Anxiety and Phobias

   Anxiety and phobic thinking may be normal emotions, distinct clusters of symptoms ("syndromes"*), or diseases in the sense of distinct illness entities.

   In psychoanalysis, "anxiety" is used as a theoretical term, the presumed unconscious state that triggers such defense mechanisms as repression (banishing unacceptable ideas from consciousness), sublimation (substituting an unacceptable drive for something more socially acceptable), and displacement (transferring psychic energy from one set of ideas to another). Symptoms of anxiety are common in most psychiatric illnesses, and anxiety occurs together with depression so frequently as to represent a distinct illness entity of its own (which English psychiatrist Peter Tyrer [1940–] calls "cothymia"). Yet, there are some landmarks in the attempts of medical practitioners to come to grips with this protean concept. In the literature, phobias have been somewhat arbitrarily differentiated from anxiety, though clinically all these forms tend to flow together without sharp delineation.

   * For example, heart failure or jaundice are syndromes caused by a variety of factors.

   Physicians during the centuries have recognized the subjective symptoms of anxiety (fearfulness), as well as the objective, or somatic, symptoms (racing heart, loose bowels), as medical syndromes attached to larger diseases but not as diseases in themselves. In his Textbook of the Disturbances of Mental Life (Lehrbuch der Störungen des Seelenlebens), Leipzig psychiatry professor Johann Christian August Heinroth (see GERMAN "ROMANTIC" PSYCHIATRY: Heinroth) described the disease "quiet fury" (mania melancholica) as having among its characteristics "anxious, oppressive, inconsolable despondency." "The anxiety and depression mount from hour to hour. . . . He seems to have lost the gift of speech, or else keeps saying, ‘it is all up with me, nobody can help me any longer’ " (p. 206).

   The use of "phobia" to mean fear of something goes back to the classifiers (nosologists) of the eighteenth century. William Cullen, for example, had used "hydrophobia" for what was later called rabies (supposed fear of water amidst convulsions), and the Philadelphia psychiatrist Benjamin Rush later parodied this sense of phobia in a contribution to a newspaper in 1798: "The CAT PHOBIA. It will be unnecessary to mention instances of the prevalence of this distemper. . . . The SOLO PHOBIA; by which I mean the dread of solitude . . . the HOME PHOBIA. This disease belongs to all those men who prefer tavern, to domestic society" (quoted in Macalpine and Hunter, 300 Years, pp. 669–670). Some landmarks in the evolution of anxiety diagnoses follow.

   Morel’s délire émotif (1866). Bénédict-Augustin Morel described in the General Archives of Medicine (Archives générales de médecine) in 1866 "emotional delusions" (délire émotif ), by which he understood a mixture of what would later be considered anxiety, panic, and obsessive-compulsive behavior. (Individuals may be delusional not just in their thinking, in other words, but in their emotions.) He found a common denominator for these various symptom pictures in disturbances of the "visceral ganglionary nervous system," especially at its "epigastric center." In describing this "neurosis," Morel said, "One is struck at the rapidity with which maladaptive emotions arise, at the instantaneous nature with which certain fixed ideas are implanted in the mind, leading to unmotivated fears, to impulsions that are virtually irresistable, to ridiculous fears that sometimes take the proportion of a kind of generic fearfulness [une véritable panophobie]" (p. 704). This may be considered the beginning of a rather broadly constructed "anxiety neurosis."

   Agoraphobia (Platzschwindel) as a concept (1870). Platzschwindel, explained Vienna neurologist Moritz Benedikt (1835–1920) in an article in the General Viennese Medical Newspaper (Allgemeine Wiener Medizinische Zeitung), meant fear of open spaces.

   Anxiety and Phobias

   "This unusual condition concerns individuals who are well so long as they remain in doors or in narrow streets; yet as soon as they enter a boulevard, or especially a public square, they are seized by dizziness, so that either they fear falling down or are seized by such anxiety that they do not even dare to cross the space" (p. 488). Benedikt later said in his autobiography that he came up with the diagnosis one evening in 1867 at a scientific meeting in Frankfurt am Main as he, Griesinger, and Ernest Lasègue were sitting together discussing "the obscure disorders of the brain and the mind." The three of them agreed on Platzschwindel as a disorder, which Benedikt then wrote up 3 years later (p. 125). Benedikt believed that it was caused by masturbation. The term, although an early description of agoraphobia, did not catch on.

   The first anxiety syndrome described: "irritable heart" (1871). During the U.S. Civil War, Jacob M. DaCosta (1833–1900), an army doctor, had seen a number of patients such as "Henry H.": "He did a great deal of hard duty with his regiment. Some time before the battle of Fredericksburg, he had an attack of diarrhoea; after the battle he was seized with lancinating pains in the cardiac region, so intense that he was obliged to throw himself down upon the ground, and with palpitation. These symptoms . . . were attended with dimness of vision and giddiness." The symptoms went away after the soldier was seconded to police duty (p. 21). DaCosta, misattributing the symptoms to cardiac disorder, called the syndrome "irritable heart," later also known as "soldiers’ heart." But the dizziness, headache, sweaty hands, palpitations, "precordial" pain (epigastric region and lower thorax), insomnia, and "nervous" symptoms that the young troopers complained of ("one solider spoke often of dreaming that he was falling off high buildings") are generally considered the somatic symptoms of anxiety. DaCosta wrote up his findings in 1871 in the American Journal of Medical Sciences, by which time he had become a physician in the Pennsylvania Hospital in Philadelphia.

   Westphal’s agoraphobia-panic (1872). "For a number of years patients have been coming to me," wrote Carl Westphal (1833–1890), then head of the Division for Psychiatric and Nervous Illnesses of the Charité Hospital in Berlin, "with the singular complaint that it is not possible for them to walk across open places or to go down certain streets and that the fear of such places constrains their freedom of movement." Westphal suggested the coinage "agoraphobia," calling it additionally in German, Platzfurcht. He emphasized the "feelings of anxiety" that overcame his patients as they contemplated these various itineraries. In the same article, Westphal also described sudden feelings of panic that came unexpectedly over others of his patients, such as a salesman who "four years ago, when engaged in writing, suddenly suffered an attack of powerful anxiety and feelings of oppressiveness in the stomach area, so that he had to run out into the street. From this moment on, he dates his complaints about all kinds of abnormal and fluctuating sensations that he localizes here and there, and about a certain anxiety in various situations. Sometimes he develops anxiety if his wife leaves their home by even just a few steps." Recently, agoraphobia had begun complicating the panicky anxiety attacks of this patient. (Westphal penned this classical description of agoraphobia and panic in 1872 in the Archive of Psychiatry and Nervous Diseases [Archiv für Psychiatrie und Nervenkrankheiten].) There had been, of course, previous descriptions in medicine of agoraphobia and panic, yet Westphal elevated agoraphobia to paradigmatic status with his term.

   Lasègue’s "mental vertigo" (1877). The syndrome begins, Ernest-Charles Lasègue said in an article in the Paris Hospital Gazette (Gazette des hôpitaux), with a feeling of compressive precordial anguish, then a sensation of being about to faint; the visual field becomes cloudy. There are mental feelings of anxiety, blanching of the visage, anxious respiration, and cold sweats. In one form of the syndrome, dizziness is the overwhelming sensation; in another, fearfulness. The patient is aware that there is no reason for his anxiety yet is unable to help himself. These attacks of anxiety may coincide with a fear of open spaces. The term "mental vertigo" itself was not widely taken up, yet it is a clear precursor of panic disorder.

   Beard’s neurasthenia: 1880 version. When New York electrotherapist George Miller Beard (1839–1883) coined the term "neurasthenia" in 1869 in an article published in the Boston Medical and Surgical Journal, he had nothing to say about anxiety. Yet, in his influential 1880 book, A Practical Treatise on Nervous Exhaustion (Neurasthenia), Beard dilated at length about anxiety as a cardinal symptom of neurasthenia, or lacking nerve force. On "morbid fears," he wrote: "A healthy man fears; but when he is functionally diseased in his nervous system he is liable to fear all the more; to have the normal, necessary fear . . . descend into an abnormal pathological state, simply from a lack of force in the disordered nervous system" (p. 26). Among the fears Beard enumerated were "topophobia," a general fear of places (Beard spoke belittlingly of Westphal’s agoraphobia), "anthropophobia" (a general fear of social encounters later labeled "social anxiety disorder"), and "pantaphobia," or "fear of everything" (pp. 29–36). Later interpretations of neurasthenia emphasized "irritable weakness," a fatigue state rather than anxiety. Yet at the beginning, anxiety was important to Beard.

   Hecker’s description of somatic anxiety as a separate syndrome (1893). Ewald Hecker (1843–1909), a previous collaborator of Kahlbaum’s (see Schizophrenia: Emergence: hebephrenia [1871]), was by 1893 director of a private nervous clinic in Wiesbaden. In an article "On Masked and Partial Anxiety Conditions in Neurasthenia" ("Über larvirte und abortive Angstzustände bei Neurasthenie") published in the Central Journal for Nervous Diseases (Zentralblatt für Nervenheilkunde), he said: "For many [neurasthenia] patients there may be just a single anxiety attack [Angstanfall] in the course of the entire illness; others may have a considerable number of anxiety attacks. As with agoraphobia and similar phobias they occur either on quite specific occasions with always the same triggering circumstances, or they occur spontaneously without exterior causation." In still further cases, "mild and to some extent chronic anxiety becomes manifest not in the form of self-contained attacks, but dominates the patient’s entire day" (p. 565). Hecker found it of interest that the patients did not always perceive these anxiety conditions as being consciously "anxious" in nature (i.e., they were somatic anxiety). He analogized to the syndrome of "dizziness in public spaces" (Platzschwindel), whereby the patients did not always feel "dizzy" but rather anxious. His conclusion: "Among neurasthenics, it happens with surprising frequency that instead of complete anxiety attacks a number of possible physical symptoms of anxiety may appear individually in pronounced attacks, without being accompanied by psychological feelings of anxiety" (p. 567).

   Freud differentiates "actual" neuroses, including anxiety neurosis, from psychoneuroses (1895). The beginning of much psychoanalytic speculation about anxiety was Sigmund Freud’s paper "On the Justification for Differentiating a Certain Syndrome from Neurasthenia as ‘Anxiety Neurosis,’ " which appeared in the Neurological Central Journal (Neurologisches Centralblatt) in 1895. Freud said that he had believed his conception of an anxiety syndrome (Symptomenkomplex) was original until he came across Hecker’s 1893 paper. Freud’s paper did, however, differentiate anxiety neurosis from Beard’s neurasthenia. Freud’s analysis of the presumed cause was, for adult women, the failure to achieve orgasm in intercourse as a result of the husband’s premature ejaculation or use of withdrawal as a means of birth control. For men, it was coitus interruptus that produced anxiety neurosis, mixed together with neurasthenia. (Freud conceded that overwork and exhaustion could also elicit anxiety neurosis.) The mechanism of the sexually produced variety: "The psychic diversion of somatic sexual arousal and a consequently abnormal application of this arousal" (Gesammelte Werke, I, p. 334). Both anxiety neurosis and neurasthenia had in common, however, that they arose from current problems (an Aktualneurose), meaning coitus interruptus (anxiety) and masturbation (neurasthenia), rather than being "psychoneuroses" such as hysteria with roots in intrapsychic conflict.

