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But let us disregard these exceptional cases and proceed with our discussion. In average circumstances we recognize that by escaping into a neurosis the ego obtains a certain internal ‘gain from illness’. In some circumstances of life this is further accompanied by an appreciable external advantage bearing a greater or less real value. Consider the commonest example of this sort. A woman who is roughly treated and ruthlessly exploited by her husband will fairly regularly find a way out in neurosis, if her constitution makes it possible, if she is too cowardly or too moral to console herself secretly with another man, if she is not strong enough to separate from her husband in the face of every external deterrent, if she has no prospect of supporting herself or obtaining a better husband and if in addition she is till attached to this brutal husband by her sexual feelings. Her illness now becomes a weapon in her battle with her dominating husband - a weapon which she can use for her defence and misuse for her revenge. To complain of her illness is allowable, though to lament her marriage was probably not. She find a helper in her doctor, she forces her usually inconsiderate husband to look after her, to spend money on her, to allow her at times to be away from home and so free from her married oppression. When an external or accidental gain from illness like this is really considerable and no real substitute for it is available, you must not reckon very high the chances of influencing the neurosis by your treatment.

You will now protest that what I have told you about the gain from illness argues entirely in favour of the view I have rejected - that the ego itself wills and creates he neurosis. Not too fast, Gentlemen! It may perhaps mean nothing more than that the ego puts up with the neurosis, which it cannot, after all, prevent, and that it makes the best of it, if anything can be made of it at all. That is only one side of the business, the pleasant side, it is true. So far as the neurosis has advantages the ego no doubt accepts it; but it does not only have advantages. As a rule it soon turns out that the ego has made a bad bargain by letting itself in for the neurosis. It has paid too dearly for an alleviation of the conflict, and the sufferings attached to the symptoms are perhaps an equivalent substitute for the torments of the conflict, but they probably involve an increase in unpleasure. The ego would like to free itself from this unpleasure of the symptoms without giving up the gain from illness, and this is just what it cannot achieve. This shows, then, that it was not so entirely active as it thought it was; and we shall bear this well in mind.

In your contact as doctors with neurotics, Gentlemen, you will soon give up expecting that the ones who raise the most lamentations and complaints about their illness will be the most eager to co-operate and will offer you the least resistance. It is rather the opposite. But of course you will easily realize that everything that contributes to the gain from illness will intensify the resistance due to repression and will increase the therapeutic difficulties. But to the portion of gain from illness which is, so to say, born with the illness we have to add another portion which arises later. When a psychical organization like an illness has lasted for some time, it behaves eventually like an independent organism; it manifests something like a self-preservative instinct; it establishes a kind of modus vivendi between itself and other parts of the mind, even with those which are at bottom hostile to it; and there can scarcely fail to be occasions when it proves once again useful and expedient and acquires, as it were, a secondary function which strengthens its stability afresh. Instead of an example from pathology, let us take a glaring instance from daily life. A capable working-man, who earns his living, is crippled by an accident in the course of his occupation. The injured man can no longer work, but eventually he obtains a small disablement pension, and he learns how to exploit his mutilation by begging. His new, though worsened, means of livelihood is based precisely on the very thing that deprived him of his former means of livelihood. If you could put an end to his injury you would make him, to begin with, without means of subsistence; the question would arise of whether he was still capable of taking up his earlier work again. What corresponds in the case of neuroses to a secondary exploitation like this of an illness may be described as the secondary gain from illness in contrast to the primary one.

In general, however, I should like to recommend that, while not under-estimating the practical importance of the gain from illness, you should not let yourselves be impressed by it theoretically. After all, apart from the exceptions recognized earlier, it always calls to mind the examples of ‘animal intelligence’ illustrated by Oberländer in Fliegende Blätter. An Arab was riding his camel along a narrow path cut in the steep face of a mountain. At a turn in the path he suddenly found himself face to face with a lion, which prepared to make a spring. He saw no way out: on one side a perpendicular cliff and on the other a precipice; retreat and flight were impossible. He gave himself up for lost. But the animal thought otherwise. He took one leap with his rider into the abyss - and the lion was left in the lurch. The help provided by a neurosis has as a rule no better success with the patient. This may be because dealing with a conflict by forming symptoms is after all an automatic process which cannot prove adequate to meeting the demands of life, and in which the subject has abandoned the use of his best and highest powers. If there were a choice, it would be preferable to go down in an honourable struggle with fate.

