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BRITISH PSYCHOLOGICAL SOCIETY.
774
BRITISH PSYCHOLOGICAL SOCIETY.
Army and the Navy, for in peace time the stresses in flying were more pronounced than in those other branches. Even the more stable type of man might break down if the stress was exceptional. The highest figures for the incidence of functional nerve disease in the Air Force were in 1922-23 ; since then there had been a steady decrease. The incidence was highest among those actually flying ; those who through age or other cause did not fly regularly came off best. In neurasthenia the predominant symptom was mental or physical fatigue, with pains, headaches, digestive disturbance, with general depression and lack of energy. In the anxiety neurosis the symptoms were mainly psychic, and the picture was one of nervousness, the patient had a sense of foreboding, worried over trifles, and was easily disturbed. Psychasthenia was characterised by a defective power of volition ; the patient was unable to make and act on decisions ; was a definite previous history of nervous disability, doubting mania also occurred, and the patient could be of but little use in the Service. claustrophobia. Only a small number of flying officers The treatment, apart from general considerations of broke down, even when subjected to exceptional stress. health and the application of electrotherapy, took Psychoneurosis developed because the subject could the form of counter-suggestion or persuasion. A not adapt himself to his environmental condition. patient who was not easily amenable to persuasion Some cases of functional nervous disorder occurred might require a prolonged course of treatment and after mild head injury, which might have been so ceased to be an economical proposition for the Army slight that concussion was not suspected. When a in peace time. Still, the principle that no man should toxic factor had been operative the case would usually be discharged from the Service uncured of a curable respond to appropriate treatment. Dr. ALDREN TURNER spoke of what had been found disability was one which he would like to see carried out. The question of specialist psychotherapeutic in officers at the War Office Medical Board. These treatment was receiving attention. The situation was cases were usually of a special character. Hysteria, different in war time, when the whole of the resources as illustrated by the usual stigmata of paralysis, fits, of the country were devoted to the maintenance of and anaesthesia, was rare. In young officers there man-power. The problem remained, in essence, one had been cases of fits developing under special cirof eugenics and upbringing. cumstances of mental strain and over-work, and Rear-Admiral E. T. MEAGHER said he was excluding perhaps to some extent aggravated by personal habits from his discussion occupational neuroses, such as and climatic conditions, as in India, and in these writer’s cramp, chorea which might arise as a result cases the fits usually ceased on the return of the of psychic shock, and exophthalmic goitre. People patient to this country. The outstanding functional fell into three groups-normal, psychopathic, and nervous disorder observed among officers was neuropathic. Some held that there was a germinal neurasthenia, using that term in its widest application. defect, and that the majority of people who subse- For the purposes of description he had made three quently developed mental defect or disorder had this groups : (1) the more purely debilitated or nervously deficiency. A terrifying shock might have a more or exhausted cases ; (2) those showing evidence of less permanent effect on the mind of a child, but anxiety, accompanied by characteristic physical unless neuropathic or psychopathic, such a person signs ; (3) those with the post-concussional syndrome. He did In the group characterised by anxiety, causes of a was not likely to develop a psychoneurosis. not know any way of determining whether such psychological kind played an important part, includinherent weakness existed in a particular individual. ing distaste for certain duties and disciplines. Thyroid He thought a new entrant to the Service should be enlargement in these cases was practically unknown, under observation in the first months to see whether but there was reason to believe there was a disturbance he manifested any characteristics indicating nervous of endocrine function and of the vegetative nervous instability. It was agreed that, apart from hereditary system. Those who suffered a breakdown during the predisposition, a normal person if subjected to excep- war were thereby rendered liable to a relapse if tional stress might break down. Conditions in the, strain and stress were renewed. Navy tended to raise the resistance to hysteria. Hysterical manifestations could often be traced to In the Navy the hysterical fit some psychic shock. BRITISH PSYCHOLOGICAL SOCIETY. was common, and for these cases a word or two of advice and discharge to duty was the best course to adopt. Hysteria was manifested most in the less The Psychiatric Section of this Society held a joint educated ; indeed, he had not seen a case of pure meeting with the Psychiatry Section of the Royal hysteria in an officer. It was easily provoked in those Society of Medicine on April 9th. The chair was of neuropathic constitution. taken by Dr. EDWARD GLOVER, President of the former