THE AMERICANJOURNALOF PSYCHOANALYSIS37:299-307(1977)
ANXIETY
REVISITED
Jack Schnee
Anxiety is perhaps the most important single factor to be dealt with in psychoanalytic theory and practice. Exactly what the term anxiety means remains obscure. There is still much to be discovered about the causes of anxieties, mechanisms of production, physiological and subjective effects, phenomenological experiences, and, mostly, biological substratum. Present advances in physiological and neurochemical research offer a new look at anxiety. In this paper, clinical observations of differing reactions to various medications will be related to known physiological and analytical concepts of anxiety. All analytic schools refer to anxiety as a consequence of psychic conflict, but differ as to the factors that create conflict and at what level the corfflict occurs. In early Freudian theory, 1 it was postulated that anxiety was caused by a damming up of libido, which was thus transformed directly into anxiety. In the revision of this theory, anxiety was considered the result of a conflict between instinctual (id) and prohibitive forces, whether the latter came from within the self (superego) or from without. Anxiety could be connected with an immediate danger such as separation, castration, body-image damage, and so forth, or it could constitute a protective mechanism, warning the person of impending danger. This protective mechanism was referred to as signal anxiety. All other pioneers in psychoanalysis have emphasized the importance of anxiety. They differ primarily about what basic factors cause anxiety. For Rank, the anxiety of birth trauma became the core of his theory of development and psychopathology. For Sullivan, anxiety was engendered by a threat to "security operations" due to interpersonal, relational distortions. The existentialists describe existential anxiety, caused primarily by one's awareness of nonexistance or morbidity. The so called "third school" (Rogers, Maslow, Goldstein, etc.) see anxiety as a reaction to growth and change. Each of these pioneers in psychoanalytic t]hought has his favorite emphasis and elaboration, but they all accept conflict and anxiety as bei ng of primary importance in character development and symptom formation. For Horney, 2anxiety was the dynamic core of neurosis. She focused as much on the clinical, subjective experience of anxiety as on its unconscious dynamics. She compared fear and anxiety, concluding that fear is a reaction proportionate to danger, whereas anxiety is a reaction disproportionate to danger (whether real or Jack Schnee, M.D., is Medical Director and Supervising Psychiatrist, New York Psychotherapy and Counseling Center, Jamaica, N.Y. 299
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JACKSCHNEE
imaginary). In anxiety, the danger is generated or magnified by intrapsychic factors. Homey also held that anxiety results from a fear of our repressed impulses, the ~ expression of which would incur an external danger. She felt that repressed hostile impulses were the main psychological force promoting anxiety. She elaborated the concept that a child developing in a noxious environment will experience basic anxiety, which she described as a "feeling of being isolated and helpless in a world conceived of as potential ly hostile." Basic anxiety is not necessarily a consequence of conflict. With this basic anxiety, spontaneity is inhibited and the child gropes for ways to cope with his threatening, dangerous world. Despite feelings of aloneness and helplessness, he unconsciously evolves tactics to meet and deal with this menacing world. These strategies develop and evolve into lasting character trends, which Homey labeled "neurotic trends." These interpersonal movements crystallize out of the three attitudes in basic anxiety. One of these behavior patterns is referred to as "moving toward" people. This happens when helplessness predominates, leading to exaggereated compliance with a need of gaining affection so as to develop a sense of belonging and support. Another behavior pattern is "moving against" people. When facing hostility in others, the individual leans toward fighting out of a desire to be the stronger and wi n, partly for his own protection and partly for revenge. The third component of basic anxiety, "isolation," evolves into the-individual "moving away" from people. For his own protection he desires neither to fight nor belong, just to keep apart. In the neurotic, these moves are desperate and inflexible. The neurotic is driven to comply, to fight, and to be aloof. These compulsive moves lead to further conflicts with their own consequent anxieties because the individual cannot really make any one of these moves wholeheartedly. When one of the above moves predominates, it does not mean that the other moves have ceased to operate. They may be more or less submerged, expressed more indirectly, and at times dominance of trends may shift. Hence, when these three compulsive attitudes are present with any intensity, conflict must ensue. These attitudes influence the entire personality. They affect not only the interpersonal sphere, but also one's whole relationship to oneself, the world, and life in general. Thus, conflict and anxiety necessitate further measures to cope with these incompatible attitudes. For Homey, conflict born from incompatible attitudes constitutes the dynamic center from which neuroses emanate. Thus, the individual becomes further alienated from his real self, an idealized image is created, and an intrapsychic character (self-effacing, expansive, resigned) evolves, repressing unacceptable traits and value systems. There is further compulsive striving toward this false self. This results in marked self-contempt because of incompatible compulsive drives (return of the repressed and/or weakening of the defenses) and because of the impossibility of realizing the idealized image. While the early interpersonal solution aims primarily at a unification of relations
ANXIETY REVISITED
301
with others, the later intrapsychic maneuvers lead to a more comprehensive integration, a feeling of identity (albeit a pseudoidentity), self-idealization, and what Homey referred to as a "comprehensive neurotic solution." Along with the concept of the self-erected neurotic character superstructure, Horney extended the factors in possible conflict to include not only instinctual drives but also interpersonal attitudes of the child toward his parents, then compulsive attitudes toward others, and finally any compulsive neurotic trait (needs, claims, attitudes, etc.) which contradicts any other equally necessary trait. Kelman 3 attributes anxiety both to integrative and disintegrative ,changes in the self. This is a holistic approach derived from Homey. He raises tlhe question of rational versus irrational anxiety. The concepts of normal (rationall, healthy) and pathological (irrational, neurotic) anxiety bring us to the question of the relation between conflict and anxiety. Homey implies that basic anxiety may evolve without conflict and that conflict can produce symptoms directly, without intervening anxiety. Attitudes, which can derive from conflict, can also be considered symptoms. This then leads to the next important question: Is there a difference between the conflict-anxiety in neurosis as compared to psychosis? Rubins4 concludes that although the defense mechanisms and solutions in the schizophrenic and the neurotic are similar dynamically, some differ quantitatively (e.g., greater extensiveness and intensity in the alienation from the self) and others differ qualitatively (e.g., fluidity and disorganization of self-concept and identity, concreteness, acting out, vulnerability, etc.). He further explains that in the neurotic, the overall shifting of the personality toward self-idealization removes the person from his real self and from his ability to experience his genuine inner emotions. The schizophrenic also dynamically experiences such alienation as a chronic result of disruptive painful experiences occurring within the self. Here, though, the process is modified and intensified. The body image, self-concept, and identity are characteristically impaired; relational attitudes are more limited; the underlying self is more impaired, disorganized, and unstable; conflicts are more diffuse, intense, variable, and so forth. Rubins can be interpreted as sayingthat in the schizophrenic, anxiety is greater in quality and quantity than in the neurotic. I share the view that schizophrenic anxiety differs qualitatively and quantitatively from neurotic anxiety. Schizophrenic anxiety stems both from conflict and from confhct-free areas of existence. Because of the vulnerabl hty and extensive damage at the core of the self with impaired perception and integrative and synthesizing functions, the schizophrenic is chronically on the brink of experiencing discomfort. The schizophrenic's discomforture (anxiety?), which may or may not be due to conflict, is an expression of his difficulty in holding onto reality, the need for sameness in a changing life, the need to hold the psychic fragmentation together in order to perceive and interpret internal and external cues, the frustrating attempts to differentiate internal awareness and external perceptions, the severe alienation, and so forth. The defenses employed to combat and cope with early chronic .
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disruptive painful experiences add further to the confusion and anxiety in a continuous self-feeding destructive manner. We know that a noxious environment plays a role in the evolution of the schizophrenic, but we must also appreciate that for the schizophrenic the noxious environment continues permanently because of personalization of perceptions, exquisite sensitivity and being easily hurt, misperception and misinterpretation of cues, and the like. This does not ignore the idea that an organic substrate can surely predispose the individual to the development of psychosis. A defective psyche will understandably be more likely to develop overwhelming anxiety to modest stimuli. Hence it will develop extensive maneuvers to avoid this disruption: extreme need for sameness, characteristic attitudes toward self and others, severe alienation, grandiosity, concreteness, break with reality, and so forth. Now we can raise another important question: What is the relationship between anxiety are distinct for each and can be handled separately. (3) Psyche and soma There are three ways of viewing this relationship: (1) Psyche and soma are separate, but interact to produce anxiety when they affect each other. (2) Psyche and soma are separate and parallel, acting independently. Therefore, the symptoms of anxiety are distinct for each and can be handled separatley. (3) Psyche and soma are one (holistic); the symptoms of anxiety can occur in either as incidental manifestations of the same process. The holistic view of the psyche and the soma as being two sides of the same coin, each having some independence from, as well as influence over, the other, seems to fit our current understanding. For some people, the anxiety experience is predominantly a physical experience--namely, tachycardia, sweating, and so on. Others describe extreme anxiety, yet there is little or no physical evidence of anxiety. This also raises the question of ego tolerance to anxiety; some people will be intolerant of (and complain bitterly about) minimal anxiety. Pure analysts feel that anxiety is purely psychological, and organically oriented psychiatrists feel that anxiety is purely biological-chemical. These views are one-sided. I believe that the question of which comes first and causes the other is a spurious one, and can be likened to the problem of the chicken and the egg. The idea that a person may be born with a chemical imbalance is as valid as the idea that emotions cause chemical changes; one condition does not exclude the other and both affect each other constantly. A holistic view equates psychosomatic with somatopsychic. Recent research has shown that anxiety is related to definite neurophysiological factors. As Bergers states in his article on the pharmacology of antianxiety agents: "Many interpretations have been made that deal with the meaning, nature, and cause of anxiety. Unitl recently, the psychoanalytic interpretation of anxiety was widely accepted. Others looked upon anxiety as a motivational force. Recent findings utilizing modern methods of experimental psychology, biochemistry and electrophysiology permit a more objective evaluation of the anxiety state and appear to indicate that anxiety is of biological origin."
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For example, anxiety has been shown to be associated with an increased electrical activity in certain parts of the brain. The subjective experience of anxiety can be produced by electrical stimulation of certain thalamic nuclei and the limbic structures. It has also been shown that the destruction of discrete parts of the thalamus or frontal lobes produces relief from chronic anxiety in humans. Chemical research reveals that anxiety episodes can be induced by injecting epinephrine or other sympathomimetic amines, or by infection of sodium lactate in anxiety-prone neurotics. It has been shown that the so-called minor tranquilizers or anti-anxiety drugs act specifically on the areas of the brain mentioned above, namely, interneurons, thalamus, and limbic system. Lader ° divided anxiety into "state anxiety" and "trait anxiety." The former refers to anxiety felt at a moment in time and the latter to a habitual tendency to be anxious. He felt that anxiety, both as a trait and as a syndrome, was strongly influenced by genetic factors. He proposed a model for "normal anxiety," wherei n external and internal stimuli are appraised for possible threat. "The cognitive factors are affected by past experience and by genetic factors. If a threat is detected, some central nervous activities increase and the affect anxiety is experienced." He added that anxiety states may be particularly common in certain cultural groups and pointed out that epidemics of acute anxiety in communities have occurred. This supports an aspect of the psychological etiology of anxiety through such factors as suggestion. Although I appreciate that anxiety is an ubiquitous, subjective phenomenon and therefore very complex and difficult to evaluate, I suggest it may prove helpful to reexamine certain psychosomatic aspects. The clinical subjective experience of anxiety, as described by Kolb, 7 is a prototype. Anxiety is "a persistant feeling of dread, apprehension, and impending disaster. It is a response to threats from repressed dangerous impulses deep within the personality or to repressed feelings striving for consciousness, a warning of danger from the pressure of unacceptable internal attitudes." The patient is ignorant of its source, though he may blame it on some external factor. In additon, anxiety is accompanied by a disturbance in the autonomic nervous system, including visceral tension, hyperventilation, sphincter spasms or dilation, intestinal irritability, with diarrhea or constipation, cardiac palpitations, tachycardia, extrasystoles, vasomotor flushing, respiratory distress, fai nti ng, weakness, nausea, tremors, sweating, increased body movements, strained voice, and dilated pupils. Its effect on concentration and thinking processes can be so incapacitating that a pseudoorganic mental syndrome can appear. It is obvious that the entire mind and body can be involved., including the sympathetic and parasympathetic nervous systems, all levels of the brain, the sensorimotor system, the hormone system, and every organ system. Thus, both expressed and repressed (inhibited or covert) anxiety may manifest themselves in the sphere of psychosomatic medicine. Cannon's flight or fight thesis is called into question here. The intensely anxious person can do neither; he is functionally
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paralyzed. The feeling of helplessness contributes to the individual's panic. Does any of this tell us what anxiety is? We can describe the subjective feelings of anxiety and its physical concomitants. We can also describe the obvious defenses against it when no evidence of the internal anxiety is experienced. Yet we are as limited as the physicist who can describe all the characteristics of the color "red"~frequency, wave length, and so forth--but cannot tell us what red looks like. The experience of color is a purely personal phenomenon. In fact, even as a purely subjective phenomenon, the experience of anxiety can vary in the same person from one momentto another, in the same way that the perception of red may vary with the way a person feels at any given time. It is a psychological truism that the emotions influence what the patient sees, hears, feels, and thinks. And so it seems, from the clinical facts, that there may well be a whole assortment of anxieties manifesting similar tones and physiological components. Diagnostically, the possibility cannot be excluded that there is a group of anxieties. Ego tolerance, the ability to tolerate frustration and conflict, can determine at what point the inner experience of anxiety manifests itself or comes into awareness as a symptom. Some people seek rapid alleviation of any anxiety and utilize specific immediate maneuvers (i.e., narcosis, situation-avoidance, etc.). Others complain bitterly of anxiety when they are apparently experiencing only a tiny amount of discomforture. Some can tolerate what would appear to be great frustration or intense conflict. Such tolerance may depend not only on inborn strengths (constitutional tolerance) but also on environmental factors, i ncludingthe family culture and society at large. Constitutional tolerance is influenced by the culture. With any single individual, we must distinguish between the constitutional threshold,--the individual's selection of defenses or solutions that determine how and when he reacts,--and the culturally favored types of defenses or solutions of anxiety Not too long ago there were many questions regarding the effects of brainwashing on Americans compared to people of other cultures, with implications that our culture may predispose us to easier psychic collapse in the face of brainwashing techniques. Perhaps the absence of a military culture in which youth is trained in warlike psychological tactics predisposes us to more core conflicts when faced with brainwashing as adults. Solid cultural attitudes presented with absolute conviction to the developing mind become more entrenched in the psyche and more difficult to shatter later on in life. Hence, there are differences in anxiety proneness. My own studies 8 of differing responses to psychotropic drugs shed additional light on anxiety. If anxiety were a constant, then anxiety in schizophrenia, psychoneurosis, depression, and other states should vary only in quantity. This is easily proven false. Different anxiety states seem to respond differentially to specific medications. Schizophrenic anxiety responds to phenothiazines. If schizophrenic anxiety is along the spectrum of decompensating neurotic anxiety, of the same nature but simply more intense, then a smaller dose of phenothiazine should work
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well with neurotic anxiety. This is not so. The so-called minor tranquilizers (anxiolytic drugs) can relieve free-flowing anxiety or anxiety episodes in the neurotic but not the schizophrenic. Yet inmost cases of either condition, psychotherapy-exploratory and/or supportive--is usually part of the treatment picture. In both, the psychodynamic factors also contributing to the anxiety can be influenced, validating the notion of a concurrent psychosomatic etiology of anxiety. Inversely, since minor tranquilizers help quell neurotic and psychosomatic anxiety, larger doses should quell schizophrenic anxiety, which is accompanied by pathological defenses (hallucinations, delusions, etc.). Again this is not true, as borne out by many experiments. We can draw the conclusion that schizophrenic anxiety very likely is different in quality from neurotic anxiety. As for the neuroses, in the area of phobias there are specific, limited, object phobias (animals, bugs, etc.) or broader, more inclusive phobias such as agoraphobia, train phobia, and pan-phobia (pan-anxiety), which involve the total personality and the ability to function at all. In my experience, drugs such as the tricyclic antidepressants help many agoraphobics and/or train phobics but do not relieve specific object phobias. Also, the tricyclic drugs only help the true phobic anxiety; they do not touch the anticipatory anxiety that seems to respond to supportive psychotherapy and/or minor tranquilizers. Minor and major tranquilizers seldom touch the limited phobias. From these results it seems, possible that agoraphobia involves two kinds of anxiety, each responding to a different kind of medicine. Anticipatory anxiety may correspond to Freud's signal anxiety, 9 or Horney's fear of future change. Since the true anxiety responds to a major antidepressant, this raises the possibility that this condition is related to the anxiety found in anxiety depression. In depression, there are times when the patient manifests only anxiety,--a so-called masked depression. I feel that many masked depressions seem masked only because their subtle clinical attributes were not properly brought out during the psychiatric examination. Paying close attention to such symptoms as early morning insomnia or feeling best in the evening will help identify a depression even though the presenting symptoms are those of anxiety. Nevertheless, when anxiety appears as the surface symptom with a hidden depression, or even with manifest anxiety depression, minor tranquilizers frequently do very little. Instead, the major antidepressants, or to a somewhat lesser extent the antipsychotic drugs, can prove very helpful. The anxiety in depression appears to be of a different quality than neurotic anxiety. Anxiety in depression is connected to the underlying depression and cannot be treated as a single, isolated symptom; it will respond best when the depression is treated. Sometimes other specific part-symptoms of anxiety also respond differentially to certain drugs. I have had a number of patients with obsessive rumination who have responded well to the tricyclic drugs. There have been many positive reports regarding the treatment of severe obsessive-compulsive neurotics with chlorimi-
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JACKSCHNEE
pramine, a tricyclic not yet available in the United States. Some antisocial personalities have also responded to the tricyclic drugs, particularly when the actingout is reactive to anxiety. Anxiety-driven hyperactivity in hyperkinetic children is also quelled by the tricyclics. Perhaps anxiety is a nonspecific, intermediate, common pathway for myriad forms of psychopathology, and perhaps a specific drug affects levels above this common pathway. We know that the so-called antianxiety drugs probably affect the activity of the part of the brain that has produced anxiety. Most antipsychotic drugs also exert their main effect by blocking chemical pathways (postsynaptic dopamine receptors) in specific regions of the brain, that is, the reticular activating system, the l imbic system, the hypothalamus, globus pal lidus, and corpus striatum. If anxiety is a variable then both our classification and thinking must be reexamined. Of course, this concept has been expanded through specific symptoms and diseases responding to specific medicines. It lends itself to the idea of a therapeutic test that would define more clearly our classification and understanding of mental illness. While there is no proof of this thesis now, there is enough evidence to make these questions relevant. With this approach, medicines could be used to distinguish forms of anxiety. It would also help to set up a new classification of psychiatric illness on the basis of specific therapeutic responses to specific medicines. Basic concepts of analytic theory would have to be reexamined in the light of different kinds of anxiety. Anxiety is of basic importance in the theories of all analytic schools. If different forms of anxiety can be delineated, then the universal application of the formula that psychic conflict leads to anxiety and thus to symptom formation is far too simple. Other approaches may prove helpful. For example, in any person the conflicts, anxiety, defenses, and so forth could be dynamically drawn up in the form of a flow sheet. Then the site of action of the specific psychotropic drug could be seen more clearly. What if we find that some psychotropic drugs are specific for conflict anxiety at certain levels (conflict of opposing compulsive trends, central conflict of the healthy versus the sick, etc.). I would suspect that these medicines affect the patient at many areas, some affecting one area more than another. Other concepts may examine which specific anxieties are affected and how they are affected. Perhaps the antipsychotic drugs help the patient cope with anxiety that is caused by the schizophrenic reality disturbance, or perhaps they help him cope with anxiety that is a consequence of fear of being overwhelmed by hostility or lust. The anxiety that responds to antidepressant drugs may be best treated by equilibrium being established in the self- nonself-hate area, and/or it may be a consequence of a struggle against depression. I suspect that antianxiety drugs (minor tranquilizers) are most effective in quieting reverberating circuits where two conflicting neurotic trends oppose each other. Obsessive-compulsive symptoms that respond to antidepressant drugs may be seen as defenses to contain the anxiety that stems from a core struggle against depression. Some of my patients taking antide-,
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pressive drugs have described forgetfulness and difficulty in word or idea finding; this may help break the circular associative circuit both in obsessiw.~-compulsive symptoms and in depressions. It is my belief that psychoanalysts can make a valuable contribution toward a deeper understanding of health and psychopathology through microscopic fractionation of the psyche, and the study of the specific effects of psychotropic drugs. Dynamically, the individual can be further followed to see how the alteration of certain levels of the psyche influences other levels. To summarize my conclusions: (1) Anxiety is a holistic phenomenon. It is related to--caused by or the cause of both psychological dysfunction and somatic dysfunction. (2) There may be completely different forms of anxiety, distinguishable diagnostically, etiologically, and symptomatically. (3) Anxiety is an intermediate, common pathway for differing initiating factors. Anxiety occupies a position of central importance in psychoanalytic theory. Certain aspects of anxiety are reexamined. What is anxiety? Is all anxiety the same? What does this mean for psychopathology and psychoanalysis? Anxiety is a holistic phenomenon and is related both to psychological dysfunction and somatic dysfunction. Anxiety may not be the same in all conditions. It is proposed that anxiety is an intermediate, common path for differing initiating factors. Psychotropic drug effects are used to validate this approach. References
1. Freud, S. The Libido Theory, In Collect Papers, Vol. V. J. Strachy, (Ed.). London: Hogarth, 1956, pp. 131-135. 2. Homey, K. The Neurotic Personality of Our Time, New York: W. W. Norton, 1937. 3. Kelman, H. Unitary Theory of Anxiety. Am. J. Psychoanal. 17: 2, 1957. 4. Rubins, J. L. A holistic (Homey) approach to the psychoses: the schizophrenias. Am. J. Psychoanal. 30:1, 1970. 5. Berger, F. M. The Pharmacology of antianxiety (anxiolytic) agents. In Psychopharmacological Treatment Theory and Practice. Denber, Herman C. B. (Ed.). New York: Marcel Dekker, 1975, p. 139. 6. Lader, M. Nature of anxiety. In Yearbook of Psychiatry and Applied Mental Health, Bracelan, F. V., et al. (Eds.). Chicago: Year Book Medical Publishers, 1974, p. 191. 7. Kolb, L. C. Noyes" Modern Clinical Psychiatry, 7th ed. Philadelphia: W. B. Saunders, 1968. 8. Schnee, J. Pharmacological and Dynamic Factors in Psychotropic Drug Therapy. Am. J. Psychoanal. 30:2, 1970. 9. Freud, S. The Problem of Anxiety. New York: The Psychoanalytic Quarterly Pressand W. W. Norton, 1936. Address reprint requests to 259 Continental Drive, Manhasset Hills, NY 11040.
ANXIETY
REVISITED
Jack Schnee
Anxiety is perhaps the most important single factor to be dealt with in psychoanalytic theory and practice. Exactly what the term anxiety means remains obscure. There is still much to be discovered about the causes of anxieties, mechanisms of production, physiological and subjective effects, phenomenological experiences, and, mostly, biological substratum. Present advances in physiological and neurochemical research offer a new look at anxiety. In this paper, clinical observations of differing reactions to various medications will be related to known physiological and analytical concepts of anxiety. All analytic schools refer to anxiety as a consequence of psychic conflict, but differ as to the factors that create conflict and at what level the corfflict occurs. In early Freudian theory, 1 it was postulated that anxiety was caused by a damming up of libido, which was thus transformed directly into anxiety. In the revision of this theory, anxiety was considered the result of a conflict between instinctual (id) and prohibitive forces, whether the latter came from within the self (superego) or from without. Anxiety could be connected with an immediate danger such as separation, castration, body-image damage, and so forth, or it could constitute a protective mechanism, warning the person of impending danger. This protective mechanism was referred to as signal anxiety. All other pioneers in psychoanalysis have emphasized the importance of anxiety. They differ primarily about what basic factors cause anxiety. For Rank, the anxiety of birth trauma became the core of his theory of development and psychopathology. For Sullivan, anxiety was engendered by a threat to "security operations" due to interpersonal, relational distortions. The existentialists describe existential anxiety, caused primarily by one's awareness of nonexistance or morbidity. The so called "third school" (Rogers, Maslow, Goldstein, etc.) see anxiety as a reaction to growth and change. Each of these pioneers in psychoanalytic t]hought has his favorite emphasis and elaboration, but they all accept conflict and anxiety as bei ng of primary importance in character development and symptom formation. For Horney, 2anxiety was the dynamic core of neurosis. She focused as much on the clinical, subjective experience of anxiety as on its unconscious dynamics. She compared fear and anxiety, concluding that fear is a reaction proportionate to danger, whereas anxiety is a reaction disproportionate to danger (whether real or Jack Schnee, M.D., is Medical Director and Supervising Psychiatrist, New York Psychotherapy and Counseling Center, Jamaica, N.Y. 299
300
JACKSCHNEE
imaginary). In anxiety, the danger is generated or magnified by intrapsychic factors. Homey also held that anxiety results from a fear of our repressed impulses, the ~ expression of which would incur an external danger. She felt that repressed hostile impulses were the main psychological force promoting anxiety. She elaborated the concept that a child developing in a noxious environment will experience basic anxiety, which she described as a "feeling of being isolated and helpless in a world conceived of as potential ly hostile." Basic anxiety is not necessarily a consequence of conflict. With this basic anxiety, spontaneity is inhibited and the child gropes for ways to cope with his threatening, dangerous world. Despite feelings of aloneness and helplessness, he unconsciously evolves tactics to meet and deal with this menacing world. These strategies develop and evolve into lasting character trends, which Homey labeled "neurotic trends." These interpersonal movements crystallize out of the three attitudes in basic anxiety. One of these behavior patterns is referred to as "moving toward" people. This happens when helplessness predominates, leading to exaggereated compliance with a need of gaining affection so as to develop a sense of belonging and support. Another behavior pattern is "moving against" people. When facing hostility in others, the individual leans toward fighting out of a desire to be the stronger and wi n, partly for his own protection and partly for revenge. The third component of basic anxiety, "isolation," evolves into the-individual "moving away" from people. For his own protection he desires neither to fight nor belong, just to keep apart. In the neurotic, these moves are desperate and inflexible. The neurotic is driven to comply, to fight, and to be aloof. These compulsive moves lead to further conflicts with their own consequent anxieties because the individual cannot really make any one of these moves wholeheartedly. When one of the above moves predominates, it does not mean that the other moves have ceased to operate. They may be more or less submerged, expressed more indirectly, and at times dominance of trends may shift. Hence, when these three compulsive attitudes are present with any intensity, conflict must ensue. These attitudes influence the entire personality. They affect not only the interpersonal sphere, but also one's whole relationship to oneself, the world, and life in general. Thus, conflict and anxiety necessitate further measures to cope with these incompatible attitudes. For Homey, conflict born from incompatible attitudes constitutes the dynamic center from which neuroses emanate. Thus, the individual becomes further alienated from his real self, an idealized image is created, and an intrapsychic character (self-effacing, expansive, resigned) evolves, repressing unacceptable traits and value systems. There is further compulsive striving toward this false self. This results in marked self-contempt because of incompatible compulsive drives (return of the repressed and/or weakening of the defenses) and because of the impossibility of realizing the idealized image. While the early interpersonal solution aims primarily at a unification of relations
ANXIETY REVISITED
301
with others, the later intrapsychic maneuvers lead to a more comprehensive integration, a feeling of identity (albeit a pseudoidentity), self-idealization, and what Homey referred to as a "comprehensive neurotic solution." Along with the concept of the self-erected neurotic character superstructure, Horney extended the factors in possible conflict to include not only instinctual drives but also interpersonal attitudes of the child toward his parents, then compulsive attitudes toward others, and finally any compulsive neurotic trait (needs, claims, attitudes, etc.) which contradicts any other equally necessary trait. Kelman 3 attributes anxiety both to integrative and disintegrative ,changes in the self. This is a holistic approach derived from Homey. He raises tlhe question of rational versus irrational anxiety. The concepts of normal (rationall, healthy) and pathological (irrational, neurotic) anxiety bring us to the question of the relation between conflict and anxiety. Homey implies that basic anxiety may evolve without conflict and that conflict can produce symptoms directly, without intervening anxiety. Attitudes, which can derive from conflict, can also be considered symptoms. This then leads to the next important question: Is there a difference between the conflict-anxiety in neurosis as compared to psychosis? Rubins4 concludes that although the defense mechanisms and solutions in the schizophrenic and the neurotic are similar dynamically, some differ quantitatively (e.g., greater extensiveness and intensity in the alienation from the self) and others differ qualitatively (e.g., fluidity and disorganization of self-concept and identity, concreteness, acting out, vulnerability, etc.). He further explains that in the neurotic, the overall shifting of the personality toward self-idealization removes the person from his real self and from his ability to experience his genuine inner emotions. The schizophrenic also dynamically experiences such alienation as a chronic result of disruptive painful experiences occurring within the self. Here, though, the process is modified and intensified. The body image, self-concept, and identity are characteristically impaired; relational attitudes are more limited; the underlying self is more impaired, disorganized, and unstable; conflicts are more diffuse, intense, variable, and so forth. Rubins can be interpreted as sayingthat in the schizophrenic, anxiety is greater in quality and quantity than in the neurotic. I share the view that schizophrenic anxiety differs qualitatively and quantitatively from neurotic anxiety. Schizophrenic anxiety stems both from conflict and from confhct-free areas of existence. Because of the vulnerabl hty and extensive damage at the core of the self with impaired perception and integrative and synthesizing functions, the schizophrenic is chronically on the brink of experiencing discomfort. The schizophrenic's discomforture (anxiety?), which may or may not be due to conflict, is an expression of his difficulty in holding onto reality, the need for sameness in a changing life, the need to hold the psychic fragmentation together in order to perceive and interpret internal and external cues, the frustrating attempts to differentiate internal awareness and external perceptions, the severe alienation, and so forth. The defenses employed to combat and cope with early chronic .
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f
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,
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disruptive painful experiences add further to the confusion and anxiety in a continuous self-feeding destructive manner. We know that a noxious environment plays a role in the evolution of the schizophrenic, but we must also appreciate that for the schizophrenic the noxious environment continues permanently because of personalization of perceptions, exquisite sensitivity and being easily hurt, misperception and misinterpretation of cues, and the like. This does not ignore the idea that an organic substrate can surely predispose the individual to the development of psychosis. A defective psyche will understandably be more likely to develop overwhelming anxiety to modest stimuli. Hence it will develop extensive maneuvers to avoid this disruption: extreme need for sameness, characteristic attitudes toward self and others, severe alienation, grandiosity, concreteness, break with reality, and so forth. Now we can raise another important question: What is the relationship between anxiety are distinct for each and can be handled separately. (3) Psyche and soma There are three ways of viewing this relationship: (1) Psyche and soma are separate, but interact to produce anxiety when they affect each other. (2) Psyche and soma are separate and parallel, acting independently. Therefore, the symptoms of anxiety are distinct for each and can be handled separatley. (3) Psyche and soma are one (holistic); the symptoms of anxiety can occur in either as incidental manifestations of the same process. The holistic view of the psyche and the soma as being two sides of the same coin, each having some independence from, as well as influence over, the other, seems to fit our current understanding. For some people, the anxiety experience is predominantly a physical experience--namely, tachycardia, sweating, and so on. Others describe extreme anxiety, yet there is little or no physical evidence of anxiety. This also raises the question of ego tolerance to anxiety; some people will be intolerant of (and complain bitterly about) minimal anxiety. Pure analysts feel that anxiety is purely psychological, and organically oriented psychiatrists feel that anxiety is purely biological-chemical. These views are one-sided. I believe that the question of which comes first and causes the other is a spurious one, and can be likened to the problem of the chicken and the egg. The idea that a person may be born with a chemical imbalance is as valid as the idea that emotions cause chemical changes; one condition does not exclude the other and both affect each other constantly. A holistic view equates psychosomatic with somatopsychic. Recent research has shown that anxiety is related to definite neurophysiological factors. As Bergers states in his article on the pharmacology of antianxiety agents: "Many interpretations have been made that deal with the meaning, nature, and cause of anxiety. Unitl recently, the psychoanalytic interpretation of anxiety was widely accepted. Others looked upon anxiety as a motivational force. Recent findings utilizing modern methods of experimental psychology, biochemistry and electrophysiology permit a more objective evaluation of the anxiety state and appear to indicate that anxiety is of biological origin."
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For example, anxiety has been shown to be associated with an increased electrical activity in certain parts of the brain. The subjective experience of anxiety can be produced by electrical stimulation of certain thalamic nuclei and the limbic structures. It has also been shown that the destruction of discrete parts of the thalamus or frontal lobes produces relief from chronic anxiety in humans. Chemical research reveals that anxiety episodes can be induced by injecting epinephrine or other sympathomimetic amines, or by infection of sodium lactate in anxiety-prone neurotics. It has been shown that the so-called minor tranquilizers or anti-anxiety drugs act specifically on the areas of the brain mentioned above, namely, interneurons, thalamus, and limbic system. Lader ° divided anxiety into "state anxiety" and "trait anxiety." The former refers to anxiety felt at a moment in time and the latter to a habitual tendency to be anxious. He felt that anxiety, both as a trait and as a syndrome, was strongly influenced by genetic factors. He proposed a model for "normal anxiety," wherei n external and internal stimuli are appraised for possible threat. "The cognitive factors are affected by past experience and by genetic factors. If a threat is detected, some central nervous activities increase and the affect anxiety is experienced." He added that anxiety states may be particularly common in certain cultural groups and pointed out that epidemics of acute anxiety in communities have occurred. This supports an aspect of the psychological etiology of anxiety through such factors as suggestion. Although I appreciate that anxiety is an ubiquitous, subjective phenomenon and therefore very complex and difficult to evaluate, I suggest it may prove helpful to reexamine certain psychosomatic aspects. The clinical subjective experience of anxiety, as described by Kolb, 7 is a prototype. Anxiety is "a persistant feeling of dread, apprehension, and impending disaster. It is a response to threats from repressed dangerous impulses deep within the personality or to repressed feelings striving for consciousness, a warning of danger from the pressure of unacceptable internal attitudes." The patient is ignorant of its source, though he may blame it on some external factor. In additon, anxiety is accompanied by a disturbance in the autonomic nervous system, including visceral tension, hyperventilation, sphincter spasms or dilation, intestinal irritability, with diarrhea or constipation, cardiac palpitations, tachycardia, extrasystoles, vasomotor flushing, respiratory distress, fai nti ng, weakness, nausea, tremors, sweating, increased body movements, strained voice, and dilated pupils. Its effect on concentration and thinking processes can be so incapacitating that a pseudoorganic mental syndrome can appear. It is obvious that the entire mind and body can be involved., including the sympathetic and parasympathetic nervous systems, all levels of the brain, the sensorimotor system, the hormone system, and every organ system. Thus, both expressed and repressed (inhibited or covert) anxiety may manifest themselves in the sphere of psychosomatic medicine. Cannon's flight or fight thesis is called into question here. The intensely anxious person can do neither; he is functionally
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paralyzed. The feeling of helplessness contributes to the individual's panic. Does any of this tell us what anxiety is? We can describe the subjective feelings of anxiety and its physical concomitants. We can also describe the obvious defenses against it when no evidence of the internal anxiety is experienced. Yet we are as limited as the physicist who can describe all the characteristics of the color "red"~frequency, wave length, and so forth--but cannot tell us what red looks like. The experience of color is a purely personal phenomenon. In fact, even as a purely subjective phenomenon, the experience of anxiety can vary in the same person from one momentto another, in the same way that the perception of red may vary with the way a person feels at any given time. It is a psychological truism that the emotions influence what the patient sees, hears, feels, and thinks. And so it seems, from the clinical facts, that there may well be a whole assortment of anxieties manifesting similar tones and physiological components. Diagnostically, the possibility cannot be excluded that there is a group of anxieties. Ego tolerance, the ability to tolerate frustration and conflict, can determine at what point the inner experience of anxiety manifests itself or comes into awareness as a symptom. Some people seek rapid alleviation of any anxiety and utilize specific immediate maneuvers (i.e., narcosis, situation-avoidance, etc.). Others complain bitterly of anxiety when they are apparently experiencing only a tiny amount of discomforture. Some can tolerate what would appear to be great frustration or intense conflict. Such tolerance may depend not only on inborn strengths (constitutional tolerance) but also on environmental factors, i ncludingthe family culture and society at large. Constitutional tolerance is influenced by the culture. With any single individual, we must distinguish between the constitutional threshold,--the individual's selection of defenses or solutions that determine how and when he reacts,--and the culturally favored types of defenses or solutions of anxiety Not too long ago there were many questions regarding the effects of brainwashing on Americans compared to people of other cultures, with implications that our culture may predispose us to easier psychic collapse in the face of brainwashing techniques. Perhaps the absence of a military culture in which youth is trained in warlike psychological tactics predisposes us to more core conflicts when faced with brainwashing as adults. Solid cultural attitudes presented with absolute conviction to the developing mind become more entrenched in the psyche and more difficult to shatter later on in life. Hence, there are differences in anxiety proneness. My own studies 8 of differing responses to psychotropic drugs shed additional light on anxiety. If anxiety were a constant, then anxiety in schizophrenia, psychoneurosis, depression, and other states should vary only in quantity. This is easily proven false. Different anxiety states seem to respond differentially to specific medications. Schizophrenic anxiety responds to phenothiazines. If schizophrenic anxiety is along the spectrum of decompensating neurotic anxiety, of the same nature but simply more intense, then a smaller dose of phenothiazine should work
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well with neurotic anxiety. This is not so. The so-called minor tranquilizers (anxiolytic drugs) can relieve free-flowing anxiety or anxiety episodes in the neurotic but not the schizophrenic. Yet inmost cases of either condition, psychotherapy-exploratory and/or supportive--is usually part of the treatment picture. In both, the psychodynamic factors also contributing to the anxiety can be influenced, validating the notion of a concurrent psychosomatic etiology of anxiety. Inversely, since minor tranquilizers help quell neurotic and psychosomatic anxiety, larger doses should quell schizophrenic anxiety, which is accompanied by pathological defenses (hallucinations, delusions, etc.). Again this is not true, as borne out by many experiments. We can draw the conclusion that schizophrenic anxiety very likely is different in quality from neurotic anxiety. As for the neuroses, in the area of phobias there are specific, limited, object phobias (animals, bugs, etc.) or broader, more inclusive phobias such as agoraphobia, train phobia, and pan-phobia (pan-anxiety), which involve the total personality and the ability to function at all. In my experience, drugs such as the tricyclic antidepressants help many agoraphobics and/or train phobics but do not