The first person account, the ‘I’, mentioned at times in the list is Freud’s voice.
The clinical picture of anxiety neurosis comprises the following symptoms:
- General irritability. Common nervous symptom. “Increased irritability always points to anaccumulation of excitation or an inability to tolerate such an accumulation-that is, to an absolute or a relative accumulation of excitation. One manifestation of this increased irritability seems to me to deserve special mention; I refer to auditory hyperaesthesia , to an oversensitiveness to noise-a symptom which is undoubtedly to be explained by the innate intimate relationship between auditory impressions and fright. Auditory hyperaesthesia frequently turns out to be a cause of sleeplessness, of which more than one form belongs to anxiety neurosis”.
“Anxious expectation, of course, shades off imperceptibly into normal anxiety, comprising all that is ordinarily spoken of as anxiousness–or a tendency to take a pessimistic view of things; but at every opportunity it goes beyond a plausible anxiousness of this kind , and it is frequently recognized by thepatient himself as a kind of compulsion. For one form of anxious expectation -that relating to the subject’s own health-we may reserve the old term hypochondria.
A further expression of anxious expectation is to be found in the inclination to moral anxiety, to scrupulousness and pedantry.
Anxiousness-which, though mostly latent as regards consciousness, is constantly lurking in the background-has other means of finding expression besides this. It can suddenly break through into consciousness without being aroused by a train of ideas, and thus provoke an anxiety attack. finally, the feeling of anxiety may have linked to it a disturbance of one or more of the
bodily functions-such as respiration, heart action, vasomotor innervation or glandular activity. the feelingof anxiety often recedes into the background or is referred to quite unrecognizably as ‘being unwell’ ‘feeling uncomfortable’ and so on.
- Anxiety attacks accompanied by disturbances of the heart action, such as palpitation, either with transitory arrhythmia or with tachycardia o longer duration which may end in serious weakness of the heart and which is not always easily differentiated from organic heart affection; and, again, pseudo angina pectoris-diagnostically a delicate subject!
- Anxiety attacks accompanied by disturbances of respiration , several forms of nervous dyspnoea, attacks resembling asthma, and the like. I would emphasize that even these attacks are not alwaysaccompanied by recognizable anxiety.
- Attacks of sweating, often at
- Attacks of tremor and shivering which are only too easily confused with hysterical
- Attacks of ravenous hunger, often accompanied by
- Diarrhoea coming on in
- Attacks of locomotor vertigo.
- Attacks of what are known as congestions, including practically everything that has been termed vasomotor
- Attacks of (But these seldom occur without anxiety or a similar feeling ofdiscomfort.)
- Waking up at night in a fright (the pavor nocturnus of adults), which is usually combined with anxiety, dyspnoea , sweating and so on, is very often nothing else than a variant of the anxiety But thepavor can also emerge in a pure form, without any dream or recurring hallucination.
- ‘Vertigo’ occupies a prominent place in the group of symptoms of anxiety neurosis. In its mildest form it is best described as ‘giddiness’; in its severer
manifestations, as ‘attacks of vertigo'(with or without anxiety), it must be classed among the gravest symptoms of the neurosis.
Furthermore, I am not sure whether it is not also right to recognize alongside of this a vertigo a stomacho laeso [of gastric origin].
- On the basis of chronic anxiousness (anxious expectation) on the one hand, and a tendency to anxiety attacks accompanied by vertigo on the other, two groups of typical phobias develop, the first relating to general physiological dangers, the second relating to locomotion. To the first group belong fear of snakes,thunderstorms, darkness, vermin, and so on, as well as the typical moral over-scrupulousness and forms ofdoubting mania . Here the available anxiety is simply employed to reinforce aversions which are instinctively implanted in everyone.
The other group includes agoraphobia with all its accessory forms, the whole of them characterized by their relation to locomotion.
- The digestive activities undergo only a few disturbances in anxiety neurosis; but these are characteristic Sensations such as an inclination to vomit and nausea are not rare, and the symptom of ravenous hunger may, by itself or in conjunction
with other symptoms (such as congestions), give rise to a rudimentary anxiety attack. As a chronic change, analogous to anxious expectation, we find an inclination to diarrhoea, and this has been the occasion of the strangest diagnostic errors.
The behaviour of the gastro-intestinal tract in anxiety neurosis presents a sharp contrast to the influenceof neurasthenia on those functions. Mixed cases often show the familiar ‘alternation between diarrhoea and constipation’. Analogous to this diarrhoea is the need to urinate that occurs in anxiety neurosis.
- The paraesthesias which may accompany attacks of vertigo or anxiety are interesting because they, like the sensations of the hysterical aura, become associated in a definite sequence; although I find that these
associations, in contrast to the hysterical ones, are atypical and changing. A further similarity to hysteria is provided by the fact that in anxiety neurosis a kind of conversion takes place on to bodily sensations, which may easily be overlooked-for instance, on to rheumatic muscles. A whole number of what are known as rheumatic individuals-who, moreover, can be shown to be rheumatic- are in reality suffering from anxiety neurosis.Along with this increase of sensitivity to pain, I have also observed in a number of cases of anxiety neurosis a tendency to hallucinations; and these could not be interpreted as hysterical.
- Several of the symptoms I have mentioned, which accompany or take the place of an anxiety attack, also appear in a chronic form. In that case they are still less easy to recognize, since the anxious sensationwhich goes with them is less clear than in an anxiety attack. This is especially true of diarrhoea, vertigo and paraesthesias (an abnormal sensation, typically tingling or pricking (‘pins and needles’), caused chiefly by pressure on or damage to peripheral nerves. Just as an attack of vertigo can be replaced by a fainting fit, so chronic vertigo can be replaced by a constant feeling of great feebleness, lassitude and so”