   Wernicke’s anxiety psychosis (Angstpsychose) (1895, 1900). First in a brief note published in 1895 in the General Journal of Psychiatry (Allgemeine Zeitschrift für Psychiatrie), then in his clinical lectures Outline of Psychiatry (Grundriss der Psychiatrie) in 1900, Carl Wernicke (1848–1905), professor of psychiatry in Breslau (see Wernicke–Kleist–Leonhard Pathway), proposed psychotic anxiety as a separate illness entity, differentiated from affective melancholy and from "acute psychoses with perplexity." Acoustic hallucinations were frequently present in psychotic anxiety, he said, along with delusions. "The basic symptom is anxiety, frequently in the thorax and in particular the heart and the epigastrium. . . . This anxiety regularly eventuates in the emergence of certain conceptions [Vorstellungen] of an anxious nature" (Outline, p. 239). Prominent in the disorder was physical (motor) agitation; the patients were impossible to keep in bed. Wernicke said that so-called agitated melancholy represented a subform of psychotic anxiety and was not further related to melancholy. The prognosis of anxiety psychosis was favorable.

   Hartenberg describes "timidity" (1901). Parisian psychiatrist Paul Hartenberg’s (1871–1949) book The Timid and Timidity (Les Timides et la timidité; 1901) is sometimes seen as being the ancestor of the DSM-III diagnosis "social phobia," later also called "social anxiety disorder." He defined timidity as "a complex state of agitation [trouble], confusion, embarrassment, fear, scrupulousness, shame etc. . . . accompanied clearly by such symptoms as heart palpitations, anxiety, cold sweating, tremor, blushing etc." Hartenberg considered these symptoms the result of "two fundamental emotions": fear and shame. "For a young man," explained Hartenberg, "it is a big deal just to enter a salon. He imagines that everybody is looking at him and he dies of the fear that there might be something in his outfit that is not absolutely impeccable" (quote from fourth ed., pp. 3–4).

   Stekel differentiates "hysterical anxiety" (Angsthysterie) from Freud’s "anxiety neurosis" (Angstneurose) (1908). At Freud’s suggestion, Vienna family doctor and psychoanalyst Wilhelm Stekel (pronounced [SHTAY-kel]) (1868–1940) separated hysterical anxiety, the core of which was various phobias, from the larger illness entity anxiety neurosis. Stekel’s 1908 book, Nervous Anxiety Conditions and Their Treatment (Nervöse Angstzustände und ihre Behandlung), argued that unlike anxiety neurosis, hysterical anxiety had psychic causes. Stekel could never accept the idea that Freud’s anxiety neurosis—if it was in fact an "actual neurosis"—was caused by current sexual problems. He deviated from the master’s view and insisted that anxiety neurosis must be psychogenic. This disagreement caused Stekel to be thrown out of the psychoanalytic movement just before the First World War, and until his death by suicide in 1940, Stekel continued to insist on intrapsychic conflict as the genesis of all neuroses. In the third edition of the book (1921), he also abandoned the distinction between hysterical anxiety and anxiety neurosis and said that only hysterical anxiety existed, although he continued to use the term "anxiety neurosis." By this point, he was con- fining the clinical use of the term "hysterical anxiety" largely to phobias: "We always note in all parapathias [Parapathien = neuroses] a disorder of affective life, meaning a struggle between two affects. It is never a question of a struggle between two thoughts but rather between two feelings. (Religious feeling fights against the sex drive, which expresses itself as love, and the other way around)" (third ed., p. 276). The category hysterical anxiety survived for many years in the psychoanalytic movement. New York psychoanalyst Otto Fenichel (pronounced PHEN-ih-kel) (1898– 1946), a Freud pupil and Viennese emigré, had a large section on it in his textbook, The Psychoanalytic Theory of Neurosis (1945), though, of course, without any reference to Stekel, who by then had long been branded a heretic.

