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CLINICAL NOTES
ON ANXIETY NEUROSIS
Sigmund Freud (1895). ‘On the Grounds for Detaching a Particular Syndrome from
Neurasthenia under the Description Anxiety Neurosis,’ in On Psychopathology,
translated by James Strachey, and edited by Angela Richards (London: Penguin
Books, 1987), pp. 31-65.
This paper, which Sigmund Freud wrote in 1895, is a clinical description of anxiety
neurosis from a psychoanalytic point of view.
It was translated into English in 1909, 1924, and 1962.
These clinical notes are based on the text from the 1962 Standard Edition that served
as the basis for the Penguin edition cited above.
These clinical notes then are an attempt to summarize the problem of anxiety
neurosis by taking into consideration the following dimensions: clinical
symptomatology; incidence and aetiology; the theory of anxiety neurosis; and its
relation to other neuroses.
This is followed by an editor’s appendix on translating the term ‘Angst’ from
German to English.
The main difficulty in translating this term is the fact that the German term ‘Angst’
can be used both in the everyday sense and as a technical term in psychiatry.
It is derived from the Latin word ‘angere’ which conjures up feelings of being
emotionally ‘choked.’ Synonyms for anxiety in the everyday sense include words
like ‘fear, fright, and alarm.’
The clinical term for anxiety neurosis in German is ‘Angstneurose.’
Freud was fond of pointing out that anxiety is the only symptom that does not
deceive.

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In other words, of all the affects encountered in analysis, anxiety is that which
functions as a ‘signal’ and is not subject to distortion.
The analyst must therefore take the patient’s anxiety seriously.
Anxiety is also a term that was used by existentialist philosophers in Germany and
France.
Existentialist approaches to psychoanalysis succeeded in getting analysts of all
schools to take anxiety more seriously than might have otherwise been the case.
The theoretical question in describing anxiety from a clinical point of view is to
decide when anxiety is ‘normal’ and when it has become a ‘symptom.’
An anxiety neurosis then is a disorder that is characterized by anxiety as the
dominant symptom. It can occur in a pure form or in a mixed form.
Freud points out that it is common to find a patient struggling with both hysteria and
anxiety neurosis. This would be an instance of the mixed form.
In such instances of mixed form, the aetiology would be much more ‘complex’ than
when it appears in a pure form.
So it is important for a clinician to ascertain whether anxiety is in the locus of a
symptom or in the locus of a clinical structure before coming up with a diagnosis.
The main theoretical move that Freud makes in this paper is to detach anxiety neurosis
from neurasthenia which he classified as an ‘actual’ neurosis.
What Freud meant by an anxiety neurosis is a clinical category that can be classified
under the aegis of the psychoneuroses rather than the actual neuroses (such as
neurasthenia); hence the convoluted title of this paper.
Why did Freud attempt to do this?
Freud attempted to detach the psychoneuroses from the actual neuroses because it
appeared to him that the aetiology of the former leads back to early childhood.
The aetiology of the actual neuroses is however mainly related to ‘contemporary’
disturbances in the sexual life of the subject.
This theoretical move then is related to Freud’s attempt to make a stronger case for
what he describes as the ‘sexual aetiology of the neuroses.’
What is the clinical symptomatology of anxiety neurosis?

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Freud’s depiction of the clinical symptomatology is an attempt to isolate those
symptoms which constitute anxiety neurosis proper – i.e. the pure form because he
wanted to study it as a separate clinical entity.
In those instances in which he encounters the mixed form, his task is to sort out the
symptoms so that he does not conflate anxiety neurosis with that of neurasthenia or
hysteria.
The most common symptom of anxiety neurosis is ‘general irritability.’
Not only is this symptom important because it is a frequent occurrence in anxiety
neurosis, it also has ‘theoretical implications’ for a theory of anxiety neurosis.
This form of irritability is an indication of the subject’s inability to work-through
excitations in the psyche; it leads to auditory hyper-aesthesia and sleeplessness.
These symptoms will then lead to an even further increase in levels of irritability.
Another important symptom is ‘expectant anxiety.’
This form of anxiety could relate to the subject himself or to those who are in the
subject’s life.
If it relates to the subject, it invariably takes the form of hypochondria; if, however, it
relates to significant others, then, it takes the form of ‘moral anxiety’ and ‘doubting
mania.’
The subject will also have bouts of ‘free-floating anxiety,’ which does not attach itself
to any particular object or situation in his life.
The subject is also susceptible under conditions of stress to ‘anxiety attacks,’ which
come and go rendering the subject helpless.
These attacks could mimic cardiac symptoms and might take the form of spasms in
the heart, profuse sweating, difficulty in respiration, palpitations, and ravenous
hunger.
Anxiety attacks not only invariably accompany cardiac problems, but could even be
mistaken for a cardiac arrest when there is no underlying basis for such a diagnosis
in the structure of the heart.
That is why Freud mentions the prevalence of ‘pseudo-angina pectoris’ as a
complicating factor for cardiologists when they attempt a differential diagnosis
between structural and functional problems.

