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ANXIETY STATES.!
By
COLONEL
Con8ult~nt
H. YELLOWLEES.
Psychiatrist, B.E.F.
THE phrase" Anxiety state" appears to be rapidly beeoming as notorious
in this war ~s " Shell-shock" was in the last.
I need not emphasize that neither term is a diagnosis. They are both
labels for illnesses which we-that is the Medical Services of the Armyregard with distaste, annoyance, and suspicion, especially upon active
service. We have no special desire to study them, and no special knowledge
of how to treat them. We only know that they have a high nuisance value,
that they increase the risks of wastage of man-power and impairment of
morale, and that they make it harder for us, in numberless ways, to treat our
honest-to-goodness medical and surgical cases and get on with the war.
It is, therefore, just too bad that these illnesses should exist at all, but
there it is,.and I cannot think that fixing labels to them and then showering
abuse on the labels, will do much to abolish them. That reaction is a
hangover from nursery days .. When we have made our last and funniest
joke about" so-called shell-shock," and emptied all the vials of our scorn
upon its hapless successor" anxiety," we have not really made any contribution to the problem of functional nervous disorder in war-time. On the
contrary, we have merely adopted the infant's method of dealing with an
unpleasant reality; the method of calling it bad names, shutting our eyes,
and crying, "Go away, I hate you." We open our eyes-some of ussooner or later, and find to our dismay that there is the horrid bogy, as near
and as real as ever.
Now the difference between the" anxiety" label and the" shell-shock"
label is just this, that whereas" shell-shock" never pretended to be anything
but a label, the term "anxiety state" happens to have a very definite
technical meaning in psychological medicine, and connotes a group of
disorders with a well-established pa~hology, symptomatology, course,
treatment, and outlook of their own. When we misapplied the label" she11shock" it was of no great importance because the term never had any
scientific meaning, but when we speak of an "anxiety state" we are, or
ought to be, committing ourselves to a diagnosis, whether we realize it or
not. Shell~shock meant "It may be anything"; . anxiety state means
" It is something." Hence in the one case a mistake was a pity, but in the
other it is a medical tragedy.
In these circumstances I thought that a short summary of modern views
on the nature of anxiety states might be of interest to the Society. It will
not help us much with the whole vast question of war neuroses, but it is at
1
A paper read before the Dieppe Medical Society.
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A nxiety States
least related to that very specialized study, and can be outlined in terms
of general medicine and within the relatively short time at our disposal.
May I hope, too, that the time question may stand for my excuse if any of
my statements should appear too dogmatic, or my survey too incomplete.
Anxiety states were first brought into prominence by Freud's original
paper on the subject, published, I think, in. 1896. I am sorry I cannot be
sure, from memory, of the exact date. In it he pointed out that the central
and_essential feature of these states was' what he called" Angst" a word
of which "morbid anxiety" is the correct and generally accepted translation.
We all tend, unfortunately, to become a little slipshod in terminology, and
it is important for us to remember, if we possibly can, that strictly speaking
" anxiety" is an ordinary, everyday, non-medical word, and describes a
normal reaction to certain circumstances, whereas" morbid anxiety" is a
medical term,connoting an abnormal reaction. It is the best translation
we can give of " Angst."
" Angst" is, of course, fundamentally a mental and emotional state, but.
like practically all such states, and more strikingly so than almost any of
them, it tends to manifest itself by means of the bodily machinery, particularly that of the autonomic nervous system. As a result of this, very
many anxiety states come to be regarded by patient and physician alike as
cases of bodily illness and nothing more. Our old friend D.A.H. and his'
young successor gastritis, are two obvious illustrations which occur to me.
Anxiety states are of two kinds: Anxiety neurosis and anxiety hysteria,
and it is to the first of these that what I have just said particularly applies.
The distinction between the two is interesting but highly technical, ahd as
I shall have to limit myself to anxiety neurosis in our' discussion, t have
decided to cut out any attempt to. differep,tiate the two main groups in this
lecture. For our present purpose we need merely remember that the
nuclear symptom, as Freud called it, however it may express itself, is
morbid anxIety. This will always be discernible in any examination of
the patient worthy of the name, and the diagnosis rests not on the physical
signs and symptoms alone, but on these plus the view the patient takes of
them, the history of his illness, and his attitude of mind in general.
The bodily manifestations are' indeed, to use Freud's word, protean.
They include sweating, tremor, tachycardia, prrecordial pain, vasomotor
disturbance, fainting, vertigo, dyspnooa, asthma, nausea, retching, vomiting,
diarrhooa, polyuria, parresthesire, neuralgic pains, and many more. Naturally
it is unlikely that all these will appear at once in the same case, but every
case shows a selection of them, grouped in varying proportions, and with
varying degrees of acuteness or chronicity. And in each instance, behind
these bodily disturbances, and colouring them all, is the central symptom of
morbid anxiety, which may be anything from a certain difficulty in collecting
one's thoughts and" pulling oneself together ," to the classical acute anxiety
attack, in which physical and mental symptoms combine to present a clinical
picture which, though usually misdiagnosed, is rarely forgotten.
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Now a few of the symptoms ment.ioned, in very minor degree, are I think,
within the personal experience of almost. anyone who has ever gone up for a
viva voce. examination or even addressed a medical society, but a striking
resemblance to a well-established, good-going anxiety state' is repeatedly
seen in cases of exophthalmic goitre. The not.-uncommon thyrotoxic cases
in which there is no exophthalmos or thyroid enlargement are often practically
indistinguishable from anxiety neuroses. The commonest error in dealing
with anxiety states and, indeed, with an neuroses, is the tendency to assume
disorder in, and therefore apply t.reatment only to, those organs to which
the patient refers his symptoms. The cases of "effort syndrome," late
D.A.H., are sent to the cardiologist. Pat.ients who complain of digestive
trouble, by far the commonest original complaint of neurotic subjects-do
you mind if I repeat that? by Jnr the commonest original complaint of neurotic
subjects; thank you-go under the care of the stomach specialist. Hysterical
paralyses go to the, orthop::edic surgeon, and functional aphonias to the
throat specialist. A few years ago a group of eminent genito-urinary
surgeons held a discussion on " the sexual neuroses," and quite receritly a
first-dass obstetrician of my acquaintance" treated" chronic masturbation
in one of his patients by amputating her clitoris. As far as I am aware,
amputation of the penis is seldom resorted to for similar trouble in the male,
but if this sort of thing is really" t.reatment," t.hen we may as well push it
to its logical conclusion. We should provide a piece oHoast for the gentleman
who considers himself a poached egg, and we should order the patient who
believes he is m;:tde of glass to receive periodic special treatments from the
window cleaner.
You will note that we do not fall into this error in, for, example, a case
that we have succeeded in diagnosing as thyrotoxicosis. In that case we go
all scientific and take no particular note of the patient's actual complaints,
because his basal metabolic rate has, !l0 to speak, given the show away. His
thyroid gland stands convicted as the villain of the piece, or, should I say,
the real cause of the trouble, and we fall upon it thankfully, supported by the
surgical specialist and the X-ray specialist. The patient often recovers.
It is clear, therefore, that if we are to understand anxiety neurosis properly
and deal with it effectively, we must turn our attention to the morbid anxiety
which is its fundamental symptom. I need not say that I am making no
attempt at a full exposition of one of the biggest and most difficult subjects
in medical psychology. I shall give b~t a brief and incomplete outline of it,
choosing out of its many aspects the one which seems most suitable for our
present p~rpose.
All 'anxiety, normal or morbid, is, in its essence, a mixture of two great
opposites, desire and fear. The truth of that statement is delightfully
illustrated by our everyday, colloquial use of the word "anxious."
" I
wish it would stop raining," we say, " I'n1 anxious to go out." But we also
say, " There's no improvement in Smith's case; I'm getting very anxious."
Before the murder of Duncan, Macbeth was in a pitiful state of anxiety, and
22
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A ~xiety States
what his wife said was that he was "letting' I dare not' wait upon' I
would '."
Now morbid anxiety very -very rarely, if ever, appears, suddf:lnly as a·
bolt from the blue in a previously healthy individual. It arises in people
who are predisposed to it because this clash between desire and fear has been
the keynote of their mental attitude and character for years. They have
been" letting' I dare not' wait upon' I would' " for so long that they have
largely ceased to realise the fact . . It has become their habitual and characteristic response to life. It is not hard to see how this arose. The simplest
and commonest and worst method. of dealing with tendencies and activities
which ,ve consider to be undesirable in a child is, of course, to make him
afraid of them. This was the speciality in which Victorian parents excelled, .
but we are perhaps hardly so far ahead of th.em as we like toimagine. Almost
every natural childish activity had some mysterious, illogical, and terrible
punishment attached, varying from solitary confinem.ent on light diet for
such lesser offences as climbing trees or stealing apples, up to the wrath of
<;iod, plus a beating from Father, for showing undue interest in one's sexual
organs or those of others.
.
Now of course it's not quito as easy as that really, but that is the sort
~f thing which resulted-=-and results-in the production of people whose
fundamental attitude of mind to all life is a mixture of desire and fear, an
attraction towards, counteracted by a shrinking from. They are the army
of the psychologically half-hearted, and note that they do not realize it,
any more than any of us are clearly conscious of our habitual gestures, or our
tricks of gait, or accent. It is just part of them. Naturally this attitude
will tend to become obvious when the individual is struggling to adjust
himself to the subject with which are associated our strongest desires and
also our most powerful prohibitions and taboos. And so it comes about that
anxiety neurosis is abundant in late adolescence or in early adult life,· and
that .a maladjustment to sex is almost always a part of the picture.
Do let us remember that this is by no means a matter of seeing both sides
of a given question, and consciously weighing up the pros and cons. If the
anxiety neurotic could appreciate a situation in that way it would be the
saving of him,but it is the very thing of which he is incapable. The more
clearly the clash between desire and fear is realized, the more does the
anxiety become normal and not morbid, and the easier is it for toe individu~l
to find means of outlet-and there are means-for the tremendously increased
nervous tension, when neither desire nor fear will yield. But that relief is
not for the anxiety neurotic. It is not easy to deal with a situation which
one not only does not understand, but of the very existence of which one is
not clearly aware .. The mind of the anxiety neurotic isa house divided
against itself. His trouble is deeper than logic or consciousness, and he only
knows that the very idea of resolute action in any direction floods his mind
with all sorts of doubts and misgivings the nature and origin of which he
can.not now in any way understand. It is the lack of outlet and the state of
tensIon so produced that form the background of all anxiety neurosis.
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Now of course all this varies enormously in degree, and may very well
pass unnoticed till the individual is faced with a situation which proves too
much for his limited powers of adaptation. But, and this is the vital point,
the actual external situation has really very little to do with the matter
where morbid anxiety is concerned. Let me try to make that clear. We
are all so made that we cannot experience an emotional state for any length
of time without finding some object in our environment to which to attach it.
We cannot merely be angry; we must be angry with somebody. We cannot
merely be afraid; we must be afraid of something. As I am sure most of
us realize by now, the particular object on which we discharge the venom
of our latent irritability on any given morning, is almost entirely a matter
of chance. If the eggs, for once, are all they should be, there is always the
matter of the hot-water supply, and ifthat should have failed to live down to
its 'reputation, one can fall back on the unpleasing appearance or habits of
some colleague. As a last resort, there is the inexhaustible subject of the
War Office. Not only do we make such things the outlets for our irritability,·
but. we actually succeed in convincing ourselves that they are its cause,
forgetting that, if so, the result apparently came first, and the cause followed
some time afterwards. This of course is precisely on the level of the Germans
and Mr. Ch\lrchill, but it is a well-nigh universal. reaction, for all that. It
takt;ls the most stable of us all his time to avoid this pitfall, and certain
ranks-proverbially full Colonels and Sergeant-Majors-are said to find it
impossible to do so, but the anxiety neurotic doesn't even begin to try.
Though he will naturally prefer a situation which, on its own merits s6 to
speak, would tend to rouse apprehension in a normal person, he attaches his
anxiety in some degree to any and every circumstance or situation in his
daily life. Both patient and physician then draw the mistaken inference
that the situation in itself is the" cause" of the abnormal symptoms, and
the way lies open for mistaken diagnosis and misdirected treatment.
To the typical anxiety neurotic, the mere sight of a. policeman suggests
the thought of arrest and punishment; all telegrams suggest possible bad
news; every stranger might be a thief and a robber;· and every summons
to the chief's office may mean the sack. He cannot explain it, understand
it, o~ reason it out. He's not afraid, he will say; why should he be? His
coinmon sense tells him there is nothing to be afraid of, but the harder he
struggles to reassure himself, to scold himself, or to laugh at himslf, the more
inevitably does his pulse-rate begin to rise, his heart to palpitate, his limbs
to tremble, his hands to sweat, and hiS very bowels to turn to water.
Now if such a person is faced with a situation involving risk of death or
pain or discomfort, he will no doubt show these reactions, but that is no.
evidence whatever that he is any more " afraid" of the situation than, his
neighbour is, still less that his symptoms are merely an elaborate attempt
to avoid his responsibilities and shirk his duty. It may quite possibly be so,
because, although the It;lvel of physical courage among anxiety neurotics is
probably higher than in most other sections of the community, there are good
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Anxiety States
and bad in all groups. The point, however, is that without evidence of a
totally different kind from that provided merely by the bodily and mental
symptoms we have mentioned, it is grossly unfair to suggest that the coward
and the anxiety- neurotic have anything in common. Death and hardship
and pain are not necessarily the things of which he is " really afraid" any
more than he is "really afraid" of the stranger or the telegram or the
policeman or the chief.
That is the crucial point: the comparative irrelevance of the situation,
and its outcome, to the morbid anxiety which the patient attaches to it.
That is the whole meaning ofthe word" inorbid." The situation is not the
cause of the anxiety; it is the occasion and the opportunity-one of an
infinite series-----'-for something already in the patient to manifest and express
itself.
Strangely enough, when any given situation does actually turn out
unfavourably, it is quite often all the better for the patient. If the letter
contains not bad but good news, or if the visitor is not a burglar after all, but
a kind friend, the patient's morbid anxiety is in no way relieved. Why
should it be? There will be plenty more letters and visitors to agonize over
in due course. But, on the other hand, if the blow really does fall, the .patient,
to begin with, experiences the unique joy of being in a position to say, " I
told you so." Further, now that the worst has happened he is, for the
moment, released from his forebodings, and very often he may be temporarily stimulated into displaying the efficiency, the courage, and sometime&
even the heroism of despair.
How utterly different is all this from the simple anxiety of a norinal man
with all his psychological cards on the table, so to speak. The cause of his
·anxiety resides in the uncertainties of the situation, and when the situation
is resolved one way or other no further anxiety remains. If the worst
happens the ordinary man accepts the fact, and does his best to act efficiently
about it and get what is possible out of the wreck. On the other hand, if
things turn out well, he thanks God and takes courage, experiencing a
glorious sense of relief to which his neurotic brother is for ever a stranger.
Perhaps a final homely illustration may show up the contrast clearly. Some
weeks ago a senior officer came into my office, looked at me without spea:king
for a moment, and then said quietly and seriously: "I want to ask you
. something." Well, I don't pretend to anything more than a reasonably
clear conscience, and r cannot tell how those of you.> who have stainless ones·
would have reacted. r only know that to my fury r became conscious of a
group of anxiety symptoms rising within me with an ever-increasing force.
r won't say that all my past life flashed before me-it wasn't as bad as thatbut many grim possibilities ran through my mind while I waited what seemed
about twenty minutes to hear the question .. When it came it was a perfectly
ordinary matter of business which I answered on the spot in a word or two.
