The subjective dimension of anxiety

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[In: J.A. den Boer, E. Murphy & H.G.M. Westenberg (Eds.), Clinical management of anxiety; theory and practical applications. New York: Marcel Dekker Inc., 43-62. (1997)]

Professor Gerrit Glas, M.D., Ph.D.

Department of Psychiatry

Academic Hospital Utrecht

Heidelberglaan 100

3584 CX Utrecht

The Netherlands February 1996


I. Introduction 1
II. Main directions in the interpretation of anxiety 2
III. The feeling of anxiety 4
IV. Descriptive psychopathology:

object-bound fear and objectless anxiety 8

V. Descriptive psychopathology: other distinctions 10
VI. Anxiety and psychosis 16
VII. The cognitive component 17
VIII. Closing remarks 19
Literature 22

I. Introduction

Subjective feelings are commonly considered as belonging to the core of emotion. When asked to define a particular emotion, people in most cases refer to mental states like feelings, sensations, sentiments, or inclinations. However, as soon as these subjective feeling states are subjected to scientific scrutiny, they seem to resist further examination. What appears to be crucial for the patient, i.e. the subjective experience of emotion, seems to withdraw and even to dissolve as soon as one tries to adjust it to the frame of scientific method and experimental design.

The study of emotion has to a large extent been concerned with physiology, motor behavior, verbal expression and cognition (Frijda 1986). These phenomena are, indeed, strongly associated with affective experience, but do not have affective quality in themselves. Bodily symptoms and cognitions may contribute to the disturbing and compelling character of feelings and emotions. But they are not as such disturbing and compelling.

This chapter on the subjective dimension of anxiety is written against the background of this gap between the ordinary and the scientific understanding of emotion. Anxiety is a major example of this gap. In the scientific literature relatively little has been written about anxiety as a feeling state (cf. Landis 1964; Baker 1989). Even less attention has been paid to the varieties of the experience of anxiety. Panic, fright, terror, dread, fear, worry and apprehension - these terms give only a weak impression of the immense diversity of the subjective experience of anxiety. Clinicians, of course, are familiar with this diversity. Their job is to unravel the meaning of the many images, metaphors and non-verbal expressions patients use in order to reveal what is going on in their minds. From a scientific point of view these communications may be called idiosyncratic. But, when listened to carefully in a clinical context, these idiosyncrasies often appear to be meaningful, for instance when seen from a biographical perspective. The history of anxiety disorder is a learning history, with often highly specific triggers and sustaining factors.

The study of the subjective dimension of anxiety is not only haunted by the enormous diversity in the experience of anxiety. There is another factor which contributes to the gap between the ordinary and the scientific understanding of anxiety. This factor seems to be related to something in the feeling of anxiety itself, i.e., its non-transparency. Freud already alluded to this in one of his early writings, when he noted that in anxiety neurosis the affect of anxiety "proves to be non-reducible in the psychological analysis" (Freud 1895, 96-97, 107). According to Freud, the fears of anxiety neurosis differ from phobic anxieties in that they can not be explained by the mechanism of substitution. Phobic anxiety becomes transparent by referring to repressed memories and representations. In the Freudian view, the phobic situation serves as a substitute for the object or situation which was feared initially. In anxiety neurosis, however, the feeling of anxiety can not be analyzed in this way. It is unanalyzable in a psychological sense. Freud explains this by referring to biology: the anxiety of anxiety neurosis is the mental analogon of a somatic quantity of (libidinal) energy which is processed inadequately and conducted to the wrong neural paths. This biological view indeed shows some resemblance with some of the recent opinions about panic disorder.

In this chapter I will take the almost impenetrable and non-reducible feeling of anxiety as a paradigm-case. This paradigm-case will serve as a guide in our examination of the subjective dimension of anxiety.

First, I will give a brief summary of three main directions in the interpretation of anxiety (2). Then, I will comment on a brief excerpt of a conversation with a patient with panic disorder with agoraphobia (3). After this I will discuss some of the distinctions which are drawn in descriptive psychopathology (4 and 5); anxiety in the context of psychosis (6); and the research on the so-called ideational or cognitive component of fear and anxiety (7).

II. Main directions in the interpretation of anxiety
From a historical point of view, three lines in the interpretation of pathological anxiety may be discerned.

