Chapter 3

ANXIETY INTERPRETED BIOLOGICALLY

The planning function of the nervous system, in the course of evolution, has culminated in the appearance of ideas, values, and pleasures—the unique manifestations of man’s social living. Man, alone, can plan for the distant future and can experience the retrospective pleasures of achievement. Man, alone, can be happy. But man, alone, can be worried and anxious. Sherrington once said that posture accompanies movement as a shadow. I have come to believe that anxiety accompanies intellectual activity as its shadow and that the more we know of the nature of anxiety the more we will know of intellect.

—Howard Liddell,
THE ROLE OF VIGILANCE IN THE
DEVELOPMENT OF ANIMAL NEUROSIS

IN THIS CHAPTER WE INQUIRE: WHAT HAPPENS TO AN organism when it is confronted with a danger situation? We will make our inquiry from the biological viewpoint, biology as including not only the reflexive responses to danger but also the broader sense of the organism as a biological whole responding to a threat.

I am aware that, in the study of anxiety, there have occurred during the last two decades a great number of researches into relatively isolated phases of neurology and physiology. Indeed, the progress in the development of more sophisticated instruments, for example, to study endocrinology, has been great indeed. Each of these researches is like an individual brick to be used in the building of a house. But where is the design for the house? Where, in other words, is the synthesis, the integration, the pattern into which all these discrete bricks are to be placed?1

Our great need, as the authors of the many papers in symposia on anxiety seem universally to agree, is for an integrating design which will bring, as Freud said half a century ago, some “order and lucidity” into the field. Our heterogeneous, isolated, segmented knowledge has vastly increased; our understanding of anxiety as a whole has scarcely increased at all. The pattern which would include all these different phases seems still to elude us.

Eugene E. Levitt, for example, describes an article in the Scientific Monthly in 1969, in which the author, Ferris Pitts, claimed to have found the chemical source of anxiety, consisting of high concentrations of lactate in the blood. This was announced as a “breakthrough,” similar to the announcement every four or five years of a “breakthrough” in the cause of schizophrenia. These breakthroughs then are forgotten, to be mentioned only in obituaries. Levitt summarizes it with these words, “Breakthrough research is low caliber work masquerading as top drawer work.”²

The reason these “discoveries” so often turn out to be disappointing is that the “cause” of a condition of life like anxiety can never be found in an isolated neurological or physiological reaction. What is necessary is a new pattern which will include all the different approaches. The neurological and physiological aspects of anxiety cannot be understood by themselves, but they must be seen in reference to the question, What needs is the organism trying to fulfill in its struggle with its world? By world I mean not only physical environment but more than that: the psychological and attitudinal environment as well.

This means that the neurophysiological processes need to be seen as one phase of the hierarchy of organization of the organism. It means what Adolph Meyer called “a subordination of physiology to the integrating functions and particularly by means of the use of symbols.”3

There are many empirical supports for this summary statement of Adolph Meyer. Aaron Beck states that the “stressful life situations, per se, are less important in the production of anxiety and physical disorders than the way in which these situations are perceived by the individual.”⁴ In their studies of anxiety in soldiers in the Vietnam War, three authors, Bourne, Rose, and Mason, summarize that what causes the variation in anxiety is not the physiology per se, but the “characteristic life style” of the particular soldier. In other words, the manner in which the individual perceives the threat is more important than the threat itself. In the life style of the person the integrative dynamism is of great importance. Mason points out that many illnesses may be disorders of this integrative mechanism. It is this integrative mechanism by which the person symbolically interprets the situations as threatening or nonthreatening.

Contrasting the “elementalistic” approach in biology, John Mason states, “The premise underlying the ‘integrative’ or ‘synthetic’ approach . . . is that ultimate understanding of the living organism lies not only in knowing its ultimate component parts, but that a unique and fundamental task in biology is to determine how the many separate bodily parts or processes are integrated with the organism as a whole.”⁵

The aim of an integrating pattern must be kept in mind in this chapter. We must ask how each research fits into the whole, if we are to avoid the quicksand lying in wait for all researches in physiology and neurology.

THE STARTLE PATTERN

We begin by noting a protective response which, although not fear or anxiety, is a precursor of these emotions—the startle pattern. The study of the startle pattern by Landis and Hunt is of particular interest, since it casts light on the order of emergence in an organism of protective response, anxiety, and fear.⁶

If one shoots off a gun behind a person, or in other ways gives a loud, sudden stimulus, the person will bend quickly, jerk his head forward, blink his eyes, and in other ways exhibit the “startle response.” This response is a primary, innate, involuntary reaction which precedes the emotions of fear and anxiety. Landis and Hunt performed varied experiments to elicit the startle pattern, using mainly a pistol shot for the stimulus and cinemaphotography to record the instantaneous reactions. The startle pattern has as its most prominent feature a general flexion of the body, “which resembles a protective contraction or ‘shrinking’ of the individual.”7 The startle pattern always is marked by a blinking of the eyes, and in the normal picture it includes “head movement forward, a characteristic facial expression, raising and drawing forward of the shoulders, abduction of the upper arms, bending of the elbows, pronation of the lower arms, flexion of the fingers, forward movement of the trunk, contraction of the abdomen, and bending of the knees . . . It is a basic reaction, not amenable to voluntary control, is universal, and is found in Negroes as well as whites, infants as well as adults, in the primates and in certain of the lower animal forms.”⁸ Neurologically, the startle pattern involves an inhibition of the higher nervous centers, since the latter are unable to integrate a stimulus of such suddenness. That is to say, we startle before we know what threatens us.

The startle response is not fear or anxiety as such. “It seems best to define startle as pre-emotional,” Landis and Hunt rightly remark.⁹ “It is an immediate response to sudden, intense stimulation which demands some out-of-the-ordinary treatment by the organism. As such it partakes of the nature of an emergency reaction, but it is a rapid, transitory response much more simple in its organization and expression than the so-called ‘emotions.’”¹⁰ Emotion proper may follow the startle reflex. The adult subjects in the Landis and Hunt experiments showed such secondary behavior (emotion) as curiosity, annoyance, and fear after the startle. The authors suggest that this secondary behavior is a “bridge from the innate and unlearned response over to the learned, socially conditioned, and often purely voluntary type of response.”¹¹

Significantly, the younger the infant in these experiments, the less secondary behavior accompanied the startle. During the first month of life the infant showed very little reaction except startle, “while our work shows,” continue Landis and Hunt, “that as the infant develops, more and more secondary behavior appears. . . . Crying and escape behavior—either a turning of the head away from the sound source or actual turning of the body and creeping away—became increasingly frequent with age.”12

A great deal can be deduced from the startle pattern as a pre-emotional response of anxiety and fear. For example, Lawrence Kubie finds in this pattern the “ontogeny of anxiety.” He holds that the startle pattern is the first indication that a gap exists between the individual and his world. The fetus, Kubie holds, cannot experience startle; in the fetus there is no interval between stimulus and response. But the infant and the startle pattern are born at the same moment. Thereafter there exists a “distance” between the individual and his environment. The infant experiences waiting, postponement, frustration. Anxiety and the thought processes both arise out of this situation of “gap” between the individual and the world, Kubie holds, with anxiety preceding the development of thought. “Anxiety in the life of the individual stands as a bridge between the startle pattern and the dawn of all processes of thought.”¹³

This startle pattern, according to Landis and Hunt, belongs to the general type of response which Goldstein calls the “catastrophic reaction.” We view the startle pattern as a primal, unlearned protective response, the precursor to the emotional reactions of the organism which are later to become anxiety and fear.