In regard to diagnosis, the chief thing was to make section. A discussion on sure that organic disease did not coexist. According THE PSYCHOPATHOLOGY OF ANXIETY to Kraepelin, 50 per cent. of cases of manic-depressivE insanity showed hysteria. In treatment the medical was opened by Dr. ERNEST JONES. He said that the officer should adopt measures to check loss oj term " morbid anxiety " distinguished a collection of emotional control by advice or by isolating the phenomena from those grouped under the name of patient. Galvanism would cure aphonia, and thE " fear." Two features justifying this distinction were hysterical fit could be cut short by physical measures disproportion between the stimulus and the response, The doctor must gain domination over the patient and disharmony between bodily and mental manifestaIt had been found that the " Old Contemptibles ’ tions. In pronounced cases, such as claustrophobia were not liable to displays of functional nervous in a closed room, these were very marked, but in disorder. The Navy did not show much change in th< borderline instances it was difficult to assess " normal" incidence of functional nervous disease as compared distress. Psycho-analysts had learned to set a very with the years before the late war. In conclusion, th( high standard of " normal " bravery, and to maintain speaker advocated uniformity of nomenclature anc that much timidity passing as normal was really neurotic and curable. The anxiety nature of the terminology for all the Services and for general use. said the L. BURTON M. physical manifestations was often overlooked clinicproblem! Squadron-Leader in the Royal Air Force differed somewhat from thos4 ally. Symptoms such as chronic diarrhoea, psychical
decide whether one was dealing with a reflex nervous disorder, such as might be associated with a wound. Hysteria might be superimposed upon an organic lesion, or upon a toxic condition. In the " Nomenclature of Diseases " of the Royal College of Physicians, which the Army adopted, no name was provided intermediate between neurasthenia and psychasthenia; hence it was difficult to place such psychoneuroses as anxiety, compulsion, and obsessional neuroses. Some of the cases diagnosed as hysteria and included in group (d) could be more accurately described as anxiety neuroses. As to the disposal of cases of hysteria, he thought the decision whether a hysterical patient should be retained in the Service or not depended on a collective consideration of the length of service, the evidence of previous history, and the effect of treatment. In cases in which hysterical symptoms developed soon after enlistment and there
in the
775
BRITISH PSYCHOLOGICAL SOCIETY.
impotence, sweating, and flatulent dyspepsia were -often wrongly interpreted. Bodily manifestations - were much more striking in morbid anxiety than in normal fear, and suggested a thwarted instinct. Another well-recognised feature was the internal .disharmony among the manifestations themselves. The physical groups did not seem to be constituted for any biological purpose. Mentally there was neither activity nor passivity, but a curious mixture of overexcitation with paralysis. Physically the dissociation might go so far as to produce a mainly monosymptomatic picture. These features strongly suggested a disorder rather than a simple exaggeration of . the fear instinct. The Freudian View
of Anxiety.
puzzling problem of the relation between external and internal danger, of the conflict between the interests of the individual organism, and the threat provided by the activity of racial impulses. Anxiety in the Psychoses. Dr. HENRY YELLOWLEES suggested that Freud meant a totally different thing by " anxiety " from the meaning applied to the term by psychiatrists. Text-books of psychiatry allowed no place to anxiety among the psychoses save in involutional melancholia, in which it almost invariably played a part. Craig and Beaton called agitated melancholia the " associated psychosis " of anxiety. Clinical observation showed that the true psychoses had little or nothing Freud had to do with Freud’s anxiety state.
Freud had, primarily on a physical basis, separated described generally increased nervous instability, -morbid anxiety from the " neurasthenia group of whereas the true psychotic was remarkably indifferent Hecker and had regarded it as due to undue sexual to stimuli like noise. The anxious patient imagined - excitation with deficient opportunity for discharge. the worst in any given set of circumstances, and ’The anxiety was found in place of frustrated libido, exaggerated possibilities, but no extension of this and the physiological basis was generated from the mechanism would ever produce the delusions of the physiological basis of libido by some unknown process melancholic, who ignored possibilities. The melanof chemical transformation. Phobias presented the cholic, if he could escape for a moment from his same picture of anxiety appearing as substitute for a delusions, dealt efficiently with real emergencies ; thwarted libidinal impulse. Morbid anxiety was a the speaker had known a melancholic doctor, who perverted manifestation of the fear instinct which, spent his time banging his head against the wall, turn in neurotic conflicts, had been stimulated to activity and deal effectively and professionally with a fellow.as a protection against the threatening libido. It was patient who had an