First and foremost, there is the medical tradition, which from Antiquity until now dominates the theoretical literature on anxiety and which, at least in the last 150 years, tends to favor a biological approach. According to this tradition anxiety is rooted in a dysbalance in a physiological and/or neuroendocrine equilibrium. Subjective feelings are the epiphenomena of this dysbalance. From a medical viewpoint, their relevance is limited. At best these feelings may provide a clue for the identification of a particular, dysfunctioning biological sub-system.

Secondly, the concept of anxiety as an inner threat must be distinguished. Well-known as it is in our days, one can hardly imagine the revolutionary significance of this concept as it emerged in the late 19th and early 20th century psychoanalytic literature. Contemporary defenders of this view can be found in psychotherapeutic circles and in some branches of cognitive psychology. They do not deny that fear and anxiety may be related to some external danger. However, in addition to this they maintain that in human anxiety it is often inner threat which is of central importance. The patient is disturbed by the inner danger of being out of control and vulnerable, physically or socially.

Finally, the existential concept of anxiety is worth mentioning, a concept which dates from the 17th and 19th century (Pascal and Kierkegaard, respectively), and which via existential phenomenology inspires the work of existential psychotherapists and anthropological psychiatrists in our age. According to this concept the feeling of anxiety must be seen as the mental expression of a frustrated urge for self-realization or as the expression of the imminent annihilation of personal identity and psychic integrity.

These three traditions are not at all on their way to converge. Contemporary psychiatry gives the appearance that medical tradition is still enlarging its domain, at the expense of the psychoanalytic and anthropological traditions. It should be noted, however, that psychiatry as a medical discipline has incorporated elements of the second tradition, for instance the idea of anxiety as a signal of inner threat and some of the contributions of cognitive psychology. This chapter attempts to show that integration of some of the viewpoints of the anthropological tradition may be of some relevance.

III. The feeling of anxiety

Let us proceed with a fragment of an audiotaped interview with a 35 year old, solitary living, male patient, who suffers from panic disorder with agoraphobia for more than fifteen years.
P(atient): "It is a kind of empty feeling. An emptiness ... here (points with his finger to his stomach) ... an empty space in which something is scraping. Yet there is nothing in there."

I(nterviewer): "Is it a feeling in your stomach?"

P.: "Yes ... yes ... it is here (points again and smiles)."

I.: "You smile?"

P.: "Yes, it is so weird. That such a thing embitters one's life! But it makes me so sick ... it is so strong ... I can not resist it."

I.: "What does it make so nasty to have that feeling?"

P.: "It is as if something is going to happen ... something very serious and threatening, I don't know what. It disturbs me. It is such a strong feeling, I can't ignore it ... I must give in. If I don't, it becomes even worse. It dominates me. My mind looses control."
There are several remarkable points in what the patient says. Most remarkable, however, perhaps what the patient does not say, i.e., that he suffers from massive fear and that he is frightened by his bodily sensations. The patient clearly suffers from an anxiety disorder. But terms like fear, panic, terror, or anxiety are not even mentioned. The patient seems to omit what is most obvious. Why is this?

From a practical point of view, one might recall the well-established fact that patients with panic disorder tend to attribute their distress to physical disease. These patients populate the consulting rooms of general practitioners, cardiologists, gastro-enterologists, endocrinologists, and gynecologists. They feel their anxiety, but do not mention it, or consider it as secondary to some physical abnormality (Markowitz et al. 1989).

But again, why is this? Why do patients with anxiety disorders talk exhaustively about all kinds of physical complaints when it is anxiety which is the ultimate source of their suffer?

The interview suggests that shame might be part of the answer. The patient smiles, he seems embarrassed by the futility of his complaints. He realizes that whatever he might say, it always will sound implausible and bizarre: "That such a thing embitters one's life!". No matter how eloquent he might be, his verbalizations will never be adequate in revealing what is going on, that he has no choice, and that his abdominal sensations do not give him the opportunity to regain his calm. And that, indeed, may be shameful to admit.

But shame is only part of the answer. The interview illustrates this. Soon after the shameful moment of self-observation the patient vehemently assures that he can not resist his abdominal sensations. It is a very strong feeling, it makes him feel sick. The vehemence of these assertions might be interpreted as an attempt to master the shame. But it also suggests that there may be an other reason for the absence of words like anxiety and fear. The patient seems to be caught in a paradoxical situation, i.e., a situation in which, on the one hand, there is no other reality than these paralyzing sensations and in which, on the other hand, little more seems to be left than admitting that these sensations are pointless. When asked for, there is simply nothing to be explicit about or to be untangled. There are just these devastating sensations - sensations without an object and without a cause; sensations which can hardly be communicated and which lock the patient in his Cartesian private world.