8 But I still owe you further enlightenment, Gentlemen, on my reasons for not starting my account of the theory of the neuroses with the common neurotic state. You may perhaps suppose that it was because in that case I should have had greater difficulty in proving the sexual causation of the neuroses. But you would be wrong there. In the case of the transference neuroses one must work one’s way through the interpretation of symptoms before one can arrive at that discovery. In the common forms of what are known as the ‘actual neuroses’ the aetiological significance of sexual life is a crude fact that springs to the observer’s eyes. I came upon it more than twenty years ago when one day I asked myself the question of why in the examination of neurotics their sexual activities were so regularly excluded from consideration. At that time I sacrificed my popularity with my patients for the sake of these enquiries; but after only a brief effort I was able to declare that ‘if the vita sexualis is normal, there can be no neurosis’ - and by this I meant no ‘actual neurosis’. No doubt this statement passes too lightly over people’s individual differences; it suffers, too, from the indefiniteness inseparable from the judgement of what is ‘normal’. But as a rough guide it retains its value to this day. I had by then reached the point of establishing specific relations between particular forms of neurosis and particular sexual noxae; and I have no doubt that I could repeat the same observations to-day if similar pathological material were still at my disposal. I found often enough that a man who indulged in a certain kind of incomplete sexual satisfaction (for instance, manual masturbation) had fallen ill of a particular form of ‘actual neurosis’, and that this neurosis promptly gave place to another if he replaced this sexual régime by another equally far from being irreproachable. I was then in a position to infer the change in a patient’s sexual mode of life from an alteration in his condition. I also learnt then to stand obstinately by my suspicions till I had overcome the patients’ disingenuousness and compelled them to confirm my views. It is true that thereafter they preferred to go to other doctors who did not make such keen enquiries about their sexual life.

Even at that time I could not fail to notice that the causation of the illness did not always point to sexual life. One person, it was true, fell ill directly from a sexual noxa; but another did so because he had lost his fortune or had been through an exhausting organic illness. The explanation of these varieties came later, when we gained an insight into the suspected interrelations between the ego and the libido, and the explanation became the more satisfactory the deeper that insight extended. A person only falls ill of a neurosis if his ego has lost the capacity to allocate his libido in some way. The stronger is his ego, the easier will it be for it to carry out that task. Any weakening of his ego from whatever cause must have the same effect as an excessive increase in the claims of the libido and will thus make it possible for him to fall ill of a neurosis. There are other and more intimate relations between the ego and the libido; but these have not yet come within our scope, so I will not bring them up as part of my present explanation. What remains essential and makes things clear to us is that, in every case and no matter how the illness is set going, the symptoms of the neurosis are sustained by the libido and are consequently evidence that it is being employed abnormally.

Now, however, I must draw your attention to the decisive difference between the symptoms of the ‘actual’ neuroses and those of the psychoneuroses, the first group of which, the transference neuroses, have occupied us so much hitherto. In both cases the symptoms originate from the libido, and are thus abnormal employments of it, substitutive satisfactions. But the symptoms of the ‘actual’ neuroses - intracranial pressure, sensations of pain, a state of irritation in an organ, weakening or inhibition of a function - have no ‘sense’, no psychical meaning. They are not only manifested predominantly in the body (as are hysterical symptoms, for instance, as well), but they are also themselves entirely somatic processes, in the generating of which all the complicated mental mechanisms we have come to know are absent. Thus they really are what psychoneurotic symptoms were so long believed to be. But if so, how can they correspond to employments of the libido, which we have recognized as a force operating in the mind? Well, Gentlemen, that is a very simple matter. Let me remind you of one of the very first objections that were brought up against psycho-analysis. It was said then that it was occupied in finding a purely psychological theory of neurotic phenomena and this was quite hopeless, since psychological theories could never explain an illness. People had chosen to forget that the sexual function is not a purely psychical thing any more than it is a purely somatic one. It influences bodily and mental life alike. If in the symptoms of the psychoneuroses we have become acquainted with manifestations of disturbances in the psychical operation of the sexual function, we shall not be surprised to find in the ‘actual’ neuroses the direct somatic consequences of sexual disturbances.

