I. Clinical Symptomatology of Anxiety Neurosis.

What I call “anxiety neurosis” can be observed in complete or rudimentary development, either isolated or in combination with other neuroses. The cases which are in a measure complete, and at the same time isolated, are naturally those which especially corroborate the impression that the anxiety neurosis possesses clinical independence. In other cases we are confronted with the task of selecting and separating from a symptom-complex which corresponds to a “mixed neurosis,” all those symptoms which do not belong to neurasthenia, hysteria, etc., but to the anxiety neurosis.

The clinical picture of the anxiety neurosis comprises the following symptoms:

1. General Irritability.—This is a frequent nervous symptom, common as such to many nervous states. I mention it here because it constantly occurs in the anxiety neurosis and is of theoretical significance. For increased irritability always points to an accumulation of excitement or to an inability to bear accumulation, hence to an absolute or relative accumulation of excitement. The expression of this increased irritability through an auditory hyperesthesia is especially worth mentioning; it is an over sensitiveness for noises, which symptom is certainly to be explained by the congenital intimate relationship between auditory impressions and fright. Auditory hyperesthesia is frequently found as a cause of insomnia, of which more than one form belongs to anxiety neurosis.

2. Anxious Expectation.—I can not better explain the condition that I have in mind, than by this name and by some appended examples. A woman, for example, who suffers from anxious expectation thinks of influenza-pneumonia whenever her husband who is afflicted with a catarrhal condition has a coughing spell; and in her mind she sees a passing funeral procession. If on her way home she sees two persons standing together in front of her house she can not refrain from the thought that one of her children fell out of the window; if she hears the bell ring she thinks that someone is bringing her mournful tidings, etc.; yet in none of these cases is there any special reason for exaggerating a mere possibility.

The anxious expectation naturally reflects itself constantly in the normal, and embraces all that is designated as “uneasiness and a tendency to a pessimistic conception of things,” but as often as possible it goes beyond such a plausible uneasiness, and it is frequently recognized as a part of constraint even by the patient himself. For one form of anxious expectation, namely, that which refers to one’s own health, we can reserve the old name of hypochondria. Hypochondria does not always run parallel with the height of the general anxious expectation; as a preliminary stipulation it requires the existence of paresthesias and annoying somatic sensations. Hypochondria is thus the form preferred by the genuine neurasthenics whenever they merge into the anxiety neurosis, a thing which frequently happens.

As a further manifestation of anxious expectation we may mention the frequent tendency observed in morally sensitive persons to pangs of conscience, scrupulosity, and pedantry, which varies as it were, from the normal to its aggravation as doubting mania.

Anxious expectation is the most essential symptom of the neurosis; it also clearly shows a part of its theory. It can perhaps be said that we have here a quantum of freely floating anxiety which controls the choice of ideas by expectation and is forever ready to unite itself with any suitable ideation.

3. This is not the only way in which the anxiousness, usually latent but constantly lurking in consciousness, can manifest itself. On the contrary it can also suddenly break into consciousness without being aroused by the issue of an idea, and thus provoke an attack of anxiety. Such an attack of anxiety consists of either the anxious feeling alone without any associated idea, or of the nearest interpretation of the termination of life, such as the idea of “sudden death” or threatening insanity; or the feeling of anxiety becomes mixed with some paresthesia (similar to the hysterical aura); or finally the anxious feeling may be combined with a disturbance of one or many somatic functions, such as respiration, cardiac activity, the vasomotor innervation, and the glandular activity. From this combination the patient renders especially prominent now this and now the other moment. He complains of “heartspasms,” “heavy breathing,” “profuse perspiration,” “inordinate appetite,” etc., and in his description the feeling of anxiety is put to the background or it is rather vaguely described as “feeling badly,” “uncomfortably,” etc.

