Obsessions and phobias their psychical mechanism and their aetiology 3 страница

The aetiological conditions applying to women can be brought into the framework of my scheme with no greater difficulties than in the case of men. Virginal anxiety is a particularly clear example. For here the groups of ideas to which the somatic sexual excitation should become attached are not yet enough developed. In the newly-married woman who is anaesthetic, anxiety only appears if the first cohabitations arouse a sufficient amount of somatic excitation. When the local indications of such excitement (spontaneous sensations of stimulation, desire to micturate and so on) are lacking, anxiety is also absent. The case of ejaculatio praecox and of coitus interruptus can be explained on the same lines as in men, namely that the libidinal desire for the psychically unsatisfying act gradually disappears, while the excitation which has been aroused during the act is expended subcortically. The alienation between the somatic and the psychical sphere is established more readily and is more difficult to remove in women than in men. The cases of widowhood and of voluntary abstinence, and also that of the climacteric, are dealt with in the same way in both sexes; but where abstinence is concerned there is in the case of women no doubt the further matter of intentional repression of the sexual circle of ideas, to which an abstinent woman, in her struggle against temptation, must often make up her mind. The horror which, at the time of the menopause, an ageing woman feels at her unduly increased libido may act in a similar sense.

The two last aetiological conditions on our list seem to fall into place without difficulty. The tendency to anxiety in masturbators who have become neurasthenic is explained by the fact that it is very easy for them to pass into a state of ‘abstinence’ after they have been accustomed for so long to discharging even the smallest quantity of somatic excitation, faulty though that discharge is. Finally, the last case, - the generation of anxiety neurosis through severe illness, overwork, exhausting sick-nursing, etc., - finds an easy interpretation when brought into relation with the effects of coitus interruptus. Here the psyche, on account of its deflection, would seem to be no longer capable of mastering the somatic excitation, a task on which, as we know, it is continuously engaged. We are aware to what a low level libido can sink under these conditions; and we have here a good example of a neurosis which, although it exhibits no sexual aetiology, nevertheless exhibits a sexual mechanism.

The view here developed depicts the symptoms of anxiety neurosis as being in a sense surrogates of the omitted specific action following on sexual excitation. In further support of this view, I may point out that in normal copulation too the excitation expends itself, among other things, in accelerated breathing, palpitation, sweating, congestion, and so on. In the corresponding anxiety attacks of our neurosis we have before us the dyspnoea, palpitations, etc. of copulation in an isolated and exaggerated form.

A further question may be asked. Why, under such conditions of psychical insufficiency in mastering sexual excitation, does the nervous system find itself in the peculiar affective state of anxiety? An answer may be suggested as follows. The psyche finds itself in the affect of anxiety if it feels unable to deal by appropriate reaction with a task (a danger) approaching from the outside; it finds itself in the neurosis of anxiety if it notices that it is unable to even out the (sexual) excitation originating from within - that is to say, it behaves as though it were projecting that excitation outwards. The affect and its corresponding neurosis are firmly related to each other. The first is a reaction to an exogenous excitation, the second a reaction to the analogous endogenous one. The affect is a state which passes rapidly, the neurosis is a chronic one; because, while exogenous excitation operates with a single impact, the endogenous excitation operates as a constant force. In the neurosis, the nervous system is reacting against a source of excitation which is internal, whereas in the corresponding affect it is reacting against an analogous source of excitation which is external.

IV. RELATION TO OTHER NEUROSES

There are still a few words to be said about the relations of anxiety neurosis to the other neuroses as regards their onset and their internal connections.

The purest cases of anxiety neurosis are usually the most marked. They are found in sexually potent youthful individuals, with an undivided aetiology, and an illness that is not of too long standing.

More often, however, symptoms of anxiety occur at the same time as, and in combination with, symptoms of neurasthenia, hysteria, obsessions or melancholia. If we were to allow ourselves to be restrained by a clinical intermixture like this from acknowledging anxiety neurosis as an independent entity, we ought, logically, also to abandon once more the separation which has been so laboriously achieved between hysteria and neurasthenia.

For the purposes of analysing ‘mixed neuroses’ I can state this important truth: Wherever a mixed neurosis is present, it will be possible to discover an intermixture of several specific aetiologies.

A multiplicity of aetiological factors such as this, which determine a mixed neurosis, may occur purely fortuitously. For instance, a fresh noxa may add its effects to those of an already existing one. Thus, a woman who has always been hysterical may begin at a certain point in her marriage to experience coitus reservatus; she will then acquire an anxiety neurosis in addition to her hysteria. Or again, a man who has hitherto masturbated and has become neurasthenic, may get engaged and become sexually excited by his fiancée; his neurasthenia will now be joined by a new anxiety neurosis.