epileptic fit. There was no better the ego’s fear of the unconscious. Real dread (i.e., fear aid to differential diagnosis than an air-raid. Freud of real danger) concerned the ego only and had had spoken of vertigo, digestive disturbances, nothing to do with the desires of repressed libido ; particularly ravenous hunger, pareasthesia, and phobias it was a normal protective mechanism. Nevertheless as characteristic of the anxiety state ; these were not real dread contained one useless element which features of melancholia. closely resembled morbid anxiety. On the affective Discussion. side there was a state of anxious preparedness and Dr. BERNARD HART said that the theory of transa but useful state useless when-as watchfulness, often—it passed over into terror, which paralysed both ference of libido into anxiety was quite intelligible body and mind. Even in situations of real danger a chemically but not as part of a psychological and state of developed dread was not part of the useful biological concept. He agreed with Dr. Jones that fear biological mechanism of defence, but an abnormal was an integral part of the reaction to danger and that Tesponse akin to the neurotic symptom. Freud had anxiety and dread were identical in their essential suggested that this developed dread was derived from mechanism-in both the ego was failing to master the the narcissistic libido attached to the ego. The situation-with the one important difference that :anxiety of war shock and probably also that of hypo- anxiety was the response to internal stress and real (chondria developed in four stages : (1) perception of fear or dread to external danger. The essence of the external danger ; (2) normal fear-response of mental reaction was not so much the protection of the ego as :alertness and physical preparedness ; (3) over- the failure to protect it adequately. Dr. Rickman investment of the ego with narcissistic libido as a had spoken in this connexion of the " helpless ego:" protective response ; and (4) evocation of morbid If the response to external danger were completely anxiety on the part of the ego to the excess of reactive there was no fear, and if the response to narcissistic libido. The last stage was useless and internal stress were completely reactive there was no indeed detrimental as far as the external danger was anxiety. If dread was not a part of the normal concerned. Obviously uncontrolled libido could be reaction to danger some other factor was required to account for it, but whatever this factor might be it a danger to the ego ; there were manifest social risks and unconscious infantile fears were at work. In face must afflict a very large proportion of the human race, Ideal" or of the infantile situation the child had been helpless, for dread was extremely common. alarmed, and at the end of its resources, and its erotic " fully adaptive " would be a better phrase than wishes had been impossible to gratify. To the infant " normal." Other exciting causes than narcissistic strong excitation without relief was tantamount to libido would fit in with the failure of the ego to losing the very capacity for obtaining relief ; the master danger. In war-neurosis there was anxiety most familiar clinical manifestation of this state was as long as the struggle to keep unpleasant memories the castration complex. The first step in the child’s out of consciousness was only partially successful ; .attempt to cope with this state of affairs was the anxiety disappeared when a fairly adequate pathogroup of reactions later to be called morbid anxiety. logical adaptation-amnesia, existed or when the ’The apparent lack of purpose and coordination situation was altered by treatment and the relation reminded the observer of the earliest reactions of the of the ego and the partial memories was adjusted. infant to distress, and they performed certain func- The full picture of anxiety neurosis did not appear in tions. Some of them, notably the over-activity of true psychoses because the clinical picture was .excretory organs, furnished a limited gratification and modified by the peculiarities of the psychosis, but the relieved tension. Others-for example, the respiratory chief characteristics of morbid anxiety, if defined manifestations-called attention to the urgent need as apprehension, tension, and unrest, were clearly for help. In more extreme states a protective discernible in psychoses, especially in involutional paralysis occurred, and the last resort of the child, as melancholia and alcoholic psychosis. The other .of the neurotic, was an artificial inhibition of vital factors mentioned by Dr. Yellowlees were secondary activity, including the disturbing impulses. Freud- and derivative. Ravenous hunger was certainly not and before him Erasmus Darwin-had suggested that typical of anxiety. Dr. R. D. GILLESPIE said that certain well-known many characteristic features of anxiety were copied ’I or even derived from the event of birth. Only careful states of mental unpleasure arose from conflict, but correlation of the phenomena of birth and of morbid he doubted whether repression or morbid sexual anxiety with the various manifestations of the fear history were essential factors. One form of anxiety instinct in animals would give final light on the was associated with cardiac lesions. It was obviously "
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776
EDINBURGH OBSTETRICAL SOCIETY.