relieve specific object phobias. Also, the tricyclic drugs only help the true phobic anxiety; they do not touch the anticipatory anxiety that seems to respond to supportive psychotherapy and/or minor tranquilizers. Minor and major tranquilizers seldom touch the limited phobias. From these results it seems, possible that agoraphobia involves two kinds of anxiety, each responding to a different kind of medicine. Anticipatory anxiety may correspond to Freud's signal anxiety, 9 or Horney's fear of future change. Since the true anxiety responds to a major antidepressant, this raises the possibility that this condition is related to the anxiety found in anxiety depression. In depression, there are times when the patient manifests only anxiety,--a so-called masked depression. I feel that many masked depressions seem masked only because their subtle clinical attributes were not properly brought out during the psychiatric examination. Paying close attention to such symptoms as early morning insomnia or feeling best in the evening will help identify a depression even though the presenting symptoms are those of anxiety. Nevertheless, when anxiety appears as the surface symptom with a hidden depression, or even with manifest anxiety depression, minor tranquilizers frequently do very little. Instead, the major antidepressants, or to a somewhat lesser extent the antipsychotic drugs, can prove very helpful. The anxiety in depression appears to be of a different quality than neurotic anxiety. Anxiety in depression is connected to the underlying depression and cannot be treated as a single, isolated symptom; it will respond best when the depression is treated. Sometimes other specific part-symptoms of anxiety also respond differentially to certain drugs. I have had a number of patients with obsessive rumination who have responded well to the tricyclic drugs. There have been many positive reports regarding the treatment of severe obsessive-compulsive neurotics with chlorimi-
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pramine, a tricyclic not yet available in the United States. Some antisocial personalities have also responded to the tricyclic drugs, particularly when the actingout is reactive to anxiety. Anxiety-driven hyperactivity in hyperkinetic children is also quelled by the tricyclics. Perhaps anxiety is a nonspecific, intermediate, common pathway for myriad forms of psychopathology, and perhaps a specific drug affects levels above this common pathway. We know that the so-called antianxiety drugs probably affect the activity of the part of the brain that has produced anxiety. Most antipsychotic drugs also exert their main effect by blocking chemical pathways (postsynaptic dopamine receptors) in specific regions of the brain, that is, the reticular activating system, the l imbic system, the hypothalamus, globus pal lidus, and corpus striatum. If anxiety is a variable then both our classification and thinking must be reexamined. Of course, this concept has been expanded through specific symptoms and diseases responding to specific medicines. It lends itself to the idea of a therapeutic test that would define more clearly our classification and understanding of mental illness. While there is no proof of this thesis now, there is enough evidence to make these questions relevant. With this approach, medicines could be used to distinguish forms of anxiety. It would also help to set up a new classification of psychiatric illness on the basis of specific therapeutic responses to specific medicines. Basic concepts of analytic theory would have to be reexamined in the light of different kinds of anxiety. Anxiety is of basic importance in the theories of all analytic schools. If different forms of anxiety can be delineated, then the universal application of the formula that psychic conflict leads to anxiety and thus to symptom formation is far too simple. Other approaches may prove helpful. For example, in any person the conflicts, anxiety, defenses, and so forth could be dynamically drawn up in the form of a flow sheet. Then the site of action of the specific psychotropic drug could be seen more clearly. What if we find that some psychotropic drugs are specific for conflict anxiety at certain levels (conflict of opposing compulsive trends, central conflict of the healthy versus the sick, etc.). I would suspect that these medicines affect the patient at many areas, some affecting one area more than another. Other concepts may examine which specific anxieties are affected and how they are affected. Perhaps the antipsychotic drugs help the patient cope with anxiety that is caused by the schizophrenic reality disturbance, or perhaps they help him cope with anxiety that is a consequence of fear of being overwhelmed by hostility or lust. The anxiety that responds to antidepressant drugs may be best treated by equilibrium being established in the self- nonself-hate area, and/or it may be a consequence of a struggle against depression. I suspect that antianxiety drugs (minor tranquilizers) are most effective in quieting reverberating circuits where two conflicting neurotic trends oppose each other. Obsessive-compulsive symptoms that respond to antidepressant drugs may be seen as defenses to contain the anxiety that stems from a core struggle against depression. Some of my patients taking antide-,
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pressive drugs have described forgetfulness and difficulty in word or idea finding; this may help break the circular associative circuit both in obsessiw.~-compulsive symptoms and in depressions. It is my belief that psychoanalysts can make a valuable contribution toward a deeper understanding of health and psychopathology through microscopic fractionation of the psyche, and the study of the specific effects of psychotropic drugs. Dynamically, the individual can be further followed to see how the alteration of certain levels of the psyche influences other levels. To summarize my conclusions: (1) Anxiety is a holistic phenomenon. It is related to--caused by or the cause of both psychological dysfunction and somatic dysfunction. (2) There may be completely different forms of anxiety, distinguishable diagnostically, etiologically, and symptomatically. (3) Anxiety is an intermediate, common pathway for differing initiating factors. Anxiety occupies a position of central importance in psychoanalytic theory. Certain aspects of anxiety are reexamined. What is anxiety? Is all anxiety the same? What does this mean for psychopathology and psychoanalysis? Anxiety is a holistic phenomenon and is related both to psychological dysfunction and somatic dysfunction. Anxiety may not be the same in all conditions. It is proposed that anxiety is an intermediate, common path for differing initiating factors. Psychotropic drug effects are used to validate this approach. References
1. Freud, S. The Libido Theory, In Collect Papers, Vol. V. J. Strachy, (Ed.). London: Hogarth, 1956, pp. 131-135. 2. Homey, K. The Neurotic Personality of Our Time, New York: W. W. Norton, 1937. 3. Kelman, H. Unitary Theory of Anxiety. Am. J. Psychoanal. 17: 2, 1957. 4. Rubins, J. L. A holistic (Homey) approach to the psychoses: the schizophrenias. Am. J. Psychoanal. 30:1, 1970. 5. Berger, F. M. The Pharmacology of antianxiety (anxiolytic) agents. In Psychopharmacological Treatment Theory and Practice. Denber, Herman C. B. (Ed.). New York: Marcel Dekker, 1975, p. 139. 6. Lader, M. Nature of anxiety. In Yearbook of Psychiatry and Applied Mental Health, Bracelan, F. V., et al. (Eds.). Chicago: Year Book Medical Publishers, 1974, p. 191. 7. Kolb, L. C. Noyes" Modern Clinical Psychiatry, 7th ed. Philadelphia: W. B. Saunders, 1968. 8. Schnee, J. Pharmacological and Dynamic Factors in Psychotropic Drug Therapy. Am. J. Psychoanal. 30:2, 1970. 9. Freud, S. The Problem of Anxiety. New York: The Psychoanalytic Quarterly Pressand W. W. Norton, 1936. Address reprint requests to 259 Continental Drive, Manhasset Hills, NY 11040.