ANXIETY AND THE CATASTROPHIC REACTION

The contribution of Kurt Goldstein is important for our present purposes because it yields a broad biological base for the understanding of anxiety.¹⁴ Goldstein’s concepts arise out of his work as a neurobiologist with diverse mental patients, but especially with patients with brain injuries. As director of a large mental hospital in Germany during World War I, Goldstein had the opportunity to observe and study many soldiers who had had part of their brains shot away. These patients, whose capacities for adequate adjustment to the demands of their environment were limited by their brain lesions, responded to a wide variety of stimuli with shock, anxiety, and defense reactions. By observing them, as by observing normal individuals in crisis situations, we can gain insights into the biological aspects of the dynamics of anxiety in all organisms.15

Goldstein’s central thesis is that anxiety is the subjective experience of the organism in a catastrophic condition. An organism is thrown into a catastrophic condition when it cannot cope with the demands of its environment and, therefore, feels a threat to its existence or to values it holds essential for its existence. The “catastrophic condition” must not be seen as always referring to high emotional intensity. It may come with just a thought running through one’s mind of a threat to his existence. The degree of intensity is not the issue; it is a qualitative experience.

The brain-injured patients Goldstein studied devised innumerable ways of avoiding catastrophic situations. Some, for example, developed compulsive patterns of orderliness: they kept their closets in perfect order. If placed in surroundings in which the objects were in disarray—i.e., if someone changed the arrangement of their shoes, clothes, etc.—they were at a loss to react adequately and exhibited profound anxiety. Others, when asked to write their names on a paper, would write in the extreme corner of the paper; any open space (any “emptiness”) represented a situation with which they could not cope. Any changes in environment were avoided by these patients, for they were unable to evaluate new stimuli adequately. In all these situations we see the patient unable to cope with the demands of his world and unable to actualize his essential capacities. The normal adult, of course, is able to cope with a much wider range of stimuli, but the problem of organism-in-catastrophic-condition remains essentially the same. The objective aspect of being in such a condition is disordered behavior. The subjective aspect is anxiety.

Goldstein denies that an organism is to be understood as a composite of various “drives,” the blocking or disturbing of which results in anxiety.¹⁶ Rather, there is only one trend in an organism—namely, to actualize its own nature. (We note the similarities between this view and Kierkegaard’s concept of self-realization.) Each organism’s primal need and tendency are to make its environment adequate to itself and itself adequate to its environment. Of course, the nature of organisms, animal or human, varies widely. Each his its own essential capacities, which determine both what it has to actualize and how it will endeavor to do so. A wild animal may actualize its own nature successfully in its jungle habitat, but placed in captivity in a cage it is often unable to react adequately and exhibits frantic behavior. Sometimes an organism overcomes the hiatus between its own nature and the environment by sacrificing some elements in its nature—presumably the wild animal above learns to avoid the catastrophic condition in the cage by sacrificing its need to roam freely. An inadequate organism may seek to shrink its world to that in which its essential capacities are adequate, thus avoiding the catastrophic situation. As an example, Goldstein mentions that Cannon’s sympathetomized cats stayed near a radiator because their capacity to react adequately to cold (and thus preserve their existence) had been curtailed by the cutting of the sympathetic nervous chain.

To one student a particular examination may be breezed through without anxiety, whereas to another student, whose life career depends on passing the examination, the situation may be traumatic and catastrophic, and reacted to with disordered behavior and anxiety. There are thus two sides to the basic concept of organism-in-catastrophic-situation: one is the objective situation itself, and the other is the nature of the organism involved. In even the normal anxiety of everyday life, in the “black threat that grips us in the pit of the stomach,” each of us can recognize the threat of the catastrophic situation.

Human beings vary enormously with respect to their capacity for meeting crisis situations. Why some individuals are so ill-prepared for crises because of conflicts within themselves is more strictly the psychological problem and is discussed in the next chapter. Let it suffice here to point out that every human being has his “threshold” beyond which additional stress makes the situation catastrophic. Grinker and Spiegel have illustrated this threshold in their studies of soldiers who have broken down in battle.17 Also Bourne, Rose and Mason, studying combat soldiers in the Vietnam War, illustrate a similar situation. The function of the various defenses of the soldiers—self-reliance to the extent of believing themselves invincible, compulsive activities, faith in the strength of the leader—all can be seen as protections of the individual from the catastrophic condition.¹⁸

Anxiety and the Loss of the World

We now turn to Goldstein’s interesting discussion of why anxiety is an emotion without a specific object. He agrees with Kierkegaard, Freud, and others that anxiety is to be distinguished from fear in that fear has a specific object, whereas anxiety is a vague and unspecific apprehension. The puzzling problem in contemporary psychology is not this definition but the rationale for it. So far as the phenomenon goes, it is readily observable that a person in severe anxiety is unable to say, or to know, what “object” he is afraid of.¹⁹ This “objectlessness” is clear in patients at the onset of psychoses, says Goldstein, but the same phenomenon can be seen in less extreme cases. When clients are in anxiety states in psychoanalysis, (like Harold Brown, to be described below) they will report that their inability to know what they are afraid of is precisely what makes the anxiety so painful and disconcerting.

Goldstein suggests that “it seems as if, in proportion to the increase of anxiety, objects and contents disappear more and more.” And he asks, “Does not anxiety consist intrinsically of that inability to know from whence the danger threatens?”20 In fear we are aware of ourselves as well as of the object, and we can orient ourselves spatially with reference to the thing feared. But anxiety “attacks us from the rear,” to use Goldstein’s phrase, or, I would say, from all sides at once. In fear, your attention is narrowed to the object, tension is mobilized for flight; you can flee from the object because it occupies a particular point spatially. In anxiety, on the other hand, your efforts to flee generally amount to frantic behavior because you do not experience the threat as coming from a particular place, and hence you do not know where to flee. As Goldstein phrases it:

In fear, there is an appropriate defense reaction, a bodily expression of tension and of extreme attention to a certain part of the environment. In anxiety, on the other hand, we find meaningless frenzy, with rigid or distorted expression, accompanied by withdrawal from the world, a shut-off affectivity, in the light of which the world appears irrelevant, and any reference to the world, any useful perception and action is suspended.

Fear sharpens the senses. Whereas anxiety paralyzes the senses and renders them unusable, fear drives them to action.²¹

Goldstein observed that when the brain-injured patients were in anxiety, they were unable to evaluate external stimuli adequately, and hence they were neither able to give an accurate account of their objective environments nor were they able to see realistically their own positions in relation to these environments. “The fact that the catastrophic condition involves the impossibility of ordered reactions,” he remarks, “precludes a subject ‘having’ an object in the outer world.”²² Everyone has noticed in his own experience how anxiety tends to confuse not only his awareness of himself but at the same time to confuse his perception of the objective situation. It is understandable that these two phenomena should go together, for, in Goldstein’s words, “to be conscious of one’s self is only a correlate of being conscious of objects.”23 The awareness of the relationship between the self and the world is precisely what breaks down in anxiety.²⁴ Hence it is not at all illogical that anxiety should appear as an objectless phenomenon.²⁵

In the light of the above discussion, Goldstein holds that severe anxiety is experienced by a person as a disintegration of the self, a “dissolution of the existence of his personality.”²⁶ Thus it is not strictly accurate to speak of “having” anxiety; rather one “is” anxiety, or “personifies” anxiety.