Dr. T. A. Ross described a case in which anxiety protective, but there was some evidence that frustrated instincts might produce a number of states, not was manifested without any lack of direct sexual anxiety alone. He questioned whether the new-born expression. The psycho-analyst might claim that this, child showed signs of anxiety, though of course it expression had been absent in early childhood, but the might have shown them before the final " knock-out " childhood of the patient had offered several far more of birth. Obstruction of breathing in a young obvious causes of fear ; he had lived in fear of hell baby produced signs not of anxiety, but of anger. inculcated by a religious father and of destitution Shakespeare had anticipated both Erasmus Darwin because his parents were in the habit of leaving him and Freud, when he ascribed the fearlessness of alone in the evenings. Sex differences were to be Macduff to the fact that he had been born by Caesarean found everywhere, but these other difficulties were section. extremely important. The whole life of many children Dr. J. A. HADFIELD said that there were difficulties was one of discomfort and fear. in the way of ascribing anxiety states to physiological Dr. JONES, in reply, agreed that by " normal " h& and die from suffer severe disorders. Patients might meant " ideal " or " completely adapted," which was’ toxic conditions without manifesting anxiety ; others very rare indeed. The total figure for shell-shock in might appear in normal health and vigour and yet the army only worked out at about 2 per cent., which have terrible dreads. Although toxic foci might be was the figure also given for homosexuality among the found in most cases of anxiety it was likely that they general population. He agreed that anxiety might would also be found, if sought, in most normal people. be due to conflict in respect of hatred or aggressiveA morbid fear might come on in a ’bus and not in aI ness, but held that the vast bulk of those emotions tube or taxi ; were we therefore to believe that the were evoked as a result of thwarted libidinal impulses. toxic condition became active only in Regent-street Why was a patient afraid of his libido ? Obviously and not in Leicester-square ?2 Anxiety might often because of what it might lead to, and murder was one be dispelled by suggestion, but it was hard to see how of the most likely things. the toxicity was cured in this way. There was an Dr. YELLOWLEES also replied. intimate connexion between adrenalin and anxiety, but to prove this relationship causal it must be shown that injection of adrenalin produced anxiety. He agreed with Dr. Jones that emphasis should be laid EDINBURGH OBSTETRICAL SOCIETY. on the psychological factor; that anxiety was abnormal under any circumstances, and that it was not a transformation of libido into fear, but he AT a meeting of this Society on March 15th, with differed in regarding anxiety as due to fear in the Dr. HAIG EERGUSON, the President, in the chair, a. ordinary sense and not only to threats to the libido. paper on It often might be due to threats to the sexual libido, A SCHEME OF MATERNITY SERVICE as in nightmares, but conflict between egoistic aggressiveness and fear of obliteration was a common cause. coordinating antenatal, domiciliary, and hospital Some marked cause of fear in infantile life very treatment was read by Dr. JAMES YOUNG. It was. agreed, he said, that the high maternal constantly turned up in analysis, and might be now generally and mortality morbidity rates were dependent regarded as a factor predisposing to the attack of fear. on the inadequacy of the machinery of primarily states were infantile reactions and fear was Anxiety present-day midwifery. The present service by one of the most constant experiences of childhood. The infant reacted by fear to noise and to the with- medical men was wasteful of lives and health because drawal of support, and the older child reacted to fear the duties of general practice were incompatible with The annual death-rate midwifery. by egoism and amenableness. Any threat to these satisfactory amongst mothers in England and Wales was about precipitated anxiety in later life. 5 per 1000 live births. This implied the death of Sir MAURICE CRAIG pointed out that no disorder about 3000 women every year and, on a moderate cohsisted of one symptom and that anxiety appeared at least 30,000 more women annually in many conditions. From the therapeutic standpoint estimate, suffered more or less lasting damage from childbearing he wanted to know why these factors became effective. and childbirth. The best results were found where the Pavlov’s work held out a hope that something might service was carried out by midwives with doctors. be done to prevent their operation. available for the emergencies. The proved advantages Dr. W. H. STODDART said that for a long time he had of such a combine were seen in the practice of the been unable to differentiate between involutional Victoria Jubilee Institute for Nurses of England Queen melancholia and the melancholia of manic-depressive and Wales and in the outdoor practice of the large insanity because anxiety occurred in both. He had maternity hospitals, where the death-rate was very found anxiety states also in paranoia, but did not low. An ideal practice in these respects was the East agree that they were characteristic of all neurosis ; End Maternity Hospital in London, where for many He some obsessional cases might show no anxiety. years the death-rate in a total of about 2000 unselected believed the value of potassium bromide to lie in its cases treated annually was under 1 in 1000-that is, anaphrodisiac properties. about one-fifth of that obtaining over the rest of the Dr. Wm.LrAnz BROWN pointed out that one-seventh community. On analysis the reason for the low of all men invalided from the army were victims of death-rate in these hospital practices was found in neurasthenia, despite the fact that 70 per cent. of the fact that they were carried out by self-contained those who came to special shell-shock centres were fit units, each serving its own district, in which the to be sent back into the line after treatment. HE normal cases were conducted physiologically by midtherefore agreed with Dr. Hart in requiring explicit wives and in which the antenatal supervision and the evidence of narcissism as the cause of the neurosis management of the abnormal cases were carried out which must be very common. Fear was the result oj by the doctors belonging to the service. In this way failure of adaptation and was distinct from th( there was a continuity of supervision and control of’ instinct of self-preservation. He protested against th( the antenatal, the domiciliary, and the hospital use of the term " libido " as if it were something thal treatment of the patients and of the personnel responbe could repressed and had its own energy. sible for the services. The system made for a physioDr. L. S. KuBlE asked whether an anxiety situatior logical management of the 90 per cent. or thereabouts would always lead to an anxiety state. The hysteri of normal cases and for early discovery and efficient might have no emotional content, although the origÎI treatment of abnormalities. of his condition lay in a difficult emotional situation Dr. Young believed that an adequate maternity often tinged with anxiety. The absence of anxiet; service was possible only if planned on a national from the picture of psychotics still left the problem o basis, having as its object a coordination of the what part anxiety might have played in the productio] activities of the midwife, the doctor, the National Health Insurance, and the local authorities, which at, of their symptomatology. .