Clinical medicine has given us a valuable pointer towards an interpretation of these disturbances, and one that has been taken into account by various enquirers. The ‘actual’ neuroses, in the details of their symptoms and also in their characteristic of influencing every organic system and every function, exhibit an unmistakable resemblance to the pathological states which arise from the chronic influence of external toxic substances and from a sudden withdrawal of them - to intoxications and conditions of abstinence. The two groups of disorders are brought together still more closely by intermediate conditions such as Grave’s disease which we have learnt to recognize as equally due to the operation of toxic substances, but of toxins which are not introduced into the body from outside but originate in the subject’s own metabolism. In view of these analogies, we cannot, I think, avoid regarding the neuroses as results of disturbances in the sexual metabolism, whether because more of these sexual toxins is produced than the subject can deal with, or whether because internal and even psychical conditions restrict the proper employment of these substances. The popular mind has from time immemorial paid homage to hypotheses of this kind on the nature of sexual desire, speaking of love as an ‘intoxication’ and believing that falling in love is brought about by love philtres - though here the operative agent is to some extent externalized. And for us this would be an occasion for recalling the erotogenic zones and our assertion that sexual excitation can be generated in the most various organs. But for the rest the phrase ‘sexual metabolism’ or ‘chemistry of sexuality’ is a term without content; we know nothing about it and cannot even decide whether we are to assume two sexual substances, which would then be named ‘male’ and ‘female’, or whether we could be satisfied with one sexual toxin which we should have to recognize as the vehicle of all the stimulant effects of the libido. The theoretical structure of psycho-analysis that we have created is in truth a superstructure, which will one day have to be set upon its organic foundation. But we are still ignorant of this.

What characterizes psycho-analysis as a science is not the material which it handles but the technique with which it works. It can be applied to the history of civilization, to the science of religion and to mythology, no less than to the theory of the neuroses, without doing violence to its essential nature. What it aims at and achieves is nothing other than the uncovering of what is unconscious in mental life. The problems of the ‘actual’ neuroses, whose symptoms are probably generated by direct toxic damage, offer psycho-analysis no points of attack. It can do little towards throwing light on them and must leave the task to biologico-medical research.

And now perhaps you understand better why I did not choose to arrange my material differently. If I had promised you an ‘Introduction to the Theory of the Neuroses’ the correct path would certainly have led from the simple forms of the ‘actual’ neuroses to the more complicated psychical illnesses due to disturbance of the libido. As regards the former I should have had to collect from various sources what we have learnt or believe we know, and in connection with the psychoneuroses psycho-analysis would have come up for discussion as the most important technical aid in throwing light on those conditions. But what I intended to give and what I announced was an ‘Introduction to Psycho-Analysis’. It was more important for me that you should gain an idea of psycho-analysis than that you should obtain some pieces of knowledge about the neuroses; and for that reason the ‘actual’ neuroses, unproductive so far as psycho-analysis is concerned, could no longer have a place in the foreground. I believe, too, that I have made the better choice for you. For, on account of the profundity of its hypotheses and the comprehensiveness of its connections, psycho-analysis deserves a place in the interest of every educated person, while the theory of the neuroses is a chapter in medicine like any other.

Nevertheless you will rightly expect that we should devote some interest to the ‘actual’ neuroses as well. Their intimate clinical connection with the psychoneuroses would alone compel us to do so. I may inform you, then, that we distinguish three pure forms of ‘actual’ neuroses: neurasthenia, anxiety neurosis and hypochondria. Even this assertion is not uncontradicted. All the names are in use, it is true, but their content is indefinite and fluctuating. There are even doctors who oppose any dividing lines in the chaotic world of neurotic phenomena, any segregation of clinical entities or individual diseases, and who do not even recognize the distinction between the ‘actual’ neuroses and the psychoneuroses. I think they are going too far and have not chosen the path which leads to progress. The forms of neurosis which I have mentioned occur occasionally in their pure form; more often, however, they are intermixed with each other and with a psychoneurotic disorder. This need not lead us to abandon the distinction between them. Consider the difference between the study of minerals and of rocks in mineralogy. The minerals are described as individuals, no doubt on the basis of the fact that they often occur as crystals, sharply separated from their environment. Rocks consist of aggregations of minerals, which, we may be sure, have not come together by chance but as a result of what determined their origin. In the theory of the neuroses we still know too little of the course of their development to produce anything resembling petrology. But we are certainly doing the right thing if we start by isolating from the mass the individual clinical entities which we recognize and which are comparable to the minerals.

A noteworthy relation between the symptoms of the ‘actual’ neuroses and of the psychoneuroses makes a further important contribution to our knowledge of the formation of symptoms in the latter. For a symptom of an ‘actual’ neurosis is often the nucleus and first stage of a psychoneurotic symptom. A relation of this kind can be most clearly observed between neurasthenia and the transference neurosis known as ‘conversion hysteria’, between anxiety neurosis and anxiety hysteria, but also between hypochondria and the forms of disorder which will be mentioned later under the name of paraphrenia (dementia praecox and paranoia). Let us take as an example a case of hysterical headache or lumbar pain. Analysis shows us that, by condensation and displacement, it has become a substitutive satisfaction for a whole number of libidinal phantasies or memories. But this pain was also at one time a real one and it was then a direct sexual-toxic symptom, the somatic expression of a libidinal excitation. We are far from asserting that all hysterical symptoms contain a nucleus of this kind. But it remains a fact that this is especially often the case and that whatever somatic influences (whether normal or pathological) are brought about by libidinal excitation are preferred for the construction of hysterical symptoms. In such cases they play the part of the grain of sand which a mollusc coats with layers of mother-of-pearl. In the same way, the passing indications of sexual excitement which accompany the sexual act are employed by the psychoneurosis as the most convenient and appropriate material for the construction of symptoms.