Origins of Anxiety and Fear as Seen by Goldstein

What is the relation, speaking developmentally, between anxiety and fears? In Goldstein’s view, anxiety is the primal and original reaction and fear a later development. The first reactions of infants to threats are diffuse and undifferentiated—i.e., anxiety reactions. Fears are a later differentiation as the individual learns to objectivate and to deal specifically with those elements in his environment which might throw him into the catastrophic condition. In an infant, even an infant in the first ten days of life, one can observe obvious anxiety—diffuse, undifferentiated reactions to threats to its security. Only later, as the growing infant becomes neurologically and psychologically mature enough to objectivate—i.e., to distinguish those items in its environment which might give rise to the catastrophic condition—do specific fears appear.

Proceeding into his more specific formulation of the relation between fear and anxiety, Goldstein makes a statement which may seem confusing to many readers. “What is it then that leads to fear?” he asks, and then asserts, “Nothing but the experience of the possibility of the onset of anxiety.”²⁷ Thus fear, he holds, is actually an apprehension that one might be thrown into the catastrophic condition. This may be illustrated by the case study to which we have already referred—that of Harold Brown (Chapter 8 of this book). At different times this young man needed to pass certain examinations if he was to be permitted to proceed in his academic life. On one occasion he felt at the moment of writing the examination that he could not succeed and was seized with panic that he might be dropped from the university and would then again be a “failure.” The very pronounced tension and conflict, with all his old symptoms of profound anxiety, were the subjective reactions to his experience of being in a “catastrophic condition.”

Part of the reason Goldstein’s formulations at this point may seem confusing is that the tendency in much of our past psychological thinking is to regard fear as the generic term and anxiety as a derivative from fear.28 Goldstein’s viewpoint is the opposite: fear is a differentiation from anxiety and a later development in the maturation of the organism. He asserts that the customary procedure of understanding anxiety as a form of fear, or the “highest form of fear,” is incorrect. “Thus it becomes clear that anxiety cannot be made intelligible from the phenomenon of fear, but that only the opposite procedure is logical.”²⁹ To be sure, fear may pass into anxiety (when the individual finds he cannot cope with the situation) or anxiety may pass into fear (as the individual begins to feel he can cope adequately). But when increasing fear turns eventually into a state of anxiety, for example, Goldstein contends that a qualitative change is occurring—that is, a change from the perception of the threat as coming from a specific object to an apprehension which engulfs the whole personality so that the person feels his very existence is endangered.

With regard to the origin of fears and anxiety, Goldstein obviously disagrees with the various theories of hereditary anxiety and inherited fears of certain objects. Stanley Hall went back so far as to assume that children’s fears were inherited from the animal ancestors of man. Stern refuted this, but he held, with Groos, that the child has an instinctive fear of the “uncanny.” Goldstein feels that this cannot be true, since the child learns by moving ahead into unfamiliar situations. Stern held that certain peculiarities of objects lead to the child’s fears of them: sudden appearance, rapid approach, intensity of the stimulus, and so forth. All these have one factor in common, says Goldstein: they make an adequate stimulus evaluation difficult, if not impossible.30 “For an explanation of anxiety in childhood,” Goldstein sums up the question, “it suffices to assume that the organism reacts to inadequate situations with anxiety, and did so in the days of his ancestors, as well as today.”³¹ This explanation, we might add, saves us from becoming lost in that labyrinth of futility, the “heredity vs. learning” debates, which have heretofore bedeviled much of the discussion of fears and anxiety. Goldstein’s view is clarifying in that it becomes no longer necessary to view the individual as a carrier of certain fears, but rather as an organism needing to make itself adequate to its environment and its environment adequate to itself. When this cannot be done, as stated above, anxiety results; and fears, rather than being hereditary, are objectivated forms of this capacity for anxiety. It is the biological capacity to have apprehension which is inherited, not the specific fears.

The Capacity to Bear Anxiety

Goldstein points toward the constructive use of anxiety when he states, The capacity to bear anxiety is important for the individual’s self-realization and for his conquest of his environment. Every person experiences continual shocks and threats to his existence; indeed, self-actualization occurs only at the price of moving ahead despite such shocks. This indicates the constructive use of anxiety. Goldstein’s view is here similar to that of Kierkegaard, who, as indicated in the previous chapter, emphasized that anxiety, from the positive point of view, is an indication of new possibility for development of the self. Goldstein holds that the freedom of the healthy individual inheres in the fact that he can choose between various alternatives, can avail himself of new possibilities in the overcoming of difficulties in his environment. In moving through rather than away from anxiety the individual not only achieves self-development but also enlarges the scope of his world.

Not to be afraid of dangers which could lead to anxiety—this represents in itself a successful way of coping with anxiety. . . .³²

Courage, in its final analysis, is nothing but an affirmative answer to the shocks of existence, which must be borne for the actualization of one’s own nature.³³

The normal child has less power to cope with his world than the adult, but the child also has a strong tendency toward actions—this inheres in the child’s nature, says Goldstein. Hence he moves ahead, growing and learning despite shocks and dangers. This is the essential difference between a normal child and a brain-injured patient, though they both represent limited powers of coping with anxiety-creating situations. The capacity to bear anxiety is found least of all in the brain-injured patient, more in the child, and most of all in the creative adult. The creative person, who ventures into many situations which expose him to shock, is more often threatened by anxiety but, assuming the creativity is genuine, he is more able to overcome these threats constructively. Goldstein quotes with approval Kierkegaard’s statement, “The more original a human being is, the deeper is his anxiety.”34

Culture is the product of man’s conquest of anxiety in that culture represents man’s progressive making of his environment adequate to himself, and himself adequate to his environment. Goldstein disagrees with Freud’s negative view of culture—viz., that culture is a result of the sublimation of repressed drives, a result of the desire to avoid anxiety. Creativity and culture, from the positive viewpoint, Goldstein holds, are associated with the joy of overcoming tasks and shocks. When creative activities are a direct product of the individual’s anxiety, or the substitute phenomena into which the individual is forced by his anxiety, there is evident a stress on partial aspects of action, compulsiveness, and lack of freedom. Hence “. . . as long as these activities are not spontaneous, are not outlets of the free personality, but are merely the sequelae of anxiety, they have only a pseudo-value for the personality.” He continues:

This can be illustrated by the difference between the sincere faith of the really religious man, which is based upon willing devotion to the infinite, and superstitious beliefs. Or by the difference between the open-minded scholar who bases his beliefs upon facts and is always ready to change his conceptions when faced with new facts, and the dogmatic scientist. . . .³⁵

Goldstein adds a comment on the age-old pattern by which people, in ancient as well as modern countries under totalitarianism, are enslaved:

Shaken on the one hand by uneasiness about the present situation and by anxiety for their existence, deceived on the other by the mockery of a brilliant future as the political demagogue depicts it, a people may give up freedom and accept virtual slavery. And it may do this in the hope of getting rid of anxiety.³⁶