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It is important for cardiologists to ascertain whether heart actions like transitory
arrhythmia and tachycardia have an organic basis in the heart or whether they are
functional disturbances due to anxiety attacks.
Anxiety attacks can also play havoc with the respiratory function by throwing up
symptoms like nervous dyspnoea and asthma. The subject may have excessive
sweat, tremors, and shivering at night.
This could then be followed by ravenous hunger, vertigo, diarrhoea, and forms of
vasomotor neurasthenia; these symptoms could either represent congestive heart
failure or mimic it effectively.
Cardiac failure is usually accompanied by anxiety attacks, but anxiety attacks do not
necessarily lead to cardiac failure. That is why differential diagnosis is as important
in cardiology as in psychiatry.
When anxiety attacks are severe, the subject will suffer from pavor nocturnus (which
is a common affliction amongst children).
This makes it difficult for the subject to sleep at night; it might be accompanied by a
hysterical element or appear with mild hallucinations.
The subject could also have bouts of vertigo (giddiness) or a fainting fit.
Freud compares the intensity of this form of vertigo to those that accompany high
places like ‘heights, mountains, and precipices.’
The anxiety might also be ‘of gastric origin.’
Anxiety attacks can also activate a number of phobias which are not subject to
further analysis since they do not represent a repressed idea.
Freud also relates the activation of obsessions during anxiety attacks; the subject will
begin to brood in excess and then come down with a ‘doubting mania’ (folie de doute).

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In pure cases of anxiety neurosis, the subject will suffer from diarrhoea. But in mixed
cases, the subject will alternate between diarrhoea and constipation.
Freud compares the diarrhoea in anxiety neurosis to Peyer’s ‘reflex diarrhoea’ which
is related to the ‘disorders of the prostate.’
He points out that there is a similarity between the factors responsible for an anxiety
neurosis with those that cause ‘disorders of the prostate.’
The subject will also have a strong need to urinate to alleviate the anxiety.
And, finally, Freud reminds us that conversion symptoms are not specific to hysteria
but occur in anxiety neurosis as well.
The site of the conversion is the rheumatic muscles. Patients who are described as
‘rheumatic’ will show a greater intolerance to pain; they may also suffer from
hallucinations.
The symptoms described above can be observed both in acute and chronic forms of
anxiety attacks. However in acute forms, they are easier to identify.
What is the aetiology of anxiety neurosis?
Freud points out that in some cases it is not possible to isolate a cause; it could well
be hereditary. But in cases where the anxiety neurosis is ‘acquired,’ the model of
sexual aetiology will explain the subject’s symptoms.
It is important to remember that anxiety neurosis is not gender specific.
Unlike hysteria, which is mainly a female affliction; and obsessional neurosis, which
is mainly a male affliction; anxiety neurosis can strike both men and women.
In the case of women, Freud points out that an anxiety neurosis is most likely to be
activated amongst adolescents; it could, for instance, take the form of ‘virginal
anxiety.’
These forms of anxiety could also appear in a mixed form in conjunction with
hysteria amongst young women.
In the case of women who are newly married, the factor that triggers off an anxiety
neurosis is whether they were previously anaesthetic to sexual stimulation.
If they are able to transit to ‘normal sensitivity,’ they are less likely to come down
with a neurosis. However it appears that if a woman is ‘really anaesthetic,’ it is less
likely that she will be subject to an anxiety neurosis.

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An anxiety neurosis can also be activated, if the husband is impotent or is not able to
complete the sexual act; this takes the form of ‘coitus interruptus’ or ‘coitus
reservatus.’
Anxiety neurosis is also likely in women who have become ‘abstinent’ due to
circumstances or who are approaching a ‘climacteric’ (i.e. menopause).
In the case of men, the main causes could include abstinence, unconsummated
excitation, coitus interruptus, impotence, and an ‘increase in libido.’
Neurasthenic men - given to compulsive forms of masturbation in their younger
years - are more likely to succumb to an anxiety neurosis because they cannot
tolerate abstinence.
Such men are also more likely to suffer from impotence as adults. They have much
more difficulty in sublimating their libido without falling ill.
The main causative mechanism at play in anxiety neurosis then is ‘summation.’
That is, a subject will not fall ill because of an occasional sexual encounter that did
not lead to adequate libidinal discharge.
It is the summation of affects from a number of unconsummated sexual encounters
that leads to a full-fledged anxiety neurosis.
So, unlike hysteria, an anxiety neurosis is not precipitated by a single encounter or a
‘single fright’ that overwhelms the subject and institutes the illness.
As Freud points out, ‘anxiety neurosis is…the product of all those factors which
prevent the somatic sexual excitation from being worked over psychically.’
In terms of aetiology, however, given that many instances of anxiety neurosis come
in a mixed form, Freud isolates the following as specific to the psychoneuroses:
‘inadequate disburdening, psychical insufficiency or defence accompanied by
substitution.’

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It is therefore important not to conflate the conditions that determine the onset of the
neurosis with the factors that cause the neurosis.
This distinction becomes all the more important because of the resemblance between
the symptomatology of anxiety neurosis with those of neurasthenia and hysteria.
Or, to put it simply, the psychoneuroses are not reducible to the actual neuroses or
to each other.
That is why Freud extracts the symptomatology of the pure form of anxiety neurosis
from the mixed form of an anxiety neurosis in his clinical description in this paper.
These clinical notes have attempted to adhere to the model set out in Freud’s paper.
SHIVA KUMAR SRINIVASAN