III. Addenda to the Theory of Anxiety Neurosis.
The following discussions claim nothing but the value of a first tentative experiment, which judgment should not influence the acceptance of the facts mentioned above. The estimation of this “Theory of Anxiety Neurosis” is rendered still more difficult by the fact that it merely corresponds to a fragment of a more comprehensive representation of the neuroses.
The facts hitherto expressed concerning the anxiety neurosis already contain some starting points for an insight into the mechanism of this neurosis. In the first place it contains the assumption that we deal with an accumulation of excitement, and then the very important fact that the anxiety underlying the manifestations of the neurosis is not of psychic derivation. Such, for example, would exist if we found as a basis for the anxiety neurosis a justified fright happening once or repeatedly which has since supplied the source of the preparedness for the anxiety neurosis. But this is not the case; a former fright can perhaps cause a hysteria or a traumatic neurosis but never an anxiety neurosis. As the coitus interruptus is rendered so prominent among the causes of anxiety neurosis I have thought at first that the source of the continuous anxiety was perhaps the repeated fear during the sexual act lest the technique will fail and conception follow. But I have found that this state of mind of the man or woman during the coitus interruptus plays no part in the origin of anxiety neurosis, that the women who are really indifferent to the possibilities of conception are just as exposed to the neurosis as those who are trembling at the possibility of it, it all depends on which person suffers the loss of sexual gratification.
Another starting point presents itself in the as yet unmentioned observation that in a whole series of cases the anxiety neurosis goes along with the most distinct diminution of the sexual libido or the psychic desire, so that on revealing to the patients that their affliction depends on “insufficient gratification,” they regularly reply that this is impossible as just now their whole desire is extinguished. The indications that we deal with an accumulation of excitement, that the anxiety which probably corresponds to such accumulated excitement is of somatic origin, so that somatic excitement becomes accumulated, and furthermore, that this somatic excitement is of a sexual nature, and that it is accompanied by a decreased psychic participation in the sexual processes—all these indications, I say, favor the expectation that the mechanism of the anxiety neurosis is to be found in the deviation of the somatic sexual excitement from the psychic, and in the abnormal utilization of this excitement occasioned by the former.
This conception of the mechanism of anxiety neurosis will become clearer if one accepts the following view concerning the sexual process in man. In the sexually mature male organism, the somatic sexual excitement is—probably continuously—produced, and this becomes a periodic stimulus for the psychic life. To make our conceptions clearer we will add that this somatic sexual excitement manifests itself as a pressure on the wall of the seminal vesicle which is provided with nerve endings. This visceral excitement thus becomes continuously increased, but not before attaining a certain height is it able to overcome the resistances of the intercalated conduction as far as the cortex, and manifest itself as psychic excitement. Then the group of sexual ideas existing in the psyche becomes endowed with energy and results in a psychic state of libidinous tension which is accompanied by an impulse to remove this tension. Such psychic unburdening is possible only in one way which I wish to designate as specific or adequate action. This adequate action for the male sexual impulse consists of a complicated spinal reflex-act which results in the unburdening of those nerve endings, and of all psychically formed preparations for the liberation of this reflex. Anything else except the adequate action would be of no avail, for after the somatic sexual excitement has once reached the liminal value, it continuously changes into psychic excitement; that must by all means occur which frees the nerve endings from their heavy pressure, and thus abolish the whole somatic excitement existing at the time and allow the subcortical conduction to reestablish its resistance.
I will desist from presenting in a similar manner more complicated cases of the sexual process. I will merely formulate the statement that this scheme can essentially be transferred to the woman despite the problem of the perplexity, artificial retardation, and stunting of the female sexual impulse. In the woman, too, it can be assumed that there is a somatic sexual excitement and a state in which this excitement becomes psychic, evoking libido and the impulse to specific action which is accompanied by the sensual feeling. But we are unable to state what analogy there may be in the woman to the unburdening of the seminal vesicles.
We can bring into the bounds of this representation of the sexual process the etiology of actual neurasthenia as well as of the anxiety neurosis. Neurasthenia always originates whenever the adequate (action) unburdening is replaced by a less adequate one, like the normal coitus under the most favorable conditions, by a masturbation or spontaneous pollution; while anxiety neurosis is produced by all moments which impede the psychic elaboration of the somatic sexual excitement. The manifestations of anxiety neurosis are brought about by the fact that the somatic sexual excitement diverted from the psyche expends itself subcortically in not at all adequate reactions.