Sometimes, this discussion is short-circuited by saying that fear and anxiety, as emotions, are to be separated from bodily sensations. According to a popular   Jamesian - view, emotions like fear and anxiety should be seen as caused by bodily sensations (James 1884). Others hold the opposite   Cannonian - view. They consider bodily sensations as the peripheral consequences of an underlying central state of anxiety (Cannon 1927). Whatever the evidence of any of those views may be, both build forth on common ground, i.e., that of a conceptual and/or experiential distinction between bodily sensation and emotion. This distinction, however, should not blind us to the fact that bodily sensations may have emotional quality themselves. The patient is not only frightened because of his bodily sensations, which is surely the case. His anxiety also consists of the specific, vital quality of these sensations. Interpretations which are based on a strong distinction between sensation and emotion, tend to overlook that the experience of bodily sensation itself often involves more than simply a `cold' perception that something is happening in the body. The interview suggests that, in case of anxiety disorder, there is no such `cold' perception or distant self-observation.

What appears to be of central importance in the patient's experience of his bodily sensation, is the ineffectiveness of his attempts to regain control, the central feeling of weakness and powerlessness, and, ultimately, the feeling of unconnectedness and the ensuing awareness of being totally isolated. All these elements seem to be implied in - and not secondary to - the experience of bodily sensation.

If this is true, the reason for the absence of terms like anxiety and fear can be construed in an another way. Then, it could be maintained

(1) that the feeling of anxiety, in this case, precisely consists of this ineffectiveness, powerlessness, and sense of isolation;

(2) that the patient's difficulty in verbalizing what is going on, should be taken as one of the expressions of this core feeling of powerlessness and lack of control; and

(3) that terms like fear and anxiety, when used in an ordinary sense, do not entail these connotations, and, for that reason, do often not occur in the vocabulary of the patient.

Of course, these statements are somewhat one-sided. Speech-samples show that in fact many anxiety disorder patients do use terms like fear, anxiety and panic. In many cases there is clearly something they are afraid of: loosing control of one's thoughts or actions, having a heart attack, suffocation, the expectation of rejection and/or abandonment, future disaster and - also - bodily sensations. But this should not lead us to deny that there is an experience of anxiety which is still more elementary than these fears. The reason why this experience is often not verbalized in terms of anxiety, could be that in ordinary language fear and anxiety are usually associated with a danger which can be identified. In cases of pathological anxiety, however, there are often no candidates which could serve as such a fear-provoking object, unlike the experience of anxiety itself or one of its consequences (loosing control, suffocation, and so forth). This is why expressions like fear of fear and fear of anxiety have been introduced into clinical and scientific language. The experience of anxiety is often a double-layered one: behind the fear of a more or less concrete danger one can find a vital, sensation-like experience, which is much more difficult to put into words because it seems to lack a definable object. It is often this anxiety which is the object of the patient's fears. Compare for instance the account of an anonymous surgeon:

"It is as difficult to describe to others what an acute anxiety state feels like as to convey to the inexperienced the feeling of falling in love. Perhaps the most characteristic impression is the constant state of causeless and apparently meaningless alarm. You feel as if you were on the battlefield or had stumbled against a wild animal in the dark, and all the time you are conversing with your fellows in normal peaceful surroundings and performing duties you have done for years. With this your head feels vague and immense and stuffed with cottonwool; it is difficult, and trying, to concentrate; and, most frightening of all, the quality of your sensory appreciation of the universe undergoes an essential change" (Lancet 1952, 83-84; cited by Landis 1964, 241-242).
What has been said here so eloquently, in many cases will remain implicit in the experience of anxiety itself. Anxiety is not primarily the consciousness of being out of control and unconnected. It is rather the way in which these powerlessness and unconnectedness are embodied and lived.

To anticipate on what will be said below, anxiety is first of all a vital and elementary experience. Its definition should not be reduced to the enumeration of its cognitive contents. Expectations, evaluations, images, and representations, they all may be part of the experience of anxiety. But anxiety can not be equated with these products of consciousness. For, many people have these anxiety-provoking expectations, evaluations, images and representations, without really becoming anxious.

IV. Descriptive psychopathology: object-bound fear and objectless anxiety
To be sure, what has been said until now comes very close to an old and well-known distinction in descriptive psychopathology, i.e., the distinction between object-bound fear and objectless anxiety. It is interesting to see how this distinction has been dealt with in the various traditions in the interpretation of anxiety.

Neurobiologically minded investigators tend to a view in which objectless anxiety is seen as the subjective correlate of an archaic and purely organic state, whereas object-bound fear is regarded as a product of the activity of brain areas mediating higher cognitive processes. Gorman et al. (1989) for instance suggest that the distinctions in the experience of anxiety correlate with different degrees of cognitive complexity. Cognitive complexity in its turn is related to neuroanatomical location. Referring to MacLean's concept of a tripartite organization of the brain they hypothesize that panic is mediated by the brain stem, free-floating anxiety by limbic activity and anticipatory anxiety by frontal processes.

Psychoanalytic investigators tend to a similar three-fold distinction, by discerning between traumatic or `automatic' anxiety, corresponding to a state of biological helplessness at birth, free-floating or signal anxiety, which serves as a warning signal of this traumatic anxiety, and anticipatory anxiety which is associated with a particular object representing a real or imaginary threat. Interestingly, however, this division is not interpreted as merely a reflection of differences in cognitive complexity, but as a challenge to uncover what is non-transparent and objectless at first sight. It is true that Freud never completely abandoned the idea of a purely organically based form of anxiety (as the basis of actual or anxiety neurosis). But in later versions of his theory of neurosis Freud developed the notion of anxiety as a warning signal. Objectless, or free-floating, anxiety is then viewed as signal, which is produced by the ego and which serves as a warning of an unconscious conflict. The cognitive impenetrable nature of this anxiety, rather than being a reflection of a more primitive neuronal state, serves as an incentive to lay bare those unconscious inner conflicts which are supposed to generate this anxiety.

Behavioral-oriented scientists traditionally have not been as interested in the phenomenal qualities of the experience of anxiety as they were in its antecedents and behavioral consequences. It is only after the rise of cognitive science that this picture has altered. We will discuss some of the results of the new research in section 7.

Finally, mention should be made of the continental, anthropological tradition. Building forth on the work of the philosopher Sören Kierkegaard (1844), psychopathologists like Jaspers (1913), Kronfeld (1935), Goldstein (1929) and Störring (1934) held the view that behind all kinds of fear which are associated with concrete objects like height, blood, crowds, small rooms, and the like, there is a more fundamental anxiety which lacks such a definable object and which does not even need to be conscious. Goldstein, for instance, exposed First World War victims with organic brain damage to complex cognitive tasks. He observed that his patients displayed overly controlling and catastrophic reactions. In spite of their massive physiological and psychomotor symptoms, the patients were often unaware of their anxiety. Because the symptoms coincided with failure in the performance of cognitive tasks, Goldstein interpreted both this failure and the other symptoms as immediate manifestations of anxiety. According to this view, anxiety itself is a kind of failure, rather than a secondary reaction to failure. The failure of Goldstein's patients resembles the insufficiency and powerlessness of the patient in the interview. This insufficiency and powerlessness represents a tendency which is opposed to the urge of self-preservation. This means, ultimately, that anxiety transcends the domain of emotions. Anthropological psychiatrists consider anxiety as the expression of a fundamental and universal disintegrating tendency in human life.

V. Descriptive psychopathology: other distinctions

We will now explore some other distinctions which are drawn with respect to the subjective experience of anxiety. Let us begin with the well-known distinction between phobic fear, obsessive-compulsive fear, and panic.

Phobic anxiety consists of an unreasonable and inappropriate fear, which is associated with situations of a particular type and which often leads to the avoidance of that situation. The family of phobias is usually divided into three groups: agoraphobia, social phobia and specific phobias. Specific phobias in their turn are sub-divided into phobias which are related to animals, physical harm (blood, injections, bodily injury), natural environment (heights, storms, water) and other specific situations (airplanes, elevators, closed spaces, and situations that may lead to contracting an illness).