NEUROLOGICAL AND PHYSIOLOGICAL ASPECTS OF ANXIETY

As I mentioned earlier, in most discussions of the neurophysiological aspects of anxiety, the procedure is to describe the functioning of the autonomic nervous system, and the bodily changes for which this division is the medium, and then to assume implicitly or explicitly that this adequately takes care of the problem. While I agree that an understanding of the function of the automatic system is one very important step in the inquiry into the neurophysiology of anxiety, I indicated why such a procedure is not in itself adequate. Anxiety is a reaction in the organism so pervasive and fundamental that it cannot be relegated to a specific neurophysiological base. As we shall see in the subsequent discussion of psychosomatics, anxiety almost always involves a complex constellation of neurophysiological interrelationships and “balances.” In the present section, therefore, we shall proceed from the simpler levels of the question—e.g., the functioning of the automatic system when the organism is subjected to threat—to the more complex levels as the organism is seen as a reacting totality in its environment.³⁷

When an organism is subjected to threat, bodily changes occur which prepare the organism for fighting or fleeing from the danger. These changes are effected by way of the autonomic nervous system. Called “autonomic” because it was believed not to be subject to direct conscious control,³⁸ this system is the medium by which emotional changes occur in the body. It has been called “the bridge between psyche and soma.” As will be discussed more fully below, the autonomic system consists of two divisions which work in opposition to or balance with each other. The parasympathetic division stimulates digestive, vegetative, and other “upbuilding” functions of the organism. The affects connected with these activities are of the comfortable, pleasurable, relaxing sort. The other division, the sympathetic, is the medium for accelerating heartbeat, raising blood pressure, releasing adrenalin into the blood, and the other phases of mobilizing the energies of the organism for fighting or fleeing from danger. The affects connected with the “general excitement” of sympathetic stimulation are typically some form of anger, anxiety, or fear.

These and many other physical expressions of anxiety-fear can be conveniently linked in the framework of Cannon’s “flight-fight” mechanism.39 The heartbeat is accelerated in order to pump more blood to the muscles which will be needed in the impending struggle. The peripheral blood vessels, near the surface of the body, are contracted and the blood pressure thereby raised to maintain arterial pressure for the emergency needs. This peripheral contraction is the physiological aspect of the popular expression “blanching with fear.” The “cold sweat” occurs preparatory to the warm sweat of actual muscular activity. The body may shiver and the hairs of the body stand on end to conserve heat and protect the organism from the increased threat of cold caused by the contraction of peripheral blood vessels. Breathing is deeper or more rapid in order to insure a plentiful supply of oxygen; this is the “pant” of strong excitement. The pupils of the eyes dilate, permitting a better view of threatening dangers; hence the expression “eyes wide with fear.” The liver releases sugar to provide energy for the struggle. A substance is released into the blood to effect its more rapid clotting, thus protecting the organism from the loss of blood through wounds.

As a part of placing the organism on this emergency footing, digestive activity is suspended, since all available blood is needed for the skeletal muscles. The mouth feels dry, because of a decreasing of the flow of saliva corresponding to the suspending of the flow of gastric juices in the stomach. The smooth muscles of internal genital organs are contracted. There is a tendency toward voiding of bladder and bowels—again recognized in vernacular expressions—which has the obvious utilitarian function of freeing the organism for strenuous activity.

Perception of Danger

The impulses moving to the autonomic nervous system go through the lower and middle brain centers—i.e., the thalamus and diencephalons—the last-named being the “coordinating apparatus” for the sympathetic stimuli involved in anxiety and fear. These lower and middle brain centers are, in turn, interrelated with the cerebral cortex—i.e., the higher brain centers which involves the function of “awareness” and “conscious interpretation” of situations.

When we are afraid, for example, crude sensory stimuli cause an automatic reaction relayed through the hypothalamus to the reticular activating system of the brain. This regulates our alertness and permits us to fight or flee. The thalamus also sends impulses to the cortex for interpretation.

This function of the cerebral cortex, or psychologically speaking, conscious awareness, is of great importance in clinical dealing with anxiety, since the apprehension depends centrally on how the individual interprets potential dangers. The central difference, neurologically speaking, between animals and human beings is that in the latter the cerebral cortex is vastly larger. This is the neurological correlate of the fact that the problems of anxiety in the human organism involve intricate and complex interpretations which the person makes of his danger situation.⁴⁰ For example, Howard Brown experienced profound anxiety whenever he engaged in a minor argument or a bridge game, because any suggestion of competition set off associations connected with his early competition with his sisters which had been a great threat to his close dependency on his mother. (Of course, we do not mean that an individual like Brown is consciously aware of all the determinants, which go into his interpretations; the influence of unconscious factors is more strictly the psychological problem and falls in the next chapter.) Thus a relatively harmless situation, objectively speaking, may become the occasion for great anxiety because of the complex ways, involving past experiences, in which the individual interprets his situation.

The matter of cortical direction and control has important bearings on learning theory and maturation which can only be mentioned here. We have noted that on the infant level (and in animals with their cortexes surgically removed) the stimuli of threat are responded to in an undifferentiated or reflexive way. “As the cortex becomes better developed with the process of growth and maturing,” Grinker and Spiegel hold,

When the individual is confronted with a situation beyond his degree of control (e.g., because of the suddenness of the stimuli or their traumatic nature), he may be thrown back into the state of less differentiated response. Grinker and Spiegel hold that this is equivalent to a “regression” to the infant stage when, neurologically speaking, there was no cortical control over the emotional response.41

Balance in the Autonomic System

It is necessary, now, to expand a point mentioned earlier—namely that the sympathetic and parasympathetic divisions work in opposition to each other. These two branches of the autonomic system are “balanced,” as Cannon suggests, somewhat like extensor and flexor muscles. The sympathetic is stronger in the sense that it is capable of overruling the parasympathetic. In other words, a moderate amount of fear or anger will inhibit digestion, whereas it requires a considerable degree of parasympathetic stimulation (e.g., eating) to overcome a moderate amount of anger or fear.

A slight degree of stimulation of the opposing nervous division, however, may simply serve to “tone up” the activity the organism is engaged in. For example, a low degree of anxiety or fear, amounting to what we may call the feeling of “adventure,” may serve to heighten the pleasure in eating or sexual relations. Folklore tells us that “stolen fruit tastes sweeter,” and it is the common experience of many persons that the element of adventure adds zest to sexual activities. This, of course, may very easily take a neurotic form if carried to any extreme, but it has its normal phase as well. An analogy is seen in the fact that the arm performs better in its extensor movements if there is a slight flexor tension at the same time. This discussion points to our later discussion of the constructive uses of moderate amounts of anxiety and fear.

As regards sexual activity as a form of allaying anxiety, it is significant that the sexual ejaculation and orgasm are mediated by the opposite or sympathetic division; this division innervates the seminal vesicles. This is the neurological aspect of the experience of aggression or rage often felt at the height of sexual activity; Havelock Ellis spoke of the “love-bite.” From a sheer neurological viewpoint, sexual experience serves to allay anxiety only up to the point of orgasm. Though the orgasm does release tension, and in normal situations does not produce anxiety, it may leave the individual who engages in masturbation or other sexual activity for anxiety-allaying purposes more anxious than he or she was to begin with. I do not wish to advance any of these psychoneurological correlations as hard and fast. The neurological functioning is so generally influenced, and so often contravened, by complex psychological factors in the picture that it is necessary to emphasize continually that behavior in a given case can be understood only by viewing that particular organism in the total situation to which it is reacting.