BRITISH PSYCHOLOGICAL SOCIETY.
Army and the Navy, for in peace time the stresses in flying were more pronounced than in those other branches. Even the more stable type of man might break down if the stress was exceptional. The highest figures for the incidence of functional nerve disease in the Air Force were in 1922-23 ; since then there had been a steady decrease. The incidence was highest among those actually flying ; those who through age or other cause did not fly regularly came off best. In neurasthenia the predominant symptom was mental or physical fatigue, with pains, headaches, digestive disturbance, with general depression and lack of energy. In the anxiety neurosis the symptoms were mainly psychic, and the picture was one of nervousness, the patient had a sense of foreboding, worried over trifles, and was easily disturbed. Psychasthenia was characterised by a defective power of volition ; the patient was unable to make and act on decisions ; was a definite previous history of nervous disability, doubting mania also occurred, and the patient could be of but little use in the Service. claustrophobia. Only a small number of flying officers The treatment, apart from general considerations of broke down, even when subjected to exceptional stress. health and the application of electrotherapy, took Psychoneurosis developed because the subject could the form of counter-suggestion or persuasion. A not adapt himself to his environmental condition. patient who was not easily amenable to persuasion Some cases of functional nervous disorder occurred might require a prolonged course of treatment and after mild head injury, which might have been so ceased to be an economical proposition for the Army slight that concussion was not suspected. When a in peace time. Still, the principle that no man should toxic factor had been operative the case would usually be discharged from the Service uncured of a curable respond to appropriate treatment. Dr. ALDREN TURNER spoke of what had been found disability was one which he would like to see carried out. The question of specialist psychotherapeutic in officers at the War Office Medical Board. These treatment was receiving attention. The situation was cases were usually of a special character. Hysteria, different in war time, when the whole of the resources as illustrated by the usual stigmata of paralysis, fits, of the country were devoted to the maintenance of and anaesthesia, was rare. In young officers there man-power. The problem remained, in essence, one had been cases of fits developing under special cirof eugenics and upbringing. cumstances of mental strain and over-work, and Rear-Admiral E. T. MEAGHER said he was excluding perhaps to some extent aggravated by personal habits from his discussion occupational neuroses, such as and climatic conditions, as in India, and in these writer’s cramp, chorea which might arise as a result cases the fits usually ceased on the return of the of psychic shock, and exophthalmic goitre. People patient to this country. The outstanding functional fell into three groups-normal, psychopathic, and nervous disorder observed among officers was neuropathic. Some held that there was a germinal neurasthenia, using that term in its widest application. defect, and that the majority of people who subse- For the purposes of description he had made three quently developed mental defect or disorder had this groups : (1) the more purely debilitated or nervously deficiency. A terrifying shock might have a more or exhausted cases ; (2) those showing evidence of less permanent effect on the mind of a child, but anxiety, accompanied by characteristic physical unless neuropathic or psychopathic, such a person signs ; (3) those with the post-concussional syndrome. He did In the group characterised by anxiety, causes of a was not likely to develop a psychoneurosis. not know any way of determining whether such psychological kind played an important part, includinherent weakness existed in a particular individual. ing distaste for certain duties and disciplines. Thyroid He thought a new entrant to the Service should be enlargement in these cases was practically unknown, under observation in the first months to see whether but there was reason to believe there was a disturbance he manifested any characteristics indicating nervous of endocrine function and of the vegetative nervous instability. It was agreed that, apart from hereditary system. Those who suffered a breakdown during the predisposition, a normal person if subjected to excep- war were thereby rendered liable to a relapse if tional stress might break down. Conditions in the, strain and stress were renewed. Navy tended to raise the resistance to hysteria. Hysterical manifestations could often be traced to In the Navy the hysterical fit some psychic shock. BRITISH PSYCHOLOGICAL SOCIETY. was common, and for these cases a word or two of advice and discharge to duty was the best course to adopt. Hysteria was manifested most in the less The Psychiatric Section of this Society held a joint educated ; indeed, he had not seen a case of pure meeting with the Psychiatry Section of the Royal hysteria in an officer. It was easily provoked in those Society of Medicine on April 9th. The chair was of neuropathic constitution. taken by Dr. EDWARD GLOVER, President of the former In regard to diagnosis, the chief thing was to make section. A discussion on sure that organic disease did not coexist. According THE PSYCHOPATHOLOGY OF ANXIETY to Kraepelin, 50 per cent. of cases of manic-depressivE insanity showed hysteria. In treatment the medical was opened by Dr. ERNEST JONES. He said that the officer should adopt measures to check loss oj term " morbid anxiety " distinguished a collection of emotional control by advice or by isolating the phenomena from those grouped under the name of patient. Galvanism would cure aphonia, and thE " fear." Two features justifying this distinction were hysterical fit could be cut