The term agoraphobia is somewhat unfortunate because of its association with fear of streets. Westphal (1872), however, to whom we owe the term agoraphobia in its technical sense, already recognized that his patients were not afraid of streets and squares as such. Their's was rather a fear of anxiety itself, an anxiety which only later may be linked to situations of a particular type. DSM-IV specifies these situations as "places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a panic attack or panic-like symptoms" (APA 1994, 393). The `panic-like symptoms' in this definition refer to any of the 13 symptoms listed for panic attacks or to other symptoms that may be incapacitating or embarrassing (e.g. loss of bladder control). These definitions not only illustrate DSM-IV's emphasis on the close relation between panic and agoraphobia, but also the irrelevance of distinguishing between internal and external stimuli. According to some older views phobias are characterized by fear of external stimuli. However, recent research has suggested that fear of interoceptive sensations may be a central element in many cases of panic disorder with or without agoraphobia (Van den Hout et al. 1987; Chambless & Gracely 1989). The concept of disease phobia is too narrow to encompass all these cases. Agoraphobics do not avoid their bodily symptoms, but the panic and helplessness which ensue from being exposed to these symptoms. In the same vein, hypochondriasis and panic disorder can be differentiated on the basis of the nature of the fear and the behaviors which accompany this fear. Hypochondriasis is exclusively related to the fear of having (or the idea that one has) a serious disease. This fear may have an obsessional quality and often leads to medical `shopping'. Hypochondriacs often show a "frustrating combination of demanding neediness and help rejecting refractoriness to treatment" (Barsky et al. 1994).

Social phobia is characterized by the DSM-IV as a "marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by other others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing" (APA 1994, 416). Social phobics and agoraphobics both fear their symptoms of anxiety. The differentiation between the two conditions is not based on the nature of these symptoms, but primarily on the patient's assessment of the nature and the reason of the fear: possible scrutiny and/or humiliation in social phobia versus no escape/no help in agoraphobia. It must be noted, however, that this distinction sometimes does not suffice (Mannuzza et al. 1990). There are for instance patients who feel both humiliated by and helpless when confronted with their symptoms. DSM-IV rightly adds that in these cases the role of the companion may be useful in differentiating between social phobia and agoraphobia. Agoraphobics typically prefer to be companied by a person who is trusted, whereas social phobics feel scrutinized irrespective of whether they have a companion or not. It has also been suggested that a distinction between primary and secondary social phobia might be useful here (Liebowitz et al. 1985; Perugi et al. 1990). Secondary social phobia would then occur in the setting of panic disorder and refer to fear of embarrassment or humiliation were the patient to have a panic attack in front of others. Primary social phobia would then be related to immediate social concerns and not to the embarrassment which secondarily results from the exhibit of symptoms of panic. As indicated above, DSM-IV has not gone so far, by including anxiety symptoms as a potential object of social phobic fear.

Obsessions are "persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress" (APA 1994, 418). Compulsions are "repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) the goal of which is to prevent or reduce anxiety or distress" (ibidem). They attempt "to ignore or suppress [their] thoughts or impulses or to neutralize them with some other thought or action" (ibidem). In short, phobics avoid and obsessives try to undo. Semantic clarity, however, also here does not preclude some overlap between phobic and obsessive fears. Avoidance and undoing may come very close to each other. Fear of dirt or contamination with faeces or sperm may provoke for instance both excessive washing rituals and avoidance of situations in which contamination can not be undone (sexual intercourse; avoidance of rooms in one's home which can not be cleaned because of lack of time). There are situations in which there is simply too much to undo. Aggressive obsessions may lead to phobic avoidance of knifes. Phobic fear, on the other hand, may have an obsessional quality, - a quality which is denoted by the old German term for phobic fear: Zwangsbefürchtung (obsessional fear).

Panic is described by DSM-IV as ".. a discrete period in which there is the sudden onset of intense apprehension, fearfulness, or terror, often associated with feelings of impending doom. During the attacks, symptoms such as shortness of breath, palpitations, chest pain or discomfort, choking or smothering sensations, and fear of `going crazy' or losing control are present" (APA 1994, 393). DSM-IV lists 13 of these bodily and cognitive symptoms, four of which are needed to meet the criteria for panic disorder. Limited-symptom attacks meet all other criteria but have fewer than four symptoms.

There has been a lot of discussion about the presence or absence of situational triggers in panic disorder. Part of this discussion was generated by the results of naturalistic `monitoring' and `experience sampling' studies (Freedman et al. 1985; Dijkman & De Vries 1987; Margraf et al. 1987). Margraf and colleagues, for instance, comment that panic patients sometimes may fail to perceive environmental triggers. Many attacks which were classified as spontaneous occurred in classical `phobic' situations. Patients also endorsed a greater number of symptoms retrospectively than in their diary.

