To be sure, the symptoms of anxiety are found more frequently as a simultaneous and common occurrence with those of neurasthenia, hysteria, compulsive ideas, and melancholia. If on account of such clinical mixtures one hesitates in recognizing anxiety neurosis as an independent unity, he will also have to abandon the laboriously acquired separation of hysteria and neurasthenia.
For the analysis of the “mixed neuroses” I can advocate the following proposition: Where a mixed neurosis exists, an involvement of many specific etiologies can be demonstrated.
Such a multiplicity of etiological moments determining a mixed neurosis can only come about accidentally, if the activities of a newly formed injury are added to those already existing. Thus, for example, a woman who was at all times a hysteric begins to practice coitus reservatus at a certain period of her married life, and adds an anxiety neurosis to her hysteria; a man who had masturbated and become neurasthenic, becomes engaged and excites himself with his fiancée so that a fresh anxiety neurosis allies itself to his neurasthenia.
The multiplicity of etiological moments in other cases is not accidental, one of them has brought the other into activity. Thus a woman, with whom her husband practices coitus reservatus without regard to her gratification, finds herself forced to finish the tormenting excitement following such an act with masturbation, as a result of which she shows an anxiety neurosis with symptoms of neurasthenia. Under the same noxiousness another woman has to contend with lewd pictures against which she wishes to defend herself, and in this way the coitus interruptus will cause her to acquire obsessions along with the anxiety neurosis. Finally a third woman, as a result of coitus interruptus loses her affection for her husband and forms another which she secretly guards, and as a result she evinces a mixture of hysteria and anxiety neurosis.
In a third category of mixed neuroses the connection of the symptoms is of a still more intimate nature, as the same etiological determinants regularly and simultaneously evoke both neuroses. Thus, for example, the sudden sexual explanation which we have found in virginal fear always produces hysteria, too; most causes of intentional abstinence connect themselves in the beginning with actual obsessions; and it seems to me that the coitus interruptus of men can never provoke a pure anxiety neurosis, but always a mixture of the same with neurasthenia, etc.
It follows from this discussion that the etiological determinants of the occurrence must moreover be distinguished from the specific etiological moments of neurasthenia. The first moments, as for example the coitus interruptus, masturbation, and abstinence, are still ambiguous, and can each produce different neuroses; and it is only the etiological moments abstracted from them, like the inadequate unburdening, psychic insufficiency, and defense with substitution, that have an unambiguous and specific relation to the etiology of the individual great neuroses.
In its intrinsic property, anxiety neurosis shows the most interesting agreements and differences when compared with the other great neuroses, particularly when compared with neurasthenia and hysteria. With neurasthenia it shares one main character, namely, that the source of excitement, the cause of the disturbance, lies in the somatic rather than in the psychic sphere as in the case of hysteria and compulsion neurosis. For the rest we can recognize a kind of contrast between the symptoms of neurasthenia and anxiety neurosis, which can be expressed in the catchwords, accumulation and impoverishment of excitement. This contrast does not hinder the two neuroses from combining with each other, but shows itself in the fact that the most extreme forms in both cases are also the purest.
When compared with hysteria anxiety neurosis shows in the first place a number of agreements in the symptomatology the valuation of which is still unsettled. The appearance of the manifestations as persistent symptoms or attacks, the aura-like grouped paresthesias, the hyperesthesias and pressure points can be found in certain substitutes for the anxiety attack, as in dyspnoea and palpitation, the aggravation of the perhaps organically determined pains (by conversion)—these and other joint features lead to the supposition that some things which are ascribed to hysteria can with full authority be fastened to anxiety neurosis. But if we enter into the mechanism of both neuroses, as far as it can at present be penetrated, we find aspects which make it appear that the anxiety neurosis is really the somatic counterpart to hysteria. Here as there we have accumulation and excitement—on which is perhaps based the similarity of the aforementioned symptoms—; here as there we have a psychic insufficiency which results from abnormal somatic processes; and here as there we have instead of a psychic elaboration a deviation of the excitement into the somatic. The difference only lies in the fact that the excitement, in which displacement the neurosis manifests itself, is purely somatic (somatic sexual excitement) in anxiety neurosis, while in hysteria it is psychic (evoked through a conflict). Hence it is not surprising that hysteria and anxiety neurosis lawfully combine with each other, as in the “virginal fear” or in the “sexual hysteria,” and that hysteria simply borrows a number of symptoms from anxiety neurosis, etc. This intimate relationship between anxiety neurosis and hysteria furnishes us with a new argument for demanding the separation of anxiety neurosis from hysteria, for if this be denied, one will also be unable to maintain the so painstakingly acquired distinction between neurasthenia and hysteria, so indispensable for the theory of the neuroses.
CHAPTER VII.
Further Observations on the Defense Neuropsychoses.
Under the caption of “Defense Neuropsychoses” I have comprised hysteria, obsessions, as well as certain cases of acute hallucinatory confusion.[[47]] All these affections evince one common aspect in the fact that their symptoms originated through the psychic mechanism of (unconscious) defense, that is, through the attempt to repress an unbearable idea which appeared in painful contrast to the ego of the patient. I was also able to explain and exemplify by cases reported in the preceding chapters in what sense this psychic process of “defense” or “repression” is to be understood. I have also discussed the laborious but perfectly reliable method of psychoanalysis of which I make use in my examinations, and which at the same time serves as a therapy.