Sympathetic stimulation results in a general state of excitement of the whole organism. This is effected neurologically by the condition that the sympathetic division has a large number of connecting and bridging fibers, resulting in a “diffuse, widespread discharge of nerve impulses through sympathetic channels, as contrasted with the limited, sharply directed discharge to specific organs in the functioning of the cranial and sacral divisions.”42 The sympatin and adrenin (for which the trade name is adrenalin) poured into the blood stream also have this generalized effect on the organism. Cannon speaks of adrenin working in “partnership” with direct sympathetic stimulation. “Since secreted adrenin has a general distribution in the blood stream, the sympathetic division, even if it did not have diffuse effects because of the way its fibers are arranged, could have such effects by the action of adrenin.”⁴³ These facts are the neurological and physiological correlates of the experience everyone has observed in himself—that anger, fear, and anxiety are felt as generalized, “over-all” emotions.

Since sympathetic stimulation leads simply to a general state of excitement in the organism, it is impossible to predict on the basis of neurophysiological data alone whether the emotion will take the form of fear, anxiety, anger, or hostility, or something else like challenge or sense of adventure. Except in the reflexive reactions, like the startle pattern, the form of the emotion will be determined by the interpretation the organism makes of the threatening situation. Speaking in general terms, if the danger is interpreted to be one which can be mastered by attack, the emotion will be anger. Then the activities of the organism become “fight” rather than “flight,” and certain physical changes follow from that interpretation. In anger, for example, the lids of the eyes are often narrowed to restrict the vision to that part of the environment the organism seeks to attack. If the situation is seen as one which cannot be overcome by assault but can be avoided by flight, the emotion will be fear. Or, if the danger is interpreted as putting the organism in a dilemma of helplessness, the emotion will be anxiety.

Since an emotion consists of a certain relation between the organism and its environment, and since the sympathetic neuro- physiological process are general rather than specific, it is misleading and erroneous to reason either from a so-called specific neurophysiological process to a specific psychological experience like fear or anxiety or vice versa. The intricately balanced neurophysiological apparatus is capable of being employed in an infinite variety of combinations, depending on the needs and patterns of the organism at the time. Likewise, it is erroneous to identify a neurophysiological process with an emotion. An illustration of this latter error is seen when one psychologist writes as follows: “the initiation of antagonism between strong excitatory and strong inhibitory nervous excitation throws the organism into a condition of generalized activity, as if a general nervous irradiation or overflow were in process. . . .” The “generalization of excitation,” he suggests, “should be equated with anxiety.”44 No, I do not believe that anxiety can be equated with any generalization of neurophysiological excitation. Anxiety is not a biochemical entity like steam. It is, rather, a term for a certain relation (e.g., one of helplessness, conflict, etc.) existing between the person and the threatening environment, and the neurophysiological processes follow from this relationship. The error arises from the fallacy which confounds the physiological mechanism through which psyche operates with the fundamental etiology.

VOODOO DEATH

The condition of traumatic fear and anxiety may be so crucial and devastating for the organism that actual death results. The phrase “scared to death” is not an exaggerated description of what happens in some cases. Some years ago, Cannon discussed the phenomenon of “voodoo” death in this light.⁴⁵ He cites several competently observed cases of death occurring to a native who was the victim of some powerful symbolic act held by the tribe to be lethal, such as the magic “bone-pointing” of the witch doctor, or the eating of tabooed food which the community believed would result in death. Observing the Maoris of New Zealand, Tregear, an anthropologist, notes: “I have seen a strong young man die the same day he was tapued [tabooed]; the victims die under it as though their strength ran out like water.”⁴⁶ The native believed, as his community believed, that the taboo carried the power to cause his death. It may well be true, says Cannon, that an “ominous and persistent state of fear can end the life of a man.”⁴⁷

There is like testimony from Africa. Leonard (1906) has written an account of the Lower Niger and its tribes in which he declares:

I have seen more than one hardened old Haussa soldier dying steadily and by inches because he believed himself to be bewitched; no nourishment or medicines that were given to him had the slightest effect either to check the mischief or to improve his condition in any way, and nothing was able to divert him from a fate which he considered inevitable. In the same way, and under very similar conditions, I have seen Kru-men and others die in spite of every effort that was made to save them, simply because they had made up their minds, not (as we thought at the time) to die, but that being in the clutch of malignant demons they were bound to die.⁴⁸

The physiological aspects of “voodoo” death are not difficult to understand. The reported symptoms of natives dying from voodoo bone-pointing or from having eaten tabooed food are in accord with those of an organism experiencing profound and persistent sympathetic-adrenal stimulation. If this stimulation continues without corresponding outlet in action—and the voodoo victim, paralyzed by anxiety since he himself believes he will die, lacks any effective outlet for action—death may result. Cannon found in his experiments with decorticate cats, which lacked the usual moderating effects of the cortex on emotional excitement, that after several hours of “sham rage” the cat expired. “In sham rage, as in wound shock, death can be explained as due to a failure of essential organs to receive a sufficient supply of blood or, specifically, a sufficient supply of oxygen, to maintain their services.”49

There is also evidence of similar occurrences in our own day. Engel tells of “young, healthy soldiers in combat who die without injury and persons trapped in disasters who succumb when they give up hope. . . . In folklore and fact, a person may be said to ‘die of grief.’”⁵⁰ And, we could add, from “voodoo” beliefs and many things other than physical causes.

But the psychological questions in “voodoo” death—such as what interpretation the native makes of his environment that leads him to experience such severe threat—are not so easy to answer, chiefly because we lack data on the subjective experiences of the particular natives involved. Cannon suggests one psychological explanation from William James’s idea of being “cut dead” when the others in one’s “group ignore one.” The primitive victim of taboo is certainly “cut dead,” and he must experience powerful psychological suggestion from the fact that his entire community not only believes he will die but, in fact, behaves toward him as though he were already dead. Dying as the consequence of overwhelming anxiety has likewise been observed in other situations, such as death from shock in war when “neither physical trauma nor any of the known accentuating factors of shock could account for the disastrous condition.”⁵¹

Cannon refers to the work of Mira, a psychiatrist in the Spanish War of 1936–1939, who has reported fatal results in patients afflicted with “malignant anxiety.” Mira observed in these patients signs of anguish and perplexity, accompanied by a permanently rapid pulse, rapid respiration, and other symptoms of excessive sympathetic-adrenal stimulation. Mira mentions as predisposing conditions “a previous liability of the sympathetic system” and “a severe mental shock in conditions of physical exhaustion due to lack of food, fatigue, sleeplessness, etc.”52 Whatever the psychological determinants of such experiences may be, it is clear that a threat to an individual’s existence can be so powerful that the individual possesses no way of coping with the threat short of giving up his existence—namely, dying.