DSM-IV uses a threefold distinction, originally defended by Klein et al. (1987; cf. also Klein & Klein 1989), between unexpected (or uncued), situationally bound (or cued) and situationally predisposed attacks. Unexpected attacks occur spontaneously `out of the blue'. Situationally bound attacks occur "immediately on exposure to, or in anticipation of, the situational trigger or cue". Situationally predisposed attacks are "more likely to occur on exposure to the situational trigger or cue and do not necessarily occur immediately after the exposure" (APA 1994, 395). The reason for this distinction is that the strong criterion of unexpectedness (DSM III) did not appear to be appropriate for many attacks in case of panic disorder. Situational cues and the anticipation of these cues may predispose to panic attacks without immediately provoking them. This is why situationally predisposed attacks were admitted to support the diagnosis of panic disorder. Situationally bound attacks typically occur in cases of social phobia and specific phobia.

DSM IV states that there should have been at least two unexpected attacks and that at least one of those attacks should have been followed by (a) "persistent concern about having additional attacks", and/or (b) "worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, `going crazy')", and/or (c) "a significant change in behavior related to the attacks" (APA 1994, 402). In spite of these refinements in the definition of panic disorder there will always be borderline cases in which it is difficult to differentiate between panic disorder, on the one hand, and social phobia, specific phobia, somatization disorder, and obsessive-compulsive disorder on the other hand (Aronson 1990). The patient may, for instance, have had a number of unexpected attacks in a distant past, but does not at present show any `persistent concern' or `worry', whereas the `significant change in behavior' is gradually diminished and changed into a phobic avoidance of a specific situation (e.g., tunnels). Other patients have a lot of symptoms, without reporting any subjective fear. Still others are clearly social phobic, but suffer also from rare, uncued attacks. DSM IV mentions four factors which can be helpful in these cases: the focus of fear, the type and number of panic attacks, the number of situations avoided, and the level of intercurrent anxiety (APA 1994, 401). The more limited the focus of the fear, the lower the number of situations and the number of panic attacks, and the lower the level of intercurrent anxiety, the less probable it is that a diagnosis of panic disorder is warranted. In panic disorder fear is primarily focussed on the occurrence of panic attacks.

The current emphasis on descriptive accuracy does not rule out the possibility that there are anxiety-related subjective phenomena, which were lost in the recent debates on classification. Depersonalization and derealization, for instance, have almost disappeared as anxiety-related phenomena (except as symptom of panic disorder), in sharp contrast to the prominent role they played in famous descriptions of men like Roth and Janet (cf. the surgeon with panic attacks, cited in section 3). The phobic anxiety-depersonalization syndrome, which was described by Roth in 1959, was a traumatically induced combination of phobic, pseudo-hallucinatory and panic-like symptoms, which today probably would be subsumed under the heading of both posttraumatic stress disorder and panic disorder with agoraphobia (Roth 1959). Depersonalization was a salient feature of this syndrome.

In Janet's descriptions of the psychasthenic state, which, unfortunately, are almost forgotten today, feelings of unreality and depersonalization play also a major role. Common to all psychasthenic patients, says Janet, is a disturbance in psychological functioning, the so-called psychasthenic state. This state is characterized by, what he calls, a `sense of incompleteness' (`sentiment d'incomplétude'); a diminishing of `the sense (or function) of reality' (`la fonction du réel'); and by exhaustion (Janet, 1903, p. 439). The sense of incompleteness refers to a pervasive feeling of ineffectiveness. Whatever one does, it seems useless and not to come to an end. Doubt, hesitance, rumination, depersonalization, feelings of doubleness and unreality, restlessness and apathy belong to the many manifestations of this state. With regard to the diminishing of `the sense (or function) of reality', Janet refers to a kind of mental presence which enables one to be alert, spontaneous, and effective. The diminishing of this so-called `coefficient of reality' is particularly important in the domains of voluntary action, attention and perception (Janet, 1903, p. 487). According to Janet, psychasthenic patients show subtle imperfections in concentration and in other `synthetic' mental functions. As a consequence of this `lowering of psychic tension' (`abaissement du niveau mental') routine daily activities may be disrupted.

From here, it is only a small step to the changes in the quality of the sensory appreciation of the world. Think for instance of the typical changes in the perception of space in agoraphobia. Landis (1964, 247) cites the following passage from W.E. Leonard's autobiographical book The Locomotive-God, which deals with the author's lifelong agoraphobia:

"Home again becomes immeasurable distance, only more immeasurable. And the distance of three blocks to the railway-bridge girders is, I feel, an infinity of street in the sun. I totter. I fly. I open my skirt to get air on my bare chest. There is a white hitching-post by the gutter near the end of the block. My imagination creates this as its goal, as its refuge" (Leonard 1939, 64).
Open spaces like streets and squares may generate a feeling of infinite distance. Objects like railway-bridge girders and hitching-posts function as safety signal. The world of the patient with agoraphobia is full of these warning and safety signals. Some agoraphobics prefer darkness when leaving home. Others use sun-glasses in order not to see the `blockages' which could keep them from the safety of home. Some of them describe the world outside as uncanny and alienating, as a paralyzing vacuum destroying all initiative and self-confidence.

