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.
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: