ANXIETY-NEUROSIS

The following considerations can only claim the value of a preliminary tentative attempt at a theory; criticism of them should not affect the reader's acceptance of the _facts_ set forth above. Moreover, this 'Theory of Anxiety-Neurosis' represents only a fragment of a more comprehensive presentation of the neuroses which increases the difficulty of assessing its value.

The material already brought forward in regard to the anxiety-neurosis has provided a few openings for some insight into its mechanism. In {96} the first place it was surmised that we are here dealing with an accumulation of excitation; secondly, there was the exceedingly important fact that the anxiety, which underlies all the clinical symptoms of this neurosis, _is not derived from any psychical source_. A psychical origin would be present, for example, if we found as the basis of an anxiety-neurosis a single or repeated shock, justified by the circumstances, which had subsequently become the source of the readiness to anxiety. But this is not what we find; an hysteria or a traumatic neurosis may develop as a result of a single shock---an anxiety-neurosis never. Since among the causes of anxiety-neurosis coitus interruptus forces itself so much into the foreground, I thought at first that the source of the continual anxiety might lie in the fear, revived with every act, that the method might miscarry and be followed by conception. But I have found that this state of mind either in man or woman during coitus interruptus is irrelevant for the genesis of anxiety-neurosis; that women who at bottom are indifferent to the consequences of a possible conception are just as liable to the neurosis as those who shudder at the possibility, and that all depends on which of the partners forfeits satisfaction in this method of intercourse.

A further indication is furnished by the observation, not before mentioned, that in whole groups of cases anxiety-neurosis is accompanied by a very noticeable abatement of sexual libido,[27] i.e. of _psychical desire_; so that, on being told that their sufferings result from 'insufficient satisfaction', patients regularly {97} answer that that is impossible, because all their need for it has now disappeared. From all these data: that an accumulation of excitation is involved; that the anxiety which probably represents this accumulated excitation is of somatic origin, so that it is somatic excitation which is accumulated; further, that the somatic excitation is of a sexual nature and that a decline in the psychical share in the sexual process goes along with it---all these data prepare our minds for the statement that _the mechanism of anxiety-neurosis is to be sought in the deflection of somatic sexual excitation from the psychical field, and in an abnormal use of it, due to this deflection_.

This conception of the mechanism of anxiety-neurosis becomes clearer if we accept the following view of the sexual process, which relates primarily to men. In the sexually mature male organism somatic sexual excitation is produced---probably continuously---and periodically acts as a psychical stimulus. In order to define this idea more clearly, let us interpolate that this somatic sexual excitation takes the form of pressure on the walls of the vesiculæ seminales which are lined with nerve-endings; this visceral excitation will then actually develop continuously, but only when it reaches a certain height will it be sufficient to overcome the resistance in the paths of conduction to the cerebral cortex and express itself as a psychical stimulus. Thereupon the constellation of sexual ideas existing in the mind becomes charged with energy and a psychical state of libidinous tension comes into existence, bringing with it the impulse to relieve this tension. The necessary psychical relief can only be effected by what I shall describe as a _specific_ or _adequate activity_. For the male sexual impulse this adequate activity consists in a complicated spinal reflex act resulting in the relief of the tension at these {98} nerve-endings and in all the preparatory psychical processes necessary to induce this reflex. Nothing but the adequate activity would be effective; for, once it has reached the required level, the somatic sexual excitation is continuously transmuted into psychical excitation; the activity which will free the nerve-endings from burdensome pressure and so abolish the whole of the somatic excitation present, thus allowing the subcortical tracts to re-establish their resistance, must absolutely be carried into operation.

I will refrain from describing more complicated forms of the sexual process in this manner. I will only add the statement that in essentials this formula is applicable also to women, notwithstanding the confusion introduced into the problem by all the artificial arresting and stunting that the female sexual impulse undergoes. In women also we must postulate a somatic sexual excitation, and a condition in which this excitation becomes a psychical stimulus, evoking libido and the impulse to a specific activity to which sensual pleasure is attached. Where women are concerned, however, we cannot state what is the process analogous to the relief of tension in the vesiculæ seminales.

The ætiology of neurasthenia proper as well as of anxiety-neurosis can now be brought within the compass of this conception of the sexual process. Neurasthenia arises whenever a less adequate relief (activity) takes the place of the adequate one, thus, when masturbation or spontaneous emission replaces normal coitus under the most favourable conditions; while anxiety-neurosis is produced by all those factors which prevent the somatic sexual excitation from being assimilated psychically. The clinical symptoms of anxiety-neurosis {99} appear when the somatic sexual excitation that is deflected from the mind is expended subcortically in quite inadequate reactions.