4. What is interesting and of diagnostic significance is the fact that the amount of admixture of these elements in the attack of anxiety varies extraordinarily, and that almost any accompanying symptom can alone constitute the attack as well as the anxiety itself. Accordingly there are rudimentary attacks of anxiety, and equivalents for the attack of anxiety, probably all of equal significance in showing a profuse and hitherto little appreciated richness in forms. A more thorough study of these larvated states of anxiety (Hecker) and their diagnostic division from other attacks ought soon to become the necessary work for the neuropathologist.

I now add a list of those forms of attacks of anxiety with which I am acquainted. There are attacks:

(a) With disturbances of heart action, such as palpitation with transitory arrythmia, with longer continued tachycardia up to grave states of heart weakness, the differentiation of which from organic heart affection is not always easy; among such we have the pseudo-angina pectoris, a delicate diagnostic sphere!

(b) With disturbances of respiration, many forms of nervous dyspnoea, asthma-like attacks, etc. I assert that even these attacks are not always accompanied by conscious anxiety;

(d) Of trembling and shaking which may readily be mistaken for hysterical attacks;

(e) Of inordinate appetite, often combined with dizziness;

(f) Of attack-like appearing diarrhoea;

(g) Of locomotor dizziness;

(h) Of so called congestions, embracing all that was called vasomotor neurasthenia; and,

(i) Of paresthesias (These are seldom without anxiety or a similar discomfort).

5. Very frequently the nocturnal frights (pavor nocturnus of adults) usually combined with anxiety, dyspnoea, perspiration, etc., is nothing other than a variety of the attack of anxiety. This disturbance determines a second form of insomnia in the sphere of the anxiety neurosis. Moreover I became convinced that even the pavor nocturnus of children evinces a form belonging to the anxiety neurosis. The hysterical tinge and the connection of the fear with the reproduction of appropriate experience or dream, makes the pavor nocturnus of children appear as something peculiar, but it also occurs alone without a dream or a recurring hallucination.

6. “Vertigo.”—This in its lightest forms is better designated as “dizziness,” assumes a prominent place in the group of symptoms of anxiety neurosis. In its severer forms the “attack of vertigo,” with or without fear, belongs to the gravest symptoms of the neurosis. The vertigo of the anxiety neurosis is neither a rotatory dizziness nor is it confined to certain planes or lines like Menier’s vertigo. It belongs to the locomotor or coordinating vertigo, like the vertigo in paralysis of the ocular muscles; it consists in a specific feeling of discomfort which is accompanied by sensations of a heaving ground, sinking legs, of the impossibility to continue in an upright position, and at the same time there is a feeling that the legs are as heavy as lead, they shake, or give way. This vertigo never leads to falling. On the other hand, I would like to state that such an attack of vertigo may also be substituted by a profound attack of syncope. Other fainting-like states in the anxiety neurosis seem to depend on a cardiac collapse.

The vertigo attack is frequently accompanied by the worst kind of anxiety and is often combined with cardiac and respiratory disturbances. Vertigo of elevations, mountains and precipices, can also be frequently observed in anxiety neurosis; moreover, I do not know whether we are still justified in recognizing a vertigo “a stomacho laeso.”

7. On the basis of the chronic anxiousness (anxious expectation) on the one hand, and the tendency to vertiginous attacks of anxiety on the other, there develop two groups of typical phobias; the first refers to the general physiological menaces, while the second refers to locomotion. To the first group belong the fear for snakes, thunderstorms, darkness, vermin, etc., as well as the typical moral overscrupulousness, and the forms of doubting mania. Here the available fear is merely used to strengthen those aversions which are instinctively implanted in every man. But usually a compulsively acting phobia is formed only after a reminiscence is added to an experience in which this fear could manifest itself; as, for example, after the patient has experienced a storm in the open air. To attempt to explain such cases as mere continuations of strong impressions is incorrect. What makes these experiences significant and their reminiscences durable is after all only the fear which could at that time appear and can also appear today. In other words such impressions remain forceful only in persons with “anxious expectations.”