This is in contrast to the world of obsessive-compulsive patients, which is full of objects and situations which could run out of control. Obsessive-compulsives feel almost continuously at the edge of chaos. They are possessed by `demons' which are at the point of overwhelming them   the demons of dirt, sperm, faeces, bad odors, physical harm, or micro-organisms. Their rituals may result in an alteration of time-perception. The endless repetition of thoughts and acts leads to an altered or decreased sense of temporal change (Von Gebsattel 1954). Their world is transformed into an imaginary world, in which temporal continuity is fragmented by the repetition of fixed behavioral sequences and thoughts which gradually take the place of real world sorrows and occupations.

VI. Anxiety and psychosis
One of the most neglected topics in descriptive psychopathology is the subject of psychotic anxiety (Schmidt-Degenhard 1986). Of course, the frequent occurrence of anxiety in the context of psychosis has not gone unnoticed. It was, for instance, Wernicke who already at the end of the 19th century coined the term anxiety psychosis to denote a psychopathological entity which was characterized by such an intense anxiety that frightening hallucinations, delusions and delusory ideas were the result (Wernicke 1895). Many clinicians, then and now, consider anxiety as a consequence of all kinds of cognitive disturbances. Wernicke challenges this view by arguing for the primacy of anxiety. The ensuing debates not only centered around this theme, but also around the nature of psychomotor agitation. According to some clinicians psychomotor agitation was to be considered as a prominent symptom of anxiety psychosis, others saw is it as a secondary phenomenon or as part of agitated melancholia or manic-depressive illness (Specht 1907; Forster 1910; Kraepelin & Lange 1927, 611 et seq.).

With the virtual disappearance of the term anxiety psychosis from clinical usage interest in anxiety symptoms in the context of psychosis also faded. However, two important, unfortunately almost forgotten, publications are worthy of mention: Störring's Zur Psychopathologie und Klinik der Angstzustände (On the psychopathology and treatment of anxiety states) and Conrad's Die beginnende Schizophrenie (incipient schizophrenia) (Störring 1934; Conrad 1958). Both works emphasize the fundamental significance of anxiety in the origin of psychosis. Both go on to describe a period of depersonalization, anxiety and anxious mood which often precedes the onset of psychosis. Conrad uses the term trema to denote this anxious delusory mood. Störring describes how this anxious delusory mood can lead to so-called 'objectivation' of anxiety. This refers to what nowadays is called projection. Feelings of anxiety are no longer experienced internally, but transformed into perceptions of a dreadful and mysteriously changed world. Feelings loose their natural bond with the I. As a consequence, they take on an enigmatic and indeterminate character. Whilst the patient does not necessarily experience anxiety subjectively, the world nevertheless changes in an obscure way, and appears to be terrifying, threatening and gruesome.

VII. The cognitive component
It is interesting to note that the surge of interest into the cognitive component of anxiety initially resulted from a fascination of the non-transparency of the feeling of anxiety, which is one of the main themes of this chapter. Beck et al. (1974) call it an unfortunate tautology that anxiety neurosis is defined as a disturbance in which the source of anxiety is unknown: ".. since, by definition, the patient is unaware of the source of his anxiety, the clinical investigator is unlikely to make a thorough examination of the content of the patient's phenomenal field" (319). Building forth on observations collected during psychodynamic psychotherapy they hypothesize that there are idiosyncratic thoughts, images and thinking patterns specific for each neurotic disorder. The thoughts and images may last only very short. In case of `anxiety neurosis' this idiosyncratic ideation mainly concerns the anticipation of physical harm (becoming sick; being attacked or involved in an accident) or psychosocial trauma (humiliation, rejection). Beck and co-workers indeed found that 90% of their 24 patients had vivid visualizations centering around the theme of danger prior to their anxiety attack. All patients had danger-related cognitions. The investigators were striked by the unique, personal content of the fear in each patient: ".. these personal variations often shed the most light on the relation between the patient's mode of integrating his experiences and the arousal of anxiety" (321). Beck and co-workers have later formulated the notion of `personal domain', representing the area of a person's vital interests (Beck 1976, 54-57; Beck et al. 1985, 38, 78-81). The study of Hibbert (1984) yielded broadly similar findings, although the fears of patients without panic attacks were less readily classified as `personal dangers'.

