Showing papers on "Somatic anxiety published in 1935"

The Syndrome of Neurotic Anxiety: The Somatic and Psychic Components of its Genesis and Therapy

Abstract: As a state of neurotic anxiety is not to be influenced by the usual pharmaco and psychotherapy, an attempt was made to find out the genesis of this state of anxiety. It was found that at the commencement of the illness it is always possible to find the “major anxiety attack” which is composed of a number of vasomotor sensations, tachycardia and intense paralysis of the motility and of the psychic apparatus, combined with acute fear. Such attacks are very seldom to be observed because the patient cannot move during the attack, and, besides that, does not speak about it. They rarely occur in the same patient again with the same violence, since, as the anxiety is unbearable, mechanisms of defence are mobilized at once. Owing to these latter there arise the modified syndromes of “agitated anxiety attacks”, of the “chronic anxiety state” with exacerbations, and with incidental graver attacks, and the “anxiety equivalents” of Freud. Clinically, one has to differentiate the anxiety neurosis, in which the anxiety overtakes the patient like an infectious disease, and in which neurotic symptoms are not to be observed in the intervals, and the anxiety hysteria, in which the hysterical disposition can be demonstrated, and the attacks are determined by psychical processes (e.g., are caused by suppressed aggressions). The investigations started with the anxiety neurosis, and especially the major anxiety attack. In the latter case the somatic anxiety syndrome is most clearly developed, and is composed of intense vasoconstriction of the skin (paraesthesias, sensation of cold, pallor), tachycardia up to 150, inhibition of salivation, cold sweating, mydriasis, arterial hypertony up to 150 mm. (of mercury), and an intense relaxation of the voluntary muscle system. This syndrome indicates a stormy excitation of the sympathetic system, which may be combined at the end of the attack with parasympathetic phenomena. It was found that this syndrome could be removed by choline preparations, which by their stimulating effect on the parasympathetic nerve produced an effect exactly the opposite to the anxiety syndrome: by an intramuscular injection of 0.1 cc. acetyl-choline the anxiety attack can be stopped also in its psychical effects, and even chronic anxiety attacks can disappear after a few days by oral administration of the choline preparations pacyl or hypotan. It appeared that the effect of choline is greater if the anxiety experience is more elementary, and smaller if the anxiety is worked through in a psychical manner. The removal of anxiety by a drug with only a peripheral action led to the supposition that the fear of an anxiety neurosis arises primarily in a somatic way. Various clinical and experimental observations led to the hypothesis that the vaso-constriction of the skin plays an important part here (vasoneurotic anxiety), and that the character of the anxiety syndrome, corresponding to the adrenaline effect, may be traced back to a primary action of the adrenal glands. Since in all cases observed there was found some sexual damage, such as the inhibition of normal relief, and since the anxiety could be removed both by the prevention of this and by choline medication, this confirms Freud's theory of the damming up of libido, and Reich's theory of the origin of anxiety being due to a sympathetic-toxic action of the sexual hormone. The fact of peripheral somatic removal of anxiety seems to have great theoretic importance for the question of the relation between psychic and somatic events in anxiety. Clinical observations showed that in an anxiety neurosis the vaso-constriction of the skin is of primary significance—a phenomenon which is understood as the “barrier syndrome”. The psychic correlation to this is experienced in the anxiety attack as a loss of connection with surroundings, and this experience is the origin of the feeling of annihilation in the anxiety attack, as K. Goldstein has proved in the anxiety in cases of brain injury. The fear of death which is experienced in the anxiety attack is understood to be the experience of threatened loss of identification by the ego which becomes realized by means of the objects. The heart neurosis described by Max Herz as phrenocardia, which not only shows the same somatic syndrome as the anxiety neurosis, but at the same time is traced to unsatisfied sexuality, allows the supposition that this disease is a kind of “anxiety neurosis without anxiety”, and that therefore the pathogenic agent is here worked through psychically in a different way to that of the anxiety neurosis. In order that anxiety should arise there must then be, apart from the somatic events, also a psychic readiness through the individual structure of the personality. In neurotic anxiety conditions there is a reciprocity between soma and psyche, the common somatic condition being a state of sympathetic excitation, the common psychic condition being the anxiety experience. Choline treatment removes the somatic experience from the psyche where it was worked through as anxiety, and in this way a vicious circle which usually cannot be interrupted by action on the psychic factor is interrupted by action on the somatic factors. The somatic genesis of neurotic anxiety can be designed in the following way: There is always a disturbance of the course of sexual irritation to be found. This disturbance results either from sexual abstinence caused by external or neurotic reasons, or from neurotic sexual hypo-aesthesia while relatively great libido is present, and leads, with a certain sympatheticotonic disposition, to a strong excitation of the sympathetic system. At this point the mechanism can be interrupted by choline medication. According to the working through of the state of sympathetic excitation there results either the syndrome phrenocardia, or, with corresponding psychic preparedness, the anxiety neurosis. If this continues for some time it can become fixated and psychically worked through so that anxiety can then also be issued by the psyche. It was possible to ascertain in nearly all cases that the ailment had started with an actual anxiety neurosis, and that by drug treatment or abolition of the sexual disturbances, one can prevent the manifestation of the psychoneurosis. The somatic neurosis only lasts for a certain time, some weeks or months, and then becomes built over in a psychoneurotic manner so that then it may only be treated by a long-continued psycho-therapy. In the cases of anxiety hysteria this psychoneurotic projection is existent from the beginning and is to be treated by psychotherapy. Psychotherapy, then, has to treat the neurotic sexual abstinence and hypo-aesthesia as sources of anxiety neurosis, and its secondary fixation.