I will now attempt to test the etiological determinants suggested before in order to see whether they show the common character formulated by me. As the first etiological moment for the man, I have mentioned intentional abstinence. Abstinence consists in foregoing the specific action which results from the libido. Such foregoing may have two consequences, namely that the somatic excitement accumulates, and then, what is more important, is the fact that it becomes diverted to another route where there is more chance for discharge than through the psyche. It will then finally diminish the libido and the excitement will manifest itself subcortically as anxiety. Where the libido does not become diminished, or the somatic excitement is expended in pollutions, or where it really becomes exhausted in consequence of repulsion, everything else except anxiety neurosis is formed. In this manner abstinence leads to anxiety neurosis. But abstinence is also the active process in the second etiological group of frustrated excitement. The third case, that of the considerate coitus reservatus, acts through the fact that it disturbs the psychic preparedness for the sexual discharge by establishing beside the subjugation of the sexual affect, another distracting psychic task. Through this psychic distraction, too, the libido gradually disappears and the further course is then the same as in the case of abstinence. The anxiety in old age (climacterium of men) requires another explanation. Here the libido does not diminish, but just as in the climacterium of women, such an increase takes place in the somatic excitement that the psyche shows itself relatively insufficient for the subjugation of the same.
The subsummation of the etiological determinants in the woman, under the aspect mentioned, does not afford any greater difficulties. The case of the virginal fear is especially clear. Here the group of ideas with which the somatic sexual excitement should combine are not as yet sufficiently developed. In anesthetically newly married the anxiety appears only if the first cohabitations awakened a sufficient amount of somatic excitement. Where the local signs of such excitability (like spontaneous feelings of excitement, desire to micturate, etc.) are lacking, the anxiety, too, stays away. The case of ejaculatio precox or coitus interruptus is explained similarly to that in the man by the fact that the libido gradually disappears in the psychically ungratified act, whereas the excitement thereby evoked is subcortically expended. The formation of an estrangement between the somatic and psychic in the discharge of the sexual excitement succeeds quicker in the woman than in the man and is more difficult to remove. The case of widowhood or voluntary abstinence, as well as the case of climacterium adjusts itself in the woman as in the man, but in the case of abstinence there surely is in addition the intentional repression of the sexual ideas, for an abstinent woman struggling with temptation must often decide to suppress it. The abhorrence perceived by an elderly woman during her menopause against the immensely increased libido can have a similar effect.
The two etiological determinants mentioned last can also be classified without any difficulty.
The tendency to anxiety of the masturbator who becomes neurasthenic is explained by the fact that these persons so easily merge into the state of abstinence after they have for long been accustomed to afford a discharge, to be sure an incorrect one, for every little quantity of somatic excitement. Finally the last case, the origin of anxiety neurosis through a severe illness, overwork, exhaustive nursing, etc., in addition to the efficacy of coitus interruptus readily permits a free interpretation. Through deviation the psyche becomes here insufficient for the subjugation of the somatic sexual excitement, a task which continuously devolves upon it. We know how deeply the libido can sink under the same conditions, and we have here a nice example of a neurosis which although not of a sexual etiology still evinces a sexual mechanism.
The conception here developed represents the symptoms of anxiety neurosis in a measure as a substitute for the omitted specific action to the sexual excitement. As a further corroboration of this I recall that also in normal coitus the excitement expends itself in respiratory acceleration, palpitation, perspiration, congestion, etc. In the corresponding attack of anxiety of our neurosis we have before us the dyspnoea, the palpitation, etc., of the coitus in an isolated and aggravated manner.
It can still be asked why the nervous system merges into a peculiar affective state of anxiety under the circumstances of psychic inadequacy for the subjugation of the sexual excitement? A hint to the answer is as follows: The psyche merges into the affect of fear when it perceives itself unable to adjust an externally approaching task (danger) by corresponding reaction; it merges into the neurosis of anxiety when it finds itself unable to equalize the endogenously originated (sexual) excitement. The psyche, therefore, behaves as if projecting this excitement externally. The affect and the neurosis corresponding to it stand in close relationship to each other; the first is the reaction to an exogenous, the latter the reaction to an analogous endogenous excitement. The affect is a rapidly passing state, the neurosis is chronic because the exogenous excitement acts like a stroke happening but once, while the endogenous acts like a constant force. The nervous system reacts in the neurosis against an inner source of excitement just as it does in the corresponding affect against an analogous external one.