I shall now try to test the ætiological conditions of anxiety-neurosis given above, in order to see whether they show the common character I have ascribed to them. The first ætiological factor in men that I mentioned is voluntary abstinence. Abstinence consists in foregoing the specific activity which otherwise follows upon libido. Privation of this kind can have two consequences, namely, that the somatic excitation becomes augmented by accumulation, and secondly, that it is then dissipated along other paths, through which it may find its discharge more easily than along the path to the mind. Libido will therefore subside again and the excitation will express itself instead subcortically as anxiety. In cases where libido does not subside or where the somatic excitation is expended by a short cut in emissions, or where it actually becomes exhausted in consequence of being restrained, anything else may arise, but not anxiety-neurosis. Abstinence leads to anxiety-neurosis in the way described. Abstinence is also the agent in the second ætiological group, that of frustrated excitement. The third case, that of coitus reservatus with regard for the woman, acts by disturbing the psychical state of preparedness for the sexual process, in that it adds to the task of dealing with the sexual affect another, a deflecting, psychical task. In consequence of this psychical deflection libido also gradually subsides, the further developments being then the same as in abstinence. Anxiety in ageing men (the male climacteric) requires another explanation. There is no reduction in libido here; but, just as during the climacteric in women, such an increase in the {100} production of somatic excitation occurs that the psyche proves relatively unable to master it.

There is no greater difficulty in bringing the ætiological conditions in women within the scope of our theory than in the case of men. Virginal anxiety is a particularly clear example; the constellations of ideas to which the somatic sexual excitation should become attached are not yet sufficiently developed. In anæsthetic newly-married women anxiety only appears when the first acts of intercourse arouse a sufficient quantity of somatic excitation. When local indications of the state of excitement (such as spontaneous local sensations, desire to micturate and the like) are lacking, then anxiety is also absent. In cases where intercourse involves ejaculatio præcox or coitus interruptus, the explanation is similar to that given for men---libido gradually declines from the psychically unsatisfying act, while the excitation called forth by the act is expended subcortically. An _estrangement_ between the somatic and the psychical in the course taken by sexual excitation is established sooner and is more difficult to remove in women than in men. In widowhood and in voluntary abstinence, as also in the climacteric, the process is the same in women as in men; although in abstinence there must also be the additional factor of an intentional repression of sexual ideas which the abstinent woman battling with desire must frequently resolve upon, and similarly, at the time of the menopause, the detestation with which the ageing woman regards the unduly increased libido must come into operation.

The two last ætiological conditions enumerated also seem to fall into line without difficulty.

The tendency to anxiety in masturbators who have become neurasthenic {101} is explained by the fact that these persons very easily pass into a condition of 'abstinence' after they have for so long been accustomed immediately to discharge every access of somatic excitation, however small, although not in a normal manner. Finally, the last case, in which anxiety-neurosis arises from serious illness, overwork, exhausting sick-nursing, etc., may be brought into relation with the mode of action of coitus interruptus and then find a simple interpretation: by reason of the deflection of interest the mind is no longer capable of mastering the somatic sexual excitation, a task which is continuously incumbent on it. We know to what a low level libido can sink under these conditions; and we have here an excellent example of a _neurosis which has, it is true, no sexual ætiology, but nevertheless shows a sexual mechanism_.

The theory here developed shows the symptoms of anxiety-neurosis to be in some measure _surrogates_ for the specific activity which should follow upon sexual excitation, but has not done so. In further corroboration of this I may point out that even in normal coitus the excitation expresses itself also in accelerated breathing, palpitations, sweating, congestion and so on. In the corresponding anxiety-attacks of our neurosis we see the dyspnœa, palpitations, etc. of coitus in an isolated and exaggerated form.

The question may now be asked: Why does the nervous system under such conditions---of psychical incapacity to master sexual excitation---take on the particular affective state of anxiety? The reply may be indicated somewhat as follows: The psyche develops the affect of anxiety when it feels itself incapable of dealing (by an adequate reaction) with a task (danger) approaching it externally; it {102} develops the neurosis of anxiety when it feels itself unequal to the task of mastering (sexual) excitation arising endogenously. That is to say, _it acts as if it had projected this excitation into the outer world_. The affect and the neurosis corresponding to it stand in a close relation to each other; the first is the reaction to an exogenous, the second to an analogous, endogenous, excitation. The affect is a state which passes rapidly, the neurosis is a chronic state; because an exogenous excitation acts like a single shock, an endogenous one like a constant pressure. _The nervous system reacts to an internal source of excitation with a neurosis, just as it reacts to an analogous external one with a corresponding affect_.