A similar course of events affords peculiar diagnostic and therapeutic interest. It not at all infrequently happens in the case of a person who is disposed to a neurosis without actually suffering from a manifest one, that a pathological somatic change (through inflammation or injury perhaps) sets the activity of symptom-formation going; so that this activity hastily turns the symptom which has been presented to it by reality into the representative of all the unconscious phantasies which have only been lying in wait to seize hold of some means of expression. In such a case the physician will adopt sometimes one and sometimes another line of treatment. He will either endeavour to remove the organic basis, without bothering about its noisy neurotic elaboration; or he will attack the neurosis which has taken this favourable opportunity for arising and will pay little attention to its organic precipitating cause. The outcome will prove the one or the other line of approach right or wrong; it is impossible to make general recommendations to meet such mixed cases.

LECTURE XXV ANXIETY

LADIES AND GENTLEMEN, - What I said to you in my last lecture about the general neurotic state will no doubt have struck you as the most incomplete and inadequate of all my pronouncements. I know that is true, and nothing will have surprised you more, I expect, than that there was nothing in it about anxiety, of which most neurotics complain, which they themselves describe as their worst suffering and which does in fact attain enormous intensity in them and may result in their adopting the craziest measures. But there at least I had no intention of giving you short measure. On the contrary, it was my intention to attack the problem of anxiety in neurotics particularly keenly and to discuss it at length with you.

I have no need to introduce anxiety itself to you. Every one of us has experienced that sensation, or, to speak more correctly, that affective state, at one time or other on our own account. But I think the question has never been seriously enough raised of why neurotics in particular suffer from anxiety so much more and so much more strongly than other people. Perhaps it has been regarded as something self-evident: the words ‘nervös’ and ‘ängstlich’ are commonly used interchangeably, as though they meant the same thing. But we have no right to do so: there are ‘ängstlich’ people who are otherwise not at all ‘nervös’ and, moreover, ‘nervös’ people who suffer from many symptoms, among which a tendency to ‘Angst’ is not included.

However that may be, there is no question that the problem of anxiety is a nodal point at which the most various and important questions converge, a riddle whose solution would be found to throw a flood of light on our whole mental existence. I will not assert that I can give you this complete solution; but you will certainly expect psycho-analysis to approach this subject too in quite a different way from academic medicine. Interest there seems mainly to be centred on tracing the anatomical paths along which the state of anxiety is brought about. We are told that the medulla oblongata is stimulated, and the patient learns that he is suffering from a neurosis of the vagus nerve. The medulla oblongata is a very serious and lovely object. I remember quite clearly how much time and trouble I devoted to its study many years ago. To-day, however, I must remark that I know nothing that could be of less interest to me for the psychological understanding of anxiety than knowledge of the path of the nerves along which its excitations pass.

3 It is possible at the start to work upon the subject of anxiety for quite a time without thinking at all of neurotic states. You will understand me at once when I describe this kind of anxiety as ‘realistic’ anxiety in contrast to ‘neurotic’ anxiety. Realistic anxiety strikes us as something very rational and intelligible. We may say of it that it is a reaction to the perception of an external danger - that is, of an injury which is expected and foreseen. It is connected with the flight reflex and it may be regarded as a manifestation of the self-preservative instinct. On what occasions anxiety appears - that is to say, in the face of what objects and in what situations - will of course depend to a large extent on the state of a person’s knowledge and on his sense of power vis-à-vis the external world. We can quite understand how a savage is afraid of a cannon and frightened by an eclipse of the sun, while a white man, who knows how to handle the instrument and can foretell the eclipse, remains without anxiety in these circumstances. On other occasions it is actually superior knowledge that promotes anxiety, because it makes an early recognition of the danger possible. Thus the savage will be terrified at a trail in the jungle that tells an uninformed person nothing, because it warns him of the proximity of a wild animal; and an experienced sailor will look with terror at a small cloud in the sky that seems trivial to a passenger, because it tells him of an approaching hurricane.