The other group contains agoraphobia with all its accessory forms, all of which are characterized by their relation to locomotion. As a determination of the phobia we frequently find a precedent attack of vertigo; I do not think that it can always be postulated. Occasionally, after a first attack of vertigo without fear, we see that though locomotion is always accompanied by the sensation of vertigo, it remains possible without any restrictions, but as soon as fear attaches itself to the attack of vertigo, locomotion fails, under the conditions of being alone, narrow streets, etc.

The relation of these phobias to the phobias of obsessions, which mechanism I discussed above,[^[42]] is as follows: The agreement lies in the fact that here as there, an idea becomes obsessive through its connection with an available affect. The mechanism of transposition of the affect therefore holds true for both kinds of phobias. But in phobias of the anxiety neurosis this affect is (1) a monotonous one, it is always one of anxiety; (2) it does not originate from a repressed idea, and on psychological analysis it proves itself not further reducible, nor can it be attacked through psychotherapy. The mechanism of substitution does not therefore hold true for the phobias of anxiety neurosis.

Both kinds of phobias (or obsessions) often occur side by side, though the atypical phobias which depend on obsessions need not necessarily develop on the basis of anxiety neurosis. A very frequent, ostensibly complicated mechanism appears if the content of an original simple phobia of anxiety neurosis is substituted by another idea, the substitution is then subsequently added to the phobia. The “protective measures” originally employed in combatting the phobia are most frequently used as substitutions. Thus, for example, from the effort to provide oneself with counter evidence that one is not crazy, contrary to the assertion of the hypochondriacal phobia, there results a reasoning mania. The hesitations, doubts, and the many repetitions of the folie du doute originate from the justified doubt concerning the certainty of one’s own stream of thoughts, for, through the compulsive like idea one is surely conscious of so obstinate a disturbance, etc. It may therefore be claimed that many syndromes of compulsion neurosis, like folie du doute and similar ones, can clinically, if not notionally be attributed to anxiety neurosis.[^[43]]

8. The digestive functions in anxiety neurosis are subject to very few but characteristic disturbances. Sensations like nausea and sickly feeling are not rare, and the symptom of inordinate appetite alone or with other congestions, may serve as a rudimentary attack of anxiety. As a chronic alteration analogous to the anxious expectations one finds a tendency to diarrhea which has occasioned the queerest diagnostic mistakes. If I am not mistaken it is this diarrhea to which Moebius [^[44]] has recently called attention in a small article. I believe, moreover, that Peyer’s [^[45]] reflex diarrhea which he attributes to a disease of the prostate is nothing other than the diarrhea of anxiety neurosis. The deceptive reflex relation is due to the fact that the same factors which are active in the origin of such prostatic affections also come into play in the etiology of anxiety neurosis.

The behavior of the gastro-intestinal function in anxiety neurosis shows a sharp contrast to the influence of this same function in neurasthenia. Mixed cases often show the familiar “fluctuations between diarrhea and constipation.” The desire to urinate in anxiety neurosis is analogous to the diarrhea.

9. The paresthesias which accompany the attack of vertigo or anxiety are interesting because they associate themselves into a firm sequence, similar to the sensations of the hysterical aura. But in contrast to the hysterical aura I find these associated sensations atypical and changeable. Another similarity to hysteria is shown by the fact that in anxiety neurosis a kind of conversion [^[46]] into bodily sensations, as for example into rheumatic muscles, takes place which otherwise can be overlooked at one’s pleasure. A large number of so called rheumatics, who are moreover demonstrable as such, really suffer from an anxiety neurosis. Besides this aggravation of the sensation of pain I have observed in a number of cases of anxiety neurosis a tendency towards hallucinations which could not be explained as hysterical.

10. Many of the so called symptoms which accompany or substitute the attack of anxiety also appear in a chronic manner. They are then still less discernible, for the anxious feeling accompanying them appears more indistinct than in the attack of anxiety. This especially holds true for the diarrhea, vertigo, and paresthesias. Just as the attack of vertigo can be substituted by an attack of syncope, so can the chronic vertigo be substituted by the continuous feeling of feebleness, lassitude, etc.