short by physical measures disproportion between the stimulus and the response, The doctor must gain domination over the patient and disharmony between bodily and mental manifestaIt had been found that the " Old Contemptibles ’ tions. In pronounced cases, such as claustrophobia were not liable to displays of functional nervous in a closed room, these were very marked, but in disorder. The Navy did not show much change in th< borderline instances it was difficult to assess " normal" incidence of functional nervous disease as compared distress. Psycho-analysts had learned to set a very with the years before the late war. In conclusion, th( high standard of " normal " bravery, and to maintain speaker advocated uniformity of nomenclature anc that much timidity passing as normal was really neurotic and curable. The anxiety nature of the terminology for all the Services and for general use. said the L. BURTON M. physical manifestations was often overlooked clinicproblem! Squadron-Leader in the Royal Air Force differed somewhat from thos4 ally. Symptoms such as chronic diarrhoea, psychical
decide whether one was dealing with a reflex nervous disorder, such as might be associated with a wound. Hysteria might be superimposed upon an organic lesion, or upon a toxic condition. In the " Nomenclature of Diseases " of the Royal College of Physicians, which the Army adopted, no name was provided intermediate between neurasthenia and psychasthenia; hence it was difficult to place such psychoneuroses as anxiety, compulsion, and obsessional neuroses. Some of the cases diagnosed as hysteria and included in group (d) could be more accurately described as anxiety neuroses. As to the disposal of cases of hysteria, he thought the decision whether a hysterical patient should be retained in the Service or not depended on a collective consideration of the length of service, the evidence of previous history, and the effect of treatment. In cases in which hysterical symptoms developed soon after enlistment and there
in the
775
BRITISH PSYCHOLOGICAL SOCIETY.
impotence, sweating, and flatulent dyspepsia were -often wrongly interpreted. Bodily manifestations - were much more striking in morbid anxiety than in normal fear, and suggested a thwarted instinct. Another well-recognised feature was the internal .disharmony among the manifestations themselves. The physical groups did not seem to be constituted for any biological purpose. Mentally there was neither activity nor passivity, but a curious mixture of overexcitation with paralysis. Physically the dissociation might go so far as to produce a mainly monosymptomatic picture. These features strongly suggested a disorder rather than a simple exaggeration of . the fear instinct. The Freudian View
of Anxiety.
puzzling problem of the relation between external and internal danger, of the conflict between the interests of the individual organism, and the threat provided by the activity of racial impulses. Anxiety in the Psychoses. Dr. HENRY YELLOWLEES suggested that Freud meant a totally different thing by " anxiety " from the meaning applied to the term by psychiatrists. Text-books of psychiatry allowed no place to anxiety among the psychoses save in involutional melancholia, in which it almost invariably played a part. Craig and Beaton called agitated melancholia the " associated psychosis " of anxiety. Clinical observation showed that the true psychoses had little or nothing Freud had to do with Freud’s anxiety state.
Freud had, primarily on a physical basis, separated described generally increased nervous instability, -morbid anxiety from the " neurasthenia group of whereas the true psychotic was remarkably indifferent Hecker and had regarded it as due to undue sexual to stimuli like noise. The anxious patient imagined - excitation with deficient opportunity for discharge. the worst in any given set of circumstances, and ’The anxiety was found in place of frustrated libido, exaggerated possibilities, but no extension of this and the physiological basis was generated from the mechanism would ever produce the delusions of the physiological basis of libido by some unknown process melancholic, who ignored possibilities. The melanof chemical transformation. Phobias presented the cholic, if he could escape for a moment from his same picture of anxiety appearing as substitute for a delusions, dealt efficiently with real emergencies ; thwarted libidinal impulse. Morbid anxiety was a the speaker had known a melancholic doctor, who perverted manifestation of the fear instinct which, spent his time banging his head against the wall, turn in neurotic conflicts, had been stimulated to activity and deal effectively and professionally with a fellow.as a protection against the threatening libido. It was patient who had an epileptic fit. There was no better the ego’s fear of the unconscious. Real dread (i.e., fear aid to differential diagnosis than an air-raid. Freud of real danger) concerned the ego only and had had spoken of vertigo, digestive disturbances, nothing to do with the desires of repressed libido ; particularly ravenous hunger, pareasthesia, and phobias it was a normal protective mechanism. Nevertheless as characteristic of the anxiety state ; these were not real dread contained one useless element which features of melancholia. closely resembled morbid anxiety. On the affective Discussion. side there was a state of anxious preparedness and Dr. BERNARD HART said that the theory of transa but useful state useless when-as watchfulness, often—it passed over into terror, which paralysed both ference of libido into anxiety was quite intelligible body and mind. Even in situations of real danger a chemically but not as part of a psychological and state of developed dread was not part of the useful biological concept. He agreed with Dr. Jones that fear biological mechanism of defence, but an abnormal was an integral part of the reaction to danger and that Tesponse akin to the neurotic symptom. Freud