II. The Occurrence and Etiology of Anxiety Neurosis.

In some cases of anxiety neurosis no etiology can readily be ascertained. It is noteworthy that in such cases it is seldom difficult to demonstrate a marked hereditary taint.

Where we have reason to assume that the neurosis is acquired we can find by careful and laborious examination that the etiologically effective moments are based on a series of injuries and influences from the sexual life. These at first appear to be of a varied nature but easily display the common character which explains their homogeneous effect on the nervous system. They are found either alone or with other banal injuries to which a reinforcing effect can be attributed. This sexual etiology of anxiety neurosis can be demonstrated so preponderately often that I venture for the purpose of this brief communication to set aside all cases of a doubtful or different etiology.

For the more precise description of the etiological determinations under which anxiety neurosis occurs, it will be advisable to treat separately those occurring in men and those occurring in women. Anxiety neurosis appears in women—disregarding their predisposition—in the following cases:

(a) As virginal fear or anxiety in adults. A number of unequivocal observations showed me that an anxiety neurosis, which is almost typically combined with hysteria, can be evoked in maturing girls, at the first encounter with the sexual problem, that is at the sudden revelation of the things hitherto veiled, by either seeing the sexual act, or by hearing or reading something of that nature;

(b) As fear in the newly married. Young women who remain anesthetic during the first cohabitation not seldom merge into an anxiety neurosis which disappears after the anesthesia is displaced by the normal sensation. As most young women remain undisturbed through such a beginning anesthesia, the production of this fear requires determinants which I will mention;

(d) In those whose husbands practice coitus interruptus or reservatus. These cases go together, for on analyzing a large number of examples one can easily be convinced that they only depend on whether the woman attained gratification during coitus or not. In the latter case one finds the determinant for the origin of anxiety neurosis. On the other hand the woman is spared from the neurosis if the husband afflicted by ejaculatio precox can repeat the congress with better results immediately thereafter. The congressus reservatus by means of the condom is not injurious to the woman if she is quickly excited and the husband is very potent; in other cases the noxiousness of this kind of preventive measure is not inferior to the others. Coitus interruptus is almost regularly injurious; but for the woman it is injurious only if the husband practices it regardlessly, that is, if he interrupt coitus as soon as he comes near ejaculating without concerning himself about the determination of the excitement of his wife. On the other hand if the husband waits until his wife is gratified, the coitus has the same significance for the latter as a normal one; but then the husband becomes afflicted with an anxiety neurosis. I have collected and analyzed a number of cases which furnished the material for the above statements.

(e) As fear in widows and intentional abstainers, not seldom in typical combination with obsessions; and,

(f) As fear in the climacterium during the last marked enhancement of the sexual desire.

The cases (c), (d), and (e), contain the determinants under which the anxiety neurosis originates in the female sex, most frequently and most independently, of hereditary predisposition. I will endeavor to demonstrate in these—curable, acquired—cases of anxiety neurosis that the discovered sexual injuries really represent the etiological moments of the neurosis. But before proceeding I will mention the sexual determinants of anxiety neurosis in men. I would like to formulate the following groups, every one of which finds its analogy in women:

(a) Fear of the intentional abstainers; this is frequently combined with symptoms of defense (obsessions, hysteria). The motives which are decisive for intentional abstinence carry along with them the fact that a number of hereditarily burdened eccentrics, etc., belong to this category.

(b) Fear in men with frustrated excitement (during the engagement period), persons who out of fear for the consequences of sexual relations satisfy themselves with handling or looking at the woman. This group of determinants which can moreover be transferred to the other sex—engagement periods, relations with sexual forbearance—furnish the purest cases of the neurosis.

(c) Fear in men who practice coitus interruptus. As observed above, coitus interruptus injures the woman if it is practiced regardless of the woman’s gratification; it becomes injurious to the man, if in order to bring about the gratification in the woman be voluntarily controls the coitus by delaying the ejaculation. In this manner we can understand why it is that in couples who practice coitus interruptus it is usually only one of them who becomes afflicted. Moreover the coitus interruptus only rarely produces in man a pure anxiety neurosis, usually it is a mixture of the same with neurasthenia.

(d) Fear in men in the senium. There are men who show a climacterium like women, and merge into an anxiety neurosis at the time when their potency diminishes and their libido increases.

Finally I must add two more cases holding true for both sexes:

(e) Neurasthenics merge into anxiety neurosis in consequence of masturbation as soon as they refrain from this manner of sexual gratification. These persons have especially made themselves unfit to bear abstinence.

What is important for the understanding of the anxiety neurosis is the fact that any noteworthy development of the same occurs only in men who remain potent, and in non-anesthetic women. In neurasthenics, who on account of masturbation have markedly injured their potency, anxiety neurosis as a result of abstinence occurs but rarely and limits itself usually to hypochondria and light chronic dizziness. The majority of women are really to be considered as “potent”; a real impotent, that is, a real anesthetic woman, is also inaccessible to anxiety neurosis, and bears strikingly well the injuries cited.

How far we are perhaps justified in assuming constant relations between individual etiological moments and individual symptoms from the complex of anxiety neurosis, I do not care to discuss here.

(f) The last of the etiological determinants to be mentioned seems, in the first place, really not to be of a sexual nature. Anxiety neurosis originates in both sexes through the moment of overwork, exhaustive exertion, as for instance, after sleepless nights, nursing the sick, and even after serious illnesses.