PSYCHOSOMATIC ASPECTS OF ANXIETY

Of more practical interest is the great variety of psychosomatic disorders in which the organism suffering anxiety maintains its struggle for existence but does so by means of a somatic alteration of function.⁵³ All through history it has been recognized in folklore and by observers of human nature that emotions like anxiety and fear have a profound and pervasive interrelationship with the sickness and health of the organism. In recent years the studies in psychosomatic relations have begun the scientific exploration of this area and have yielded new illumination on the dynamics and meaning of fear and anxiety. Psychosomatic symptoms may be viewed as “one of the modes of expression of the emotional life, especially of the unconscious emotional life—one of its languages, like dreams, slips of the tongue, and neurotic behavior.”⁵⁴

Psychosomatic ailments have also been described as arising from inhibited communication, since “input into the organism must be followed by an adequate output. When verbal or motor components of emotional states are partly or completely inhibited the organism tends to substitute other forms of behavior along other output channels.”⁵⁵

There are frequent instances of the overproduction of sugar in the body and ensuing diabetes mellitus in states of anxiety and fear.⁵⁶ It is not surprising that many heart conditions are found accompanying anxiety, since the heart in everyone is directly sensitive to emotional stress. Oswald Bumke holds that most of the “so-called ‘cardiac neuroses’ are nothing but a somatic manifestation of anxiety.”57

Many cases of excessive appetite (bulimia) and consequent obesity accompanying chronic anxiety have been cited. Saul describes one in which the desires to eat “were displacements to food of intense frustrated desires for love. . . .” A number of such patients were found to have been children of overprotective mothers—a childhood situation which often predisposes the child to anxiety. The opposite condition, pathological lack of appetite (anorexia nervosa), has been found in persons in whom there were intense frustrated wishes for love and attention from the other which led to hostility toward the mother and consequent guilt because of the hostile feelings.⁵⁸ The frequent association of diarrhea with anxiety is well known. Saul cites a case from his own analytic practice of a young physician who had been overprotected by his parents as a child. When he graduated from medical school and began to assume his own professional responsibilities, he reacted with anxiety and diarrhea. The diarrhea, remarks Saul, was an expression of his hostility that he should be forced to be independent and responsible. Thus the hostility was a reaction to his anxiety.⁵⁹

Though essential hypertension (elevated blood pressure without evidence of other disease) is generally associated in psychosomatic literature with suppressed rage and hostility, a pattern of anxiety is often found underlying the aggressive affects. Saul cites cases of hypertension to illustrate that the rage and hostility are reactions to situations of conflict on the part of persons who were predisposed to anxiety by excessive dependence on a parent and who were, at the same time, submissive to this parent.⁶⁰ As regards asthma, Saul remarks on the basis of a number of studies, “It appears that the outstanding personality traits of asthmatics are over-anxiety, lack of self-confidence, and a deep seated clinging dependence upon the parents which is often a reaction to parental oversolicitude.” Asthma attacks “bear a relationship to anxiety and to crying (weeping changing to wheezing).”

Frequency of urination has been found accompanying anxiety connected with competitive ambition.⁶¹ Though epilepsy, to the extent that it can be viewed psychosomatically, is generally conceded to represent a mass discharge of repressed hostility, there is evidence in some cases of epilepsy that anxiety attacks and anxiety-provoking feelings (sometimes specifically related to the mother) underlie the hostility.62

An Example: Gastric Functions

That stomach functions and other gastrointestinal activities are closely related to emotional states has been known throughout history. Folk language is rich in expressions like “not being able to stomach” something or being “fed up” with a situation. The neurophysiological aspects of this interrelationship have been pointed out by Pavlov, Cannon, Engel, and others. Psychosomatically, the basic consideration is the close association of gastro-intestinal functions with desires for care, support, and a dependent form of love—all of which are related genetically to being fed by one’s mother. Conflict situations, such as in anxiety, hostility, and resentment, accentuate these receptive needs. But these needs are bound to be frustrated, partly because of their excessive character and partly because in our culture they have to be repressed under the façade of the “he-man” who is characterized by ambition and conscientious striving. In the ulcer patients and in Tom, these receptive needs took the somatic expression, as we shall see, of increased gastric activity, and hence gastric ulcers.

A psychoanalyst, a psychiatrist, and a physician—Mittelmann, Wolff, and Scharf—carried on interviews with thirteen ulcer subjects, during which physiological changes in the patient were recorded. By inducing the person to discuss topics such as marriage or vocation which were known from the case history to be anxiety-creating, the experimenters were able to correlate the accompanying changes in gastroduodenal function. It was discovered that when conflicts involving anxiety and related emotions were touched upon, the patients regularly exhibited accelerated gastric activity. Increased stomach acidity, increased peristaltic motility, and hyperaemia (increased blood supply) were evidenced. These conditions are known to be ulcer-producing. But in interviews in which the doctors reassured the person and allayed his anxiety, gastric activity was restored toward normal and the symptoms were eliminated. It was clearly demonstrated that the gastric activities which cause or exacerbate the ulcer-formation were increased by anxiety and were decreased as security supplanted anxiety in the patient’s affective condition.63

Whether this kind of reaction to anxiety occurs only with persons of a particular psychophysical type, whether it is a general occurrence in our culture or a general human reaction, are still open questions. The thirteen control cases investigated in this study—persons who were healthy and without special anxiety—exhibited in general similar gastric responses to emotional stress but of lesser magnitude and duration than those of the ulcer patients. At any time of basic change in their life pattern—such as divorce, being assigned to a totally new location in one’s employment—people will experience more or less anxiety and stress. Those who have characteristics described above often have stomach symptoms, whereas other types react with a different “language” of symptoms.

The Case of Tom

Equally significant for our present inquiry is Tom, whose gastric activities during periods of emotional stress could be observed through a fistula in his stomach. Tom was studied intensively by S. G. Wolf and H. G. Wolff over a period of seven months.⁶⁴ Now a fifty-seven-year-old man of Irish stock, Tom had drunk some boiling hot chowder as a boy of nine which caused his esophagus to close. Following this accident, an enterprising physician had made an aperture surgically through his abdomen and into his stomach. For almost fifty years he had fed himself successfully by means of a funnel through this fistula. Since Tom was an emotionally labile individual who ran through the gamut of fear, anxiety, sadness, anger, and resentment, Wolf and Wolff had abundant opportunity to observe through the aperture the interrelation of these emotions with Tom’s gastric functions.

In periods of fear, Tom’s gastric activity was sharply decreased:

Sudden fright occurred one morning during a control period of accelerated gastric function, when an irate doctor, a member of the staff, suddenly entered the room, began hastily opening drawers, looking on shelves, and swearing to himself. He was looking for protocols to which he attached great importance. Our subject, who tidies up the laboratory, had mislaid them the previous afternoon, and he was fearful of detection and of losing his precious job. He remained silent and motionless and his face became pallid. The mucous membrane of his stomach also blanched from a level of 90 to 20 and remained so for five minutes until the doctor had located the objects of his search and left the room. Then gastric mucosa gradually resumed its former color.65

Other affects associated with such hypofunctioning of the stomach were sadness, discouragement, and self-reproach. Tom and his wife had made tentative arrangements to move into a new apartment, a change they very much desired. But mainly because of their own negligence, the landlord leased the desired apartment to someone else. The morning after this discovery, Tom was downcast, uncommunicative, and sad. He felt defeated and had no desire to fight back; his dominant mood was self-reproach. That morning his gastric activity was markedly decreased.