In other cases the multiplicity of aetiological factors is by no means fortuitous: one of the factors has brought the other into operation. For example, a woman with whom her husband practises coitus reservatus without regard to her satisfaction may find herself compelled to masturbate in order to put an end to the distressing excitation that follows such an act; as a result, she will produce, not an anxiety neurosis pure and simple, but an anxiety neurosis accompanied by symptoms of neurasthenia. Another woman suffering from the same noxa may have to fight against lascivious images against which she tries to defend herself; and in this way she will, through the coitus interruptus, acquire obsessions as well as an anxiety neurosis. Finally, as a result of coitus interruptus, a third woman may lose her affection for her husband and feel an attraction for another man, which she carefully keeps secret; in consequence, she will exhibit a mixture of anxiety neurosis and hysteria.

In a third category of mixed neuroses the interconnection between the symptoms is still more intimate, in that the same aetiological determinant regularly and simultaneously provokes both neuroses. Thus, for instance, the sudden sexual enlightenment, which we have found present in virginal anxiety, always gives rise to hysteria as well; by far the majority of cases of intentional abstinence become linked from the beginning with true obsessional ideas; coitus interruptus in men never seems to me to be able to provoke a pure anxiety neurosis, but always a mixture of it with neurasthenia.

From these considerations it appears that we must further distinguish the aetiological conditions for the onset of the neuroses from their specific aetiological factors. The former - for example, coitus interruptus, masturbation or abstinence - are still ambiguous, and each of them can produce different neuroses. Only the aetiological factors which can be picked out in them, such as inadequate disburdening, psychical insufficiency or defence accompanied by substitution, have an unambiguous and specific relation to the aetiology of the individual major neuroses.

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

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

VIENNA, December 1894.

A REPLY TO CRITICISMS OF MY PAPER ON ANXIETY NEUROSIS(1895)

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

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

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

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

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

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

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

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

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

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

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

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

It is impossible to pursue an aetiological investigation based on anamneses if we accept those anamneses as the patients present them, or are content with what they are willing to volunteer. If syphilidologists still depended on the statements of their patients for tracing back an initial infection of the genitals to sexual intercourse, they would be able to attribute an imposing number of chancres in allegedly virginal persons to catching a chill; and gynaecologists would have little difficulty in confirming the miracle of parthenogenesis among their unmarried lady clients. I hope that one day the idea will prevail that neuropathologists, too, in collecting the anamneses of major neuroses, may proceed upon aetiological prejudices of a similar kind.

(2) Löwenfeld says further that he has repeatedly seen anxiety states appear and disappear where a change in the subject’s sexual life had certainly not taken place but where other factors were in play.

I, too, have made exactly the same observation, without, however, being misled by it. I myself have caused anxiety attacks to disappear by means of psychical treatment, improvement of the patient’s general health, and so on; but I have naturally not concluded from this that what had caused the anxiety attack was a lack of treatment. Not that I should like to foist a conclusion of this sort upon Löwenfeld. My joking remark is only intended to show that the state of affairs may easily be complicated enough to render Löwenfeld’s objection quite invalid. I have not found it difficult to reconcile the fact brought forward here with my assertion that anxiety neurosis has a specific aetiology. It will readily be granted that there are aetiological factors which, in order to exercise their effect, must operate with a certain intensity (or quantity) and over a certain period of time - which, that is to say, become summated. The effects of alcohol are a standard example of causation like this through summation. It follows that there must be a period of time in which the specific aetiology is at work but in which its effect is not yet manifest. During this time the subject is not ill as yet, but he is predisposed to a particular illness - in our case, to anxiety neurosis - and now the addition of a stock noxa will be able to set the neurosis off, just as would a further intensification of the operation of the specific noxa. The situation may also be expressed as follows: it is not enough for the specific noxa to be present; it must also reach a definite amount; and, in the process of reaching that limit, a quantity of specific noxa can be replaced by a quota of stock noxa. If the latter is removed once more, we find ourselves below a certain threshold and the clinical symptoms depart once more. The whole therapy of the neuroses rests upon the fact that the total load upon the nervous system, to which it has succumbed, can be brought below this threshold by influencing the aetiological mixture in a great variety of ways. From these circumstances we can draw no conclusion as to the existence or non-existence of a specific aetiology. These considerations are surely indisputable and assured. But anyone who does not think them sufficient may be influenced by the following argument. According to the views of Löwenfeld and very many others, the aetiology of anxiety states is to be found in heredity. Now heredity is certainly immune to alteration; thus if anxiety neurosis is curable by treatment, we should have to conclude according to Löwenfeld’s argument that its aetiology cannot reside in heredity.

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