The main objection against my formulation of a sexual etiology of the anxiety neurosis will probably be to the purport that such abnormal relations of the sexual life can be found so very often that wherever one will look for them they will be found near at hand. Their occurrence, therefore, in the cases cited of anxiety neurosis does not prove that the etiology of the neurosis was revealed in them. Moreover, the number of persons practicing coitus interruptus, etc., is incomparably greater than the number of those who are burdened with anxiety neurosis, and the overwhelming number of the first are quite well in spite of this injury.

To this I can answer that we certainly ought not to expect a rarely occurring etiological moment in the conceded enormous frequency of the neurosis, and especially anxiety neurosis; furthermore, that it really fulfills a postulate of pathology if on examining an etiology the etiological moments can be more frequently demonstrated than their effects, for, for the latter still other determinants (predisposition, summation of the specific etiology, reinforcement through other banal injuries) could be demanded; and furthermore, that the detailed analysis of suitable cases of anxiety neurosis show quite unequivocally the significance of the sexual moment. I shall, however, here confine myself to the etiological moment of coitus interruptus, and I will render prominent obvious individual experiences.

1. As long as the anxiety neurosis in young women is not yet constituted but appears in fragments which again spontaneously disappear, it can be shown that every such turn of the neurosis depends on a coitus with lack of gratification. Two days after this influence, and in persons of little resistance the day after, there regularly appears the attack of anxiety or vertigo to which all the other symptoms of the neurosis attach themselves, only to separate again on rarer marriage relations. An unexpected journey of the husband, a sojourn in the mountains causing a separation of the married couple, does good; the benefit from a course of gynecological treatment is due to the fact that during its continuation the marriage relations are stopped. It is noteworthy that the success of a local treatment is only transitory, the neurosis reappears while in the mountains if the husband joins his wife for his own vacation, etc. If, in a not as yet constituted neurosis, a physician aware of this etiology causes a substitution of the coitus interruptus by normal relations there results a therapeutic proof of the assertion here formulated. The anxiety is removed and does not return unless there be a new or similar cause.

2. In the anamnesis of many cases of anxiety neurosis we find in both men and women a striking fluctuation in the intensity of the appearances in both the coming and going of the whole condition. This year was almost wholly good, the following was terrible, etc.; on one occasion the improvement occurred after a definite treatment which, however, failed to produce a response at the next attack. If we inform ourselves about the number and the sequence of the children, and compare this marriage chronicle with the peculiar course of the neurosis, the result of the simple solution shows that the periods of improvement or well being corresponded with the pregnancies of the woman during which, naturally, the occasions for preventive relations were unnecessary. The treatment which benefited the husband, be it Father Kneip’s or the hydrotherapeutic institute, was the one which he has taken after he found his wife was pregnant.

3. From the anamnesis of the patients we often find that the symptoms of the anxiety neurosis are relieved at a certain time by another neurosis, perhaps a neurasthenia which has supplanted it. It can then be regularly demonstrated that shortly before this change of the picture there occurred a corresponding change in the form of a sexual injury.

Whereas such experiences, which can be augmented at pleasure, plainly obtrude upon the physician the sexual etiology for a certain category of cases, other cases which would have otherwise remained incomprehensible can at least without gainsaying be solved and classified by the key of the sexual etiology. We refer to those numerous cases in which everything exists that has been found in the former category, such as the appearance of anxiety neurosis on the one hand, and the specific moment of the coitus interruptus on the other, but yet something else slips in, namely, a long interval between the assumed etiology and its effect, and perhaps other etiological moments of a non-sexual nature. We have here, for example, a man who was seized with an attack of palpitation on hearing of his father’s death, and who since that time suffered from an anxiety neurosis. The case cannot be understood, for up to that time this man was not nervous. The death of the father, well advanced in years, did not occur under any peculiar circumstances, and it must be admitted that the natural expected death of an aged father does not belong to those experiences which are wont to make a healthy adult sick. The etiological analysis will perhaps seem clearer if I add that out of regard for his wife this man practiced coitus interruptus for eleven years. At all events the manifestations are precisely the same as those appearing in other persons after a short sexual injury of this nature, and without the intervention of another trauma. The same judgment may be pronounced in the case of a woman who merges into an anxiety neurosis after the death of her child, or in the case of the student who becomes disturbed by an anxiety neurosis while preparing for his final state examination. I find that here, as there, the effect is not explained by the reported etiology. One must not necessarily “overwork” himself studying, and a healthy mother is wont to react to the death of her child with normal grief. But, above all, I would expect that the overworked student would acquire a cephalasthenia, and the mother in our example a hysteria. That both became afflicted with anxiety neurosis causes me to attach importance to the fact that the mother lived for eight year in marital coitus interruptus, and that the student entertained for three years a warm love affair with a “respectable” girl whom he was not allowed to impregnate.

These examples tend to show that where the specific sexual injury of the coitus interruptus is in itself unable to provoke an anxiety neurosis it at least predisposes to its acquisition. The anxiety neurosis then comes to light as soon as the effect of another banal injury enters into the latent effect of the specific moment. The former can quantitatively substitute the specific moment but not supplant it qualitatively. The specific moment always remains that which determines the form of neurosis. I hope to be able to prove to a greater extent this proposition for the etiology of the neurosis.

Furthermore, the last discussions contain the, not in itself, improbable assumption that a sexual injury like coitus interruptus asserts itself through summation. The time required before the effect of this summation becomes visible depends upon the predisposition of the individual and the former burdening of his nervous system. The individuals who bear coitus interruptus manifestly without disadvantage really become predisposed by it to the disturbance—anxiety neurosis—which can at any time burst forth spontaneously or after a banal, otherwise inadequate, trauma, just as the chronic alcoholic finally develops a cirrhosis or another disease by summation, or under the influence of a fever he merges into a delirium.