But in periods of anxiety, Tom, like the ulcer patients, showed accelerated gastric activity:

The most marked alterations in gastric functions which were encountered were associated with anxiety provoked by our failure to inform the subject how long he might expect an income from the laboratory. He had been receiving government aid prior to his employment with us, and the rise in his family’s standard of living since his new job meant a great deal to him. The subject of how long his job would last had come up in a discussion between his wife and himself the previous evening. He decided to inquire about it the next morning. Both he and his wife were so anxious about the answer, however, that neither of them slept at all. The next morning the values for vascularity and acidity were the highest encountered in any of the studies. . . .66

This illustrates a pattern which was regularly found with Tom. “Anxiety and the complex conflicting feelings found associated with it were regularly accompanied by hyperaemia, hypersecretion, and hypermotility of the stomach.”⁶⁷

In experiences of hostility and resentment Tom likewise exhibited increased stomach activity. Two different instances are cited when he felt aspersions had been cast upon his ability and conscientiousness by members of the hospital staff. In these situations, his gastric secretions were greatly increased. During one of these periods when Tom was diverted from his hostile feelings by conversation, the overactivity subsided, but it rose afterward when he again lapsed into brooding over his wounds.

Though Tom did not have peptic ulcers, the pattern of his personality was in many ways similar to that of the patients in the prior study. As a child he had been very dependent on his mother, though apparently he did not experience much emotional warmth in his relation with her. “He had a fear and a love for his mother,” write Wolf and Wolff, “such as he had for the Lord.”⁶⁸ He was seized with panic when she died, after which he became dependent on his sister. A like ambivalence was shown in his relation to the doctors: he exhibited considerable dependence, and he frequently reacted with hostility toward them when this dependence was frustrated. He placed great emphasis on being the “strong man,” the successful provider for his family. “If I couldn’t support my family,” he remarked, “I’d as soon jump off the end of the dock.” This sentence is a vivid revelation of how profound a psychological value was at stake in Tom’s façade of the strong, responsible man. He could not release his emotions in crying, since there was the need to keep a firm appearance of strength. This personality pattern, characterized by affective dependence covered over by the need to appear strong, presumably bears a decisive relationship to the fact that Tom reacted to anxiety and hostility with acceleration of his gastric functions.

This accelerated gastric activity as a response to conflict situations may be viewed in two ways. First, it may be a somatic expression of the psychologically repressed needs of the organism to be cared for. The person endeavors to resolve anxiety and hostility and gain security through eating.69 Second, it may represent a form of aggression and hostility toward those who deny the comfort and solace desired. Eating as a form of aggression is common in animal life—e.g., “eating up” the prey.⁷⁰

These studies demonstrate that it is an oversimplification, and an inaccuracy, to relegate anxiety solely to automatic nervous activity. The neurological functions in anxiety cannot be understood except as we see them in the light of the needs and purposes of the organism confronting its threat. “It is not possible with the evidence at hand,” remark Wolf and Wolff, “to attribute the pattern of bodily changes observed solely to vagus or sympathetic activity. It seems more profitable to consider gastric changes which accompany emotional disturbances as part of a general bodily reaction pattern.”⁷¹ Mittelmann, Wolff, and Scharf state the same thing in a different way: “The question as to which parts of the nervous system will dominate under stress is of secondary importance; of primary importance is the interplay or combination which will best serve the needs of the animal in meeting a given life situation.”⁷²

CULTURE AND THE MEANING OF DISEASE

Having a disease is one way of resolving a conflict situation. Disease is a method of shrinking one’s world so that, with lessened responsibilities and concerns, the person has a better chance of coping successfully. Health, on the contrary, is a freeing of the organism to realize its capacities.

George Engel puts this pithily when he writes that “health and disease may be seen as phases of life.”⁷³ He adds, “thinking of disease as an entity separate from oneself has a great appeal to the human mind.” In other words, I believe that people utilize disease in the same way older generations used the devil—as an object on which to project their hated experiences in order to avoid having to take responsibility for them. But beyond giving a temporary sense of freedom from guilt feeling, these delusions do not help. Health and disease are part and parcel of our continuous process throughout life of making ourselves adequate to our world and our world adequate to ourselves.

When a person experiences a conflict situation which continues and which cannot be resolved on the level of conscious awareness, somatic symptoms of various types typically appear. These are a kind of “body language.” One type is the hysterical conversion symptom, such as hysterical blindness in situations of terror (the person can’t bear to see it), or the hysterical paralysis of certain muscles. Having a fairly direct psychological etiology, hysterical symptoms may involve any part of the neuromuscular apparatus. In contrast, the psychosomatic type of symptom, in its limited sense, is a dysfunction mediated by the autonomic nervous system. But from a broader perspective anxiety may be involved in any illness whether or not it takes specifically hysterical or psychosomatic forms. An example of this third type is the infectious diseases. The susceptibility of the organism to such diseases is influenced by anxiety as well as other affects. It is possible that deterioration diseases like tuberculosis may be associated with repressed discouragement following chronic conflict situations which have not been soluble by the person on the level of direct awareness or on the specifically psychosomatic level.74

What determines whether a person will be able to resolve his conflict in conscious awareness or will have to manifest psychosomatic or hysterical symptoms or a different form of disease? This complicated question can be answered only by a thorough study of the person concerned. Certainly the answers would involve constitutional factors, the person’s experiences in infancy as well as other past experiences, the nature and intensity of the immediate threat, and the cultural situation. In every case, however, the organism is to be viewed as endeavoring to resolve a conflict situation, a conflict characterized in its subjective aspect by anxiety and in its objective aspect by illness. The symptom—when it is present—is one expression of the organism’s endeavor at resolution of the conflict.

It will be recalled that the control cases (patients without ulcers) studied by Mittelmann, Wolff, and Scharf exhibited the same hyper-function of gastric activities in periods of emotional conflict, though in lesser degree than the ulcer patients. Tom, also not an ulcer patient, exhibited the same reaction. These data would point to a hypothesis that this psychosomatic reaction pattern is not only a matter of individual type but occurs with some frequency in Western culture. Whether there is a specifically American cultural factor present is also an interesting question. In discussing the relation between the repressed needs for dependency and gastro-intestinal symptoms frequently found in their work with soldiers in conflict situations, Grinker and Spiegel remark on the accentuated desire to drink milk on the part of these soldiers. The “particular food so intensely desired is that associated with the earliest signs of maternal affection and care,” and they add that “drinking milk is a cultural trait of most Americans.”75 There is presumptive evidence for the hypothesis that the emphasis upon individual competition in Western culture took root with special influence in the American branch of that culture.

Since the individual lives and moves and has his being in a given culture, with his own reaction patterns having been formed in terms of that culture and with the conflict situation confronting him likewise given in terms of that culture, it is readily understandable that cultural factors should be interrelated with psychosomatic as well as other behavior disorders. It would seem that the affects, biological needs, and forms of behavior most repressed in a given culture are the ones most likely to give rise to symptoms. In the Victorian period Freud found the repression of sex central in symptom-formation. In American culture in the forties, as Horney held, the repression of hostility was more common than the repression of sex and thus could have been expected to be frequently related to psychosomatic symptoms. It would certainly not be gainsaid that our competitive culture generates considerable hostility.

As shifts in cultural emphasis occur, corresponding shifts in the incidence of various diseases likewise occur. Examples are the rise in incidence of cardiovascular disturbances and the decline of hysterical cases in World War II from World War I. Another significant point is that in our culture it is considered much more acceptable to have an organic illness than an emotional or mental disorder; this would influence the fact that anxiety and other emotional stresses in our culture so often take a somatic form. In short, the culture conditions the way a person tries to resolve his anxiety, and specifically what symptoms he may employ.