On further consideration we must tell ourselves that our judgement that realistic anxiety is rational and expedient calls for drastic revision. For the only expedient behaviour when a danger threatens would be a cool estimate of one’s own strength in comparison with the magnitude of the threat and, on the basis of that, a decision as to whether flight or defence, or possibly even attack, offers the best prospect of a successful issue. But in this situation there is no place at all for anxiety; everything that happens would be achieved just as well and probably better if no anxiety were generated. And you can see, indeed, that if the anxiety is excessively great it proves in the highest degree inexpedient; it paralyses all action, including even flight. Usually the reaction to danger consists n a mixture of the affect of anxiety and defensive action. A terrified animal is afraid and flees; but the expedient part of this is the ‘flight’ and not the ‘being afraid’.

Thus one feels tempted to assert that the generation of anxiety is never an expedient thing. It may perhaps help us to see more clearly if we dissect the situation of anxiety more carefully. The first thing about it is preparedness for the danger, which manifests itself in increased sensory attention and motor tension. This expectant preparedness can be unhesitatingly recognized as an advantage; indeed, its absence may be made responsible for serious consequences. From it there then proceeds on the one hand motor action - flight in the first instance and at a higher level active defence - and on the other hand what we feel as a state of anxiety. The more the generation of anxiety is limited to a mere abortive beginning - to a signal - the more will the preparedness for anxiety transform itself without disturbance into action and the more expedient will be the shape taken by the whole course of events. Accordingly, the preparedness for anxiety seems to me to be the expedient element in what we call anxiety, and the generation of anxiety the inexpedient one.

I shall avoid going more closely into the question of whether our linguistic usage means the same thing or something clearly different by ‘Angst [anxiety]’, ‘Furcht [fear]’ and ‘Schreck [fright]’. I will only say that I think ‘Angst’ relates to the state and disregards the object, while ‘Furcht’ draws attention precisely to the object. It seems that ‘Schreck’, on the other hand, does have a special sense; it lays emphasis, that is, on the effect produced by a danger which is not met by any preparedness for anxiety. We might say, therefore, that a person protects himself from fright by anxiety.

A certain ambiguity and indefiniteness in the use of the word ‘Angst’ will not have escaped you. By ‘anxiety’ we usually understand the subjective state into which we are put by perceiving the ‘generation of anxiety’ and we call this an affect. And what is an affect in the dynamic sense? It is in any case something highly composite. An affect includes in the first place particular motor innervations or discharges and secondly certain feelings; the latter are of two kinds - perceptions of the motor actions that have occurred and the direct feelings of pleasure and unpleasure which, as we say, give the affect its keynote. But I do not think that with this enumeration we have arrived at the essence of an affect. We seem to see deeper in the case of some affects and to recognize that the core which holds the combination we have described together is the repetition of some particular significant experience. This experience could only be a very early impression of a very general nature, placed in the prehistory not of the individual but of the species. To make myself more intelligible - an affective state would be constructed in the same way as a hysterical attack; and, like it, would be the precipitate of a reminiscence. A hysterical attack may thus be likened to a freshly constructed individual affect, and a normal affect to the expression of a general hysteria which has become a heritage.

Do not suppose that the things I have said to you here about affects are the recognized stock-in-trade of normal psychology. They are on the contrary views that have grown up on the soil of psycho-analysis and are native only to it. What you may gather about affects from psychology - the James-Lange theory, for example - is quite beyond understanding or discussion to us psycho-analysts. But we do not regard our knowledge about affects as very assured either; it is a first attempt at finding our bearings in this obscure region. I will proceed, however. We believe that in the case of the affect of anxiety we know what the early impression is which it repeats. We believe that it is in the act of birth that there comes about the combination of unpleasurable feelings, impulses of discharge and bodily sensations which has become the prototype of the effects of a mortal danger and has ever since been repeated by us as the state of anxiety. The immense increase of stimulation owing to the interruption of the renovation of the blood (internal respiration) was at the time the cause of the experience of anxiety; the first anxiety was thus a toxic one. The name ‘Angst - ‘augustiae’, ‘Enge’¹ - emphasizes the characteristic of restriction in breathing which was then present as a consequence of the real situation and is now almost invariably reinstated in the affect. We shall also recognize it as highly relevant that this first state of anxiety arose out of separation from the mother. It is, of course, our conviction that the disposition to repeat the first state of anxiety has been so thoroughly incorporated into the organism through a countless series of generations that a single individual cannot escape the affect of anxiety even if, like the legendary Macduff, he ‘was from his mother’s womb untimely ripped’ and has therefore not himself experienced the act of birth. We cannot say what has become the prototype of the state of anxiety in the case of creatures other than mammals. And in the same way we do not know either what complex of feelings is in such creatures the equivalent to our anxiety.

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