxiety in adolescents. A number of unambiguous observations have shown me that anxiety neurosis can be produced in girls who are approaching maturity by their first encounter with the problem of sex, by any more or less sudden revelation of what had till then been hidden - for instance, by witnessing the sexual act, or being told or reading about these things. Such an anxiety neurosis is combined with hysteria in an almost typical fashion.

(b) As anxiety in the newly married. Young married women who have remained anaesthetic during their first cohabitations not seldom fall ill of an anxiety neurosis, which disappears once more as soon as the anaesthesia gives place to normal sensitivity. Since most young wives remain healthy where there is initial anaesthesia of this kind, it follows that, in order that this kind of anxiety shall emerge, other determinants are required; and these I will mention later.

(c) As anxiety in women whose husbands suffer from ejaculatio praecox or from markedly impaired potency; and (d) whose husbands practise coitus interruptus or reservatus. These cases belong together, for on analysing a great number of instances it is easy to convince oneself that they depend simply on whether the woman obtains satisfaction in coitus or not. If not, the condition for the genesis of an anxiety neurosis is given. On the other hand, she is saved from the neurosis if the husband who is affected with ejaculatio praecox is able immediately to repeat coitus with better success. Coitus reservatus by means of condoms is not injurious to the woman, provided she is very quickly excitable and the husband very potent; otherwise, this kind of preventive intercourse is no less injurious than the others. Coitus interruptus is nearly always a noxa. But for the wife it is only so if the husband practises it regardlessly - that is to say, if he breaks off intercourse as soon as he is near emission, without troubling himself about the course of the excitation in her. If, on the other hand, the husband waits for his wife’s satisfaction, the coitus amounts to a normal one for her; but he will fall ill of an anxiety neurosis. I have collected and analysed a large number of observations, on which these assertions are based.

(e) Anxiety neurosis also occurs as anxiety in widows and intentionally abstinent women, not seldom in a typical combination with obsessional ideas; and

(f) As anxiety in the climacteric during the last major increase of sexual need.

Cases (c) (d) and (e) comprise the conditions under which anxiety neurosis in the female sex arises most frequently and most readily, independently of hereditary disposition. It is in reference to these cases of anxiety neurosis - these curable acquired cases - that I shall try to show that the sexual noxae discovered in them are really the aetiological factor of the neurosis.

Before doing so, however, I will discuss the sexual determinants of anxiety neurosis in men. I propose to distinguish the following groups, all of which have their analogies in women:

(a) Anxiety of intentionally abstinent men, which is frequently combined with symptoms of defence (obsessional ideas, hysteria). The motives which are responsible for intentional abstinence imply that a number of people with a hereditary disposition, eccentrics, etc., enter into this category.

(b) Anxiety in men in a state of unconsummated excitation (e.g. during the period of engagement before marriage), or in those who (from fear of the consequences of sexual intercourse) content themselves with touching or looking at women. This group of determinants - which, incidentally, can be applied unaltered to the other sex (during engagements or relations in which sexual intercourse is avoided) - provides the purest cases of the neurosis.

(c) Anxiety in men who practise coitus interruptus. As has been said, coitus interruptus is injurious to the woman if it is practised without regard to her satisfaction; but it is injurious to the man if, in order to obtain satisfaction for her, he directs coitus voluntarily and postpones emission. In this way it becomes intelligible that when a married couple practise coitus interruptus, it is, as a rule, only one partner who falls ill. Moreover, in men coitus interruptus only rarely produces a pure anxiety neurosis; it usually produces a mixture of anxiety neurosis and neurasthenia.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

IIIFIRST STEPS TOWARD A THEORY OF ANXIETY NEUROSIS

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

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

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

This concept of the mechanism of anxiety neurosis can be made clearer if one accepts the following view of the sexual process, which applies, in the first instance, to men. In the sexually mature male organism somatic sexual excitation is produced probably continuously - and periodically becomes a stimulus to the psyche. In order to make our ideas on this point firmer, I will add by way of interpolation that this somatic excitation is manifested as a pressure on the walls of the seminal vesicles, which are lined with nerve endings; thus this visceral excitation will develop continuously, but it will have to reach a certain height before it is able to overcome the resistance of the intervening path of conduction to the cerebral cortex and express itself as a psychical stimulus. When this has happened, however, the group of sexual ideas which is present in the psyche becomes supplied with energy and there comes into being the psychical state of libidinal tension which brings with it an urge to remove that tension. A psychical unloading of this kind is only possible by means of what I shall call specific or adequate action. This adequate action consists, for the male sexual instinct, in a complicated spinal reflex act which brings about the unloading of the nerve-endings, and in all the psychical preparations which have to be made in order to set off that reflex. Anything other than the adequate action would be fruitless, for once the somatic sexual excitation has reached threshold value it is turned continuously into psychical excitation, and something must positively take place which will free the nerve endings from the load of pressure on them - which will, accordingly, remove the whole of the existing somatic excitation and allow the subcortical path of conduction to re-establish its resistance.

I shall refrain from describing more complicated instances of the sexual process in a similar way. I will only state that in essentials this formula is applicable to women as well, in spite of the confusion introduced into the problem by all the artificial retarding and stunting of the female sexual instinct. In women too we must postulate a somatic sexual excitation and a state in which this excitation becomes a psychical stimulus - libido - and provokes the urge to the specific action to which voluptuous feeling is attached. Where women are concerned, however, we are not in a position to say what the process analogous to the relaxation of tension of the seminal vesicles may be.

We can include within the framework of this description of the sexual process not only the aetiology of anxiety neurosis but that of genuine neurasthenia. Neurasthenia develops whenever the adequate unloading (the adequate action) is replaced by a less adequate one - thus, when normal coition, carried out in the most favourable conditions, is replaced by masturbation or spontaneous emission. Anxiety neurosis, on the other hand, is the product of all those factors which prevent the somatic sexual excitation from being worked over psychically. The manifestations of anxiety neurosis appear when the somatic excitation which has been deflected from the psyche is expended subcortically in totally inadequate reactions.

I will now attempt to discover whether the aetiological conditions for anxiety neurosis which I set out above exhibit the common character that I have just attributed to them. The first aetiological factor I postulated for men was intentional abstinence. Abstinence consists in the withholding of the specific action which ordinarily follows upon libido. Such withholding may have two consequences. In the first place, the somatic excitation accumulates; it is then deflected into other paths, which hold out greater promise of discharge than does the path through the psyche. Thus the libido will in the end sink, and the excitation will manifest itself subcortically as anxiety. In the second place, if the libido is not diminished, or if the somatic excitation is expended, by a short cut, in emissions, or if, in consequence of being forced back, the excitation really ceases, then all kinds of things other than an anxiety neurosis will ensue. Abstinence, then, leads to anxiety neurosis in the manner described above. But it is also the operative agent in my second aetiological group, that of unconsummated excitation. My third group, that of coitus reservatus with consideration for the woman, operates by disturbing the man’s psychical preparedness for the sexual process, in that it introduces alongside of the task of mastering the sexual affect another psychical task, one of a deflecting sort. In consequence of this psychical deflection, once more, libido gradually disappears, and the further course of things is then the same as in the case of abstinence. Anxiety in senescence (the male climacteric) requires another explanation. Here there is no diminution of libido; but, as in the female climacteric, so great an increase occurs in the production of somatic excitation that the psyche proves relatively insufficient to master it.

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