THE PSYCHOSOMATIC studies throw light upon the distinction between, and the relative importance of, the various emotions. First, take the distinction between anxiety and fear. In some treatments of anxiety and fear there has been a reluctance to make a distinction between these two affects, since it was assumed that they had the same neurophysiological base.76 But when the person is viewed as a functioning unit in a life situation, very important distinctions between anxiety and fear surely appear. In the instance of Tom, we recall that his neuropsychological behavior was radically different in fear from what it was in anxiety. His affects which came with a withdrawal without inclination to struggle—such as fear, sadness, self-reproach—were accompanied by a suspension of gastric activity. But in situations in which Tom was engaged in conflict and struggle—when the affect was anxiety, hostility, or resentment—the gastric functions were employed overtime. This is the opposite to what would be expected on the basis of the conventional analysis of neurophysiological processes (i.e., anxiety identified with sympathetic activity). I therefore submit that the distinction between fear and anxiety must be made if we are to understand the organism as a behaving unit endeavoring to adjust to a given life situation. How this distinction may be made I propose to summarize in Chapter 7 below. One added observation, however, may be offered at this point: Fear ordinarily does not lead to illness if the organism can flee successfully. If the individual cannot flee, but is forced to remain in a conflict situation which cannot be resolved, fear may turn into anxiety and psychosomatic changes may then accompany the anxiety.

A distinction is to be drawn between anxiety and the aggressive affects, such as anger and hostility. Though repressed rage and hostility are specific etiological factors in certain psychosomatic disorders, it is significant that rage and hostility can frequently be discovered on more thorough analysis of the patient to be reactions to an underlying anxiety. (Cf. the above discussion of hypertension and epilepsy.) The rationale of this situation can be suggested as follows. Anger does not lead to illness unless it cannot be expressed in fighting or some other direct form. When it must be repressed—because of the dangers to the organism if the aggression were carried out in action—psychosomatic symptoms like hypertension may appear. But if underlying anxiety were not present, the hostility would not have to be repressed in the first place. This accords with our emphasis that the basic picture is that of the organism in a conflict situation, the conflict being represented on the psychic side by anxiety. There is ground, then, for Felix Deutsch’s statement that “every disease is an anxiety disease,” if we mean by this that anxiety is the psychic component of every disease.

THE MOST intricate problem in the relation of anxiety to somatic changes is the meaning of the organ symptom. Somatic symptoms may be approached through two questions, both of which are necessary for an understanding of why the anxiety takes a somatic form. First, how does the organ symptom function in the organism’s struggle to cope with the threatening situation, or, to put it somewhat figuratively, what is the organism trying to do via the symptom? Second, what are the intrapsychic mechanisms by which this interrelationship of anxiety and symptom takes place?

Several pertinent clinical observations throw light upon these questions. There tends to be an inverse relation between the individual’s capacity to tolerate conscious anxiety and the appearance of psychosomatic symptoms. Whereas conscious anxiety and fears are aggravating factors, there is evidence that the anxiety and fears and conflicts which have been excluded from consciousness are of the greatest significance—that is, those most likely to be etiological in illness. The more overt the anxiety and the greater its manifestation in neurotic behavior, the less severe the organic disease. While the person is endeavoring to master the conflict consciously he may be experiencing considerable conscious anxiety, but he is still confronting the threat through direct awareness. “In general it may be stated that the existence of anxiety implies lack of serious disintegration. . . . It may be compared with the prognostic significance of fever.”77 But when the conscious struggle can no longer be tolerated, either because of its increasing severity or because of its lack of success, symptomatic changes in the organism take place. These relieve the strain of the conflict and make a quasi- or pseudo-adjustment possible when the conflict cannot actually be solved. Thus it may be said that the symptoms are often ways of containing the anxiety; they are the anxiety in structuralized form. Freud rightly remarks about psychological symptoms: “The symptom is bound anxiety,” or, in other words, anxiety which has been crystallized into an ulcer or heart palpitations or some other symptom.

In the case of Brown (page 239), we observed that the progression taken by anxiety states was roughly as follows: First he reported an organ symptom, such as momentary spells of dizziness, about which he had no conscious anxiety except the discomfort of the symptom itself. Several days subsequently anxiety dreams began to appear. Later came conscious anxiety, with considerable dependence and many demands upon the therapist. As the anxiety came more into consciousness, he was more severely discomforted but the organ symptom disappeared.

It is extremely interesting that when people become ill in organic ways, anxiety tends to disappear. When, in the midst of this study, I became ill with tuberculosis at a time when drugs were not available for its treatment, I observed a curious phenomenon in patients around me with the same disease. When a patient became aware that he was seriously ill, a considerable amount of anxiety associated with his behavior patterns before the illness seemed to disappear. Conscious anxiety often reappeared as the patient neared the state of physical health when he could return to work and responsibilities. One could remark superficially that the disease served to relieve him from responsibilities, afforded him protection, etc. But the phenomenon seems to be more profound. Assuming that succumbing to the disease in the first place was partly the result of chronic unsolved conflicts, the disease itself may represent one way of shrinking the scope of the conflicts to an area in which they might be solved. This may throw light on the clinically observed phenomenon that when the disease appears, there is a lessened awareness of anxiety, and when the disease is overcome, anxiety may reappear.78

The problem of the interchange of symptoms and anxiety is explained by writers using Freud’s first anxiety hypothesis in terms of the libido theory. F. Deutsch, for example, holds that the organ symptom results from dammed-up libido. If libido cannot be discharged normally, it takes the form of anxiety, and this anxiety may discharge itself in the form of a somatic symptom. Hence, “psychologically speaking, to remain or to become organically healthy the individual must either invest his libido or get rid of his anxiety.”79 The viewpoint I take here is that anxiety occurs not because the individual is a “carrier of libido” but because he is confronted with a threatening situation with which he cannot deal and which therefore throws him into a state of helplessness and inner conflict. It may well be that the presence of the libido—e.g., sexual drives—pushes the person into the conflict; but it is important to remember that the problem is the conflict and not the sex. Thus our conclusion is that the purpose of the symptom is not to protect the organism from dammed-up libido, but rather from the anxiety-creating situation.

I SUGGEST the following rough schema as a framework which brings together the points of this chapter. First, the organism interprets the reality situation which it confronts in terms of symbols and meanings. Second, these produce attitudes toward the reality situation. And third, the attitudes, in turn, involved the various emotions (and the neurophysiological and hormonal components thereof) as preparations for activity in meeting the reality situation. I have already emphasized the importance of symbols and meanings by which the human being interprets situations as anxiety-creating. We noted at the outset of this chapter Adolph Meyer’s emphasis on “the integrating functions” and “the use of symbols as tools.” It is these to which neurology and physiology are subordinated.

We have also noted that these interpretations occur chiefly in the cortex, that part of the human being’s neurological apparatus which grossly distinguishes him from animals. Cannon’s work on sympathetic activity, which is the basis for most discussions in which the neurophysiological aspects of anxiety are identified with sympathetic activity, was done chiefly with animals. Thus one cannot reason from these studies to human behavior without making clear the qualification that the animal reactions represent a parallel to human reactions only when certain aspects of the human being are isolated out of this total context.⁸⁰

It is possible, then, to avoid three common errors in psychology. The first is the error, on one side, of identifying an emotion with a neurophysiological process. The second is the error in the middle of “neurologizing tautology” (e.g., merely describing sympathetic activity as the neurophysiological aspect of anxiety). And the third is the error on the other side of assuming a simple dichotomy between neurophysiological and psychological processes.