had anxiety and dread were identical in their essential suggested that this developed dread was derived from mechanism-in both the ego was failing to master the the narcissistic libido attached to the ego. The situation-with the one important difference that :anxiety of war shock and probably also that of hypo- anxiety was the response to internal stress and real (chondria developed in four stages : (1) perception of fear or dread to external danger. The essence of the external danger ; (2) normal fear-response of mental reaction was not so much the protection of the ego as :alertness and physical preparedness ; (3) over- the failure to protect it adequately. Dr. Rickman investment of the ego with narcissistic libido as a had spoken in this connexion of the " helpless ego:" protective response ; and (4) evocation of morbid If the response to external danger were completely anxiety on the part of the ego to the excess of reactive there was no fear, and if the response to narcissistic libido. The last stage was useless and internal stress were completely reactive there was no indeed detrimental as far as the external danger was anxiety. If dread was not a part of the normal concerned. Obviously uncontrolled libido could be reaction to danger some other factor was required to account for it, but whatever this factor might be it a danger to the ego ; there were manifest social risks and unconscious infantile fears were at work. In face must afflict a very large proportion of the human race, Ideal" or of the infantile situation the child had been helpless, for dread was extremely common. alarmed, and at the end of its resources, and its erotic " fully adaptive " would be a better phrase than wishes had been impossible to gratify. To the infant " normal." Other exciting causes than narcissistic strong excitation without relief was tantamount to libido would fit in with the failure of the ego to losing the very capacity for obtaining relief ; the master danger. In war-neurosis there was anxiety most familiar clinical manifestation of this state was as long as the struggle to keep unpleasant memories the castration complex. The first step in the child’s out of consciousness was only partially successful ; .attempt to cope with this state of affairs was the anxiety disappeared when a fairly adequate pathogroup of reactions later to be called morbid anxiety. logical adaptation-amnesia, existed or when the ’The apparent lack of purpose and coordination situation was altered by treatment and the relation reminded the observer of the earliest reactions of the of the ego and the partial memories was adjusted. infant to distress, and they performed certain func- The full picture of anxiety neurosis did not appear in tions. Some of them, notably the over-activity of true psychoses because the clinical picture was .excretory organs, furnished a limited gratification and modified by the peculiarities of the psychosis, but the relieved tension. Others-for example, the respiratory chief characteristics of morbid anxiety, if defined manifestations-called attention to the urgent need as apprehension, tension, and unrest, were clearly for help. In more extreme states a protective discernible in psychoses, especially in involutional paralysis occurred, and the last resort of the child, as melancholia and alcoholic psychosis. The other .of the neurotic, was an artificial inhibition of vital factors mentioned by Dr. Yellowlees were secondary activity, including the disturbing impulses. Freud- and derivative. Ravenous hunger was certainly not and before him Erasmus Darwin-had suggested that typical of anxiety. Dr. R. D. GILLESPIE said that certain well-known many characteristic features of anxiety were copied ’I or even derived from the event of birth. Only careful states of mental unpleasure arose from conflict, but correlation of the phenomena of birth and of morbid he doubted whether repression or morbid sexual anxiety with the various manifestations of the fear history were essential factors. One form of anxiety instinct in animals would give final light on the was associated with cardiac lesions. It was obviously "
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Dr. T. A. Ross described a case in which anxiety protective, but there was some evidence that frustrated instincts might produce a number of states, not was manifested without any lack of direct sexual anxiety alone. He questioned whether the new-born expression. The psycho-analyst might claim that this, child showed signs of anxiety, though of course it expression had been absent in early childhood, but the might have shown them before the final " knock-out " childhood of the patient had offered several far more of birth. Obstruction of breathing in a young obvious causes of fear ; he had lived in fear of hell baby produced signs not of anxiety, but of anger. inculcated by a religious father and of destitution Shakespeare had anticipated both Erasmus Darwin because his parents were in the habit of leaving him and Freud, when he ascribed the fearlessness of alone in the evenings. Sex differences were to be Macduff to the fact that he had been born by Caesarean found everywhere, but these other difficulties were section. extremely important. The whole life of many children Dr. J. A. HADFIELD said that there were difficulties was one of discomfort and fear. in the way of ascribing anxiety states to physiological Dr. JONES, in reply, agreed that by " normal " h& and die from suffer severe disorders. Patients might meant " ideal " or " completely adapted," which was’ toxic conditions without manifesting anxiety ; others very rare indeed. The total figure for shell-shock in might appear in normal health and vigour and yet the army only worked out at about 2 per cent., which have terrible dreads. Although toxic foci might be was the figure also given for homosexuality among the found in most cases of anxiety it was likely that they general population. He agreed