   Freud’s conception of anxiety collapses many previous subdivisions (1926). As the psychoanalytic movement gained in influence, Freud’s concepts increasingly displaced previous distinctions in psychopathology. In Freud’s 1926 book, best known in English as The Problem of Anxiety (Hemmung, Symptom und Angst), he argued that, "Anxiety is a reaction to the danger of object loss" (Gesammelte Werke, XIV, p. 202). Thus anxiety, next to mourning, became one of the great motors of the dynamics of the psyche, and in the psychoanalytic tradition anxiety is more a mechanism than a symptom. Thus, the psychopathologic study of anxiety initiated by Morel in 1866 came to a provisional end. Leonhard describes "anxiety-ecstasy psychosis" (Angst-Eingebungspsychose) (1939). Working at Karl Kleist’s clinic in Frankfurt (see Wernicke–Kleist–Leonhard Pathway), Karl Leonhard differentiated from Emil Kraepelin’s great bloc diagnosis dementia praecox (see Schizophrenia: Emergence: Kraepelin [from 1893]) a circular disorder in which patients alternated between anxiety psychosis and an unreal sense of ecstasy: "The anxiety phase (paranoid anxiety psychosis) deviates from anxiety psychosis through the presence of perplexity, ideas of reference [paranoid thinking], and sensory hallucinations; the ecstatic phase (Kleist’s Eingebungspsychose) is accompanied by an ecstatic mood [and] boundless personal grandiosity." Leonhard said in his article in the Journal of Combined Neurology and Psychiatry (Zeitschrift für die gesamte Neurologie und Psychiatrie) that the circular disorder had heavy hereditary roots and a good prognosis, including full remission between episodes.

   Anxiety and phobia disorders in DSM "One" (1952). The first edition of the DSM series gave "phobic reaction" a category of its own (following the World Health Organization’s International Classification of Diseases in 1947); the guide also included "anxiety reaction," putting it and phobia under the category "psychoneurotic disorders." "The chief characteristic of these [psychoneurotic] disorders," the guide noted, "is ‘anxiety’ which may be directly felt and expressed or which may be unconsciously . . . controlled by . . . various psychological defense mechanisms" (p. 31).

   Anxiety and phobic disorders in DSM-III (1980). There had been no change in the classification of anxiety and phobia from DSM-I (1952) to DSM-II (1968), except to rename the "reactions" of DSM-I as "neuroses." DSM-III, however, recast the nosology substantially, calling all the entities "disorders" rather than "neuroses." As the "Research Diagnostic Criteria" of 1978 in the Archives of General Psychiatry by Robert Spitzer, Jean Endicott (a Columbia University psychologist, born in 1936), and Eli Robins had forecast (see Panic Disorder), anxiety neurosis was split into panic disorder and generalized anxiety disorder. Phobic neurosis was subdivided into five categories: agoraphobia with and without panic, "social phobia" (or fear of doing certain activities in public), "simple phobia" (a residual category), and "separation anxiety disorder (childhood)." DSM-III-R (1987) and DSM-IV (1994) made no major changes to this schema, aside from suggesting in the 1994 edition "social anxiety disorder" as a synonym for "social phobia," and "specific phobia" for the former "simple phobia." (These may sound like trivial changes, but they are important, for example, in the marketing of pharmaceuticals.)

   The distinction between somatic and psychological anxiety is reactivated (2003). "The sympathetic nervous system has been forgotten by psychiatry," said Conrad M. Swartz (1946–), head of psychiatric research at Southern Illinois University in Springfield, in 2003. In Psychiatric Times, Swartz called attention to "jumpiness, startle, agitation, restlessness and muscle pain" as symptoms of somatic anxiety (once called anguish [angoisse] in the psychiatric literature). To decrease the effects of neurotransmitters epinephrine and norepinephrine, he recommended prescribing such "beta-blockers" as propranolol for the treatment of somatic anxiety, leaving the selective serotonin reuptake inhibitors for the psychological variety.

   See PANIC DISORDER: anxiety, panic, and phobic disorders in ICD-10 (1992).