But then, and this is the point, I gave away the entire show by saying, tactlessly perhaps, but with a sigh ofimmense relief, " I thought it was something
important t "
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•
333
Well, gentlemen, that is the best I can do in the time at our disposal, and
you will naturally expect me to say something about treatment before I
sit down. It is not entirely lack of time which leads me to compress what I
have to say about that into a very few sentences. I have outlined a disorder
which to my bigoted mind seems intelligible enough, and which involves
conceptions and theories which do not seem to me to be any more complicated
and far-fetched than many. of the physiological theories which we invoke so
readily, not to say glibly, in ordinary medicine. But if you insist that it is a
thoroughly difficult and specialized business, as indeed it is, then you can
hardly help agreeing with me that its treatment is a matter for the trained
specialist. I say that with every pleasantness, but with all sincerity. The
untrained man should be as uJ).willing to accept the responsibility of treatillg
an anxiety neurosis as to accept that of personally operating on an appendix
abscess. In the absence of trained specialists, the untrained man does his
best, and sometimes it is an amazingly good best. It all depends on the man,
and we can't open up the subject now. We can say, however, that a thoughtful and careful man will find 'various minor uses for some coniplicated instrument, such as the great science and art of psychotherapy, even though he
does not fully understand its powers and functions, and has not been trained
in handling it. A bumptious ass will harm his patients and ruin the
instrument.
Cases of. obvious and well-established true anxiety neurosis, while not
rare, are by no means abundant in this area just now, but an immense amount.
of minor and ill-defined neurotic reaction and faulty adaptation to present
conditions does exist, for which "anxiety state" has become one of the
.recognized waste-paper baskets. Now, as I said at the beginning, .this is
lamentable from a medical and scientific point of view, but I am quite prepared
to admit that at this early stage in the development of the psychiatric branch
of the medical services, it is a labour-saving device which is not without its
practical and administrative advantages. My own feeling is that at the
present stage, having given this outline of the perfectly good illness whose
name we are apt to take in vain, there is no further action I feel called on
to take in the matter .
. May I speak for a moment in a more general way, in closing?
True war-shock or anything remotely resembling it has riot yet arisen.
The word" war-neurosis" as yet means absolutely nothing with regard to
this war. A junior officer from another area, who was not in the last war,
and has nmv been in France for three weeks, came to see me the other day
. and informed me that he had just given a lecture to his fellow officers which
had been well received and had aroused much interest. His subject was
"War Neuroses." To quote Shakespeare once again: "I was not angry
since I came to France, until that instant." If arid when we are faced with
~eal war~neurosis, Army psychiatry, which is always the most fascinatingly
interesting of the medical services, 'will become one of the most vitally and
urgently important, and will stand or fall by the way in which it deals with·
situation.
the
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A nxiety States
Meanwhile there is plenty to do in the way of organization, preparation,
weeding out, and the routine work with nervous and insane patients. That
is notour pI;esent concern, but I must say here a word.in recognition of some
of the splendid bits of medical work done by individual medical officers in
hospitals in this and other areas, with isolated cases of neuroses of all kinds
that have cropped up. There have been some brilliant results of the attempts
of these men to apply modern curative psychological treatment to the cases
that have come their way, and I cannot think it is mere coincidence that the
wards of the general duty officer who " does the psychiatry" are so often
regarded as the most interesting in the hospital.
But apart from the routine things, we are faced with one new and great
psychiatric problem, which was perhaps not quite fully foreseen, namely the
difficulty of enduring with unimpaired cheerfulness, efficiency, and morale,
not strain, privation, exhaustion, bombardment and the risk of wounds and
death, but inactivity, boredom, Ihinor discomfort, monotony and, above all,
absence of opportunity to do the work that we know and love, and that smne
of us have perhaps given up a good deal for the~hance of doing here. Well,
there's material for another lecture or two in that, but I must point out how
it brings in at once that fundamental question of lack of outlet, and so predisposes the ""hole lot of us to anxiety states. For believe me, this particular trouble is as prevalent, to say the least, at the base as it is at the
front, and I have seen a good many cases, not only among the patients, but
among the medical officers who look after them. Further than that I cannot
go. Detail~ of prophylaxis and treatment would require another lectureor perhaps a private interview would be better! But irriprovement always
follows upon realization and acceptance of the position, and once that has.
been achieved the prognosis, you will be glad to know, is almost invariably
excellent.
o
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Anxiety States
H. Yellowlees
J R Army Med Corps 1940 74: 327-334
doi: 10.1136/jramc-74-06-02
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