that anxiety might would also be found, if sought, in most normal people. be due to conflict in respect of hatred or aggressiveA morbid fear might come on in a ’bus and not in aI ness, but held that the vast bulk of those emotions tube or taxi ; were we therefore to believe that the were evoked as a result of thwarted libidinal impulses. toxic condition became active only in Regent-street Why was a patient afraid of his libido ? Obviously and not in Leicester-square ?2 Anxiety might often because of what it might lead to, and murder was one be dispelled by suggestion, but it was hard to see how of the most likely things. the toxicity was cured in this way. There was an Dr. YELLOWLEES also replied. intimate connexion between adrenalin and anxiety, but to prove this relationship causal it must be shown that injection of adrenalin produced anxiety. He agreed with Dr. Jones that emphasis should be laid EDINBURGH OBSTETRICAL SOCIETY. on the psychological factor; that anxiety was abnormal under any circumstances, and that it was not a transformation of libido into fear, but he AT a meeting of this Society on March 15th, with differed in regarding anxiety as due to fear in the Dr. HAIG EERGUSON, the President, in the chair, a. ordinary sense and not only to threats to the libido. paper on It often might be due to threats to the sexual libido, A SCHEME OF MATERNITY SERVICE as in nightmares, but conflict between egoistic aggressiveness and fear of obliteration was a common cause. coordinating antenatal, domiciliary, and hospital Some marked cause of fear in infantile life very treatment was read by Dr. JAMES YOUNG. It was. agreed, he said, that the high maternal constantly turned up in analysis, and might be now generally and mortality morbidity rates were dependent regarded as a factor predisposing to the attack of fear. on the inadequacy of the machinery of primarily states were infantile reactions and fear was Anxiety present-day midwifery. The present service by one of the most constant experiences of childhood. The infant reacted by fear to noise and to the with- medical men was wasteful of lives and health because drawal of support, and the older child reacted to fear the duties of general practice were incompatible with The annual death-rate midwifery. by egoism and amenableness. Any threat to these satisfactory amongst mothers in England and Wales was about precipitated anxiety in later life. 5 per 1000 live births. This implied the death of Sir MAURICE CRAIG pointed out that no disorder about 3000 women every year and, on a moderate cohsisted of one symptom and that anxiety appeared at least 30,000 more women annually in many conditions. From the therapeutic standpoint estimate, suffered more or less lasting damage from childbearing he wanted to know why these factors became effective. and childbirth. The best results were found where the Pavlov’s work held out a hope that something might service was carried out by midwives with doctors. be done to prevent their operation. available for the emergencies. The proved advantages Dr. W. H. STODDART said that for a long time he had of such a combine were seen in the practice of the been unable to differentiate between involutional Victoria Jubilee Institute for Nurses of England Queen melancholia and the melancholia of manic-depressive and Wales and in the outdoor practice of the large insanity because anxiety occurred in both. He had maternity hospitals, where the death-rate was very found anxiety states also in paranoia, but did not low. An ideal practice in these respects was the East agree that they were characteristic of all neurosis ; End Maternity Hospital in London, where for many He some obsessional cases might show no anxiety. years the death-rate in a total of about 2000 unselected believed the value of potassium bromide to lie in its cases treated annually was under 1 in 1000-that is, anaphrodisiac properties. about one-fifth of that obtaining over the rest of the Dr. Wm.LrAnz BROWN pointed out that one-seventh community. On analysis the reason for the low of all men invalided from the army were victims of death-rate in these hospital practices was found in neurasthenia, despite the fact that 70 per cent. of the fact that they were carried out by self-contained those who came to special shell-shock centres were fit units, each serving its own district, in which the to be sent back into the line after treatment. HE normal cases were conducted physiologically by midtherefore agreed with Dr. Hart in requiring explicit wives and in which the antenatal supervision and the evidence of narcissism as the cause of the neurosis management of the abnormal cases were carried out which must be very common. Fear was the result oj by the doctors belonging to the service. In this way failure of adaptation and was distinct from th( there was a continuity of supervision and control of’ instinct of self-preservation. He protested against th( the antenatal, the domiciliary, and the hospital use of the term " libido " as if it were something thal treatment of the patients and of the personnel responbe could repressed and had its own energy. sible for the services. The system made for a physioDr. L. S. KuBlE asked whether an anxiety situatior logical management of the 90 per cent. or thereabouts would always lead to an anxiety state. The hysteri of normal cases and for early discovery and efficient might have no emotional content, although the origÎI treatment of abnormalities. of his condition lay in a difficult emotional situation Dr. Young believed that an adequate maternity often tinged with anxiety. The absence of anxiet; service was possible only if planned on a national from the picture of psychotics still left the problem o basis, having as its object a coordination of the what part anxiety might have played in the productio] activities of the midwife, the doctor, the National Health Insurance, and the local authorities, which at, of their symptomatology. .