This picture also emerges from the study of Argyle (1988), in which DSM-III criteria were used. He found a difference in the focus of fear between sudden and gradual-onset anxiety attacks, irrespective of whether the attacks occurred in the context of panic disorder or another anxiety or (even) affective disorder. Sudden attacks were associated with cognitions referring to immediate catastrophe, such as dying, fainting, collapsing and going crazy. Cognitions of gradual-onset anxiety were related to everyday worries, travelling, being alone, other illnesses and social embarrassment. Most of these cognitions concerned future events. During sudden attacks the range of cognitions was narrowed and attention appeared to be directed inwardly to the mental or physical catastrophe which was in the process of occurring.

These results, however, do not allow to draw unequivocal conclusions about the relation between type of cognition or sensation and type of anxiety disorder. Investigations, which focused on this relation, have provided only meager results. Hoehn-Saric (1982), Anderson et al. (1984), Barlow et al. (1984; 1985), Cameron et al. (1986), and Borden & Turner (1989) indeed found slight differences in the symptom profiles of panic disorder patients with or without agoraphobia, generalized anxiety disorder and a number of phobias. But these differences turned out to be insufficient to establish a diagnosis of anxiety disorder. Over-all intensity of the symptoms also did not appear to be of diagnostic relevance. Finally, non-fearful panic disorder was discerned as a subgroup of panic disorder, suggesting that cognitions are irrelevant for a subgroup of panic disorder patients (Beitman et al. 1987). The most consistent finding in all these studies is the presence of cardiovascular and respiratory symptoms in panic disorder (cf. Clark et al. 1994).

As a consequence, the focus of cognitive research has shifted from correlations between descriptive entities such as those mentioned to explanatory constructs like anxious apprehension (Clark 1986; 1988), fear of bodily sensations (Van den Hout et al. 1987; de Ruiter & Garssen 1989) and fear of fear (Goldstein & Chambless 1978; Foa et al. 1984). Fear of fear in its turn has been divided into anxiety sensitivity (Reiss & McNally 1985; Reiss 1987; Reiss et al. 1988) and expectancy (or predictability) (Rachmann & Levitt 1985; Barlow 1988; Barlow & Craske 1988; Adler et al. 1989; Street et al. 1989; Reiss 1991). Chambless & Gracely (1989) mention fear of bodily sensations as a component of fear of fear. Uncontrollability has been suggested to represent an important dimension of posttraumatic stress disorder (Foa et al. 1992).

Recent research suggests that there are least three fundamental fears: anxiety sensitivity, fear of negative evaluation, and injury/illness sensitivity (Reiss 1991). These fundamental fears appear to be factorially distinct and account for 22-41% of the variance of common forms of fear and trait anxiety (Taylor 1993). Taylor suggests that the unexplained variance is mainly due to idiosyncratic factors in fear acquisition (e.g., aversive and traumatic experiences).

Finally, worry has been investigated as a central phenomenon in generalized anxiety disorder. Results of these investigations suggest that worry primarily involves thought, rather than imaginal, activity (Borkovec & Inz 1990). Generalized anxiety disorder patients do seem to fail in terminating their worries (Craske et al. 1989). It has been suggested that worry and (obsessive) checking are functionally similar (Tallis & De Silva 1992).

VIII. Closing remarks
From this overview one can only conclude that there is an enormous diversity in the phenomenology and subjective experience of anxiety. We have seen that this diversity to a large extent can be explained by idiosyncratic factors in fear acquisition. This might imply that our expectations about future research on the categorical and/or factorial separateness of different types of anxiety should remain modest. However, the problem of diversity   and of co-morbidity   may also be a reflection of shortcomings in our methodologies and in the theoretical constructs on which these methodologies are based.

The term anxiety is typically a lay construct. Science transforms this construct into one of the `components' of anxiety: verbal report. This transformation of subjective experience into verbal report, however, easily results in isolation and decontextualization of the feeling aspect of anxiety:

"... if a client reports that [he or she has] acute attacks of somatic distress and a feeling of doom, this is not regarded as the verbal/subjective component of a panic disorder but an item of behavior that should be interpreted structurally (in relation to the presence or absence of other behaviours in the repertoire), contextually (as an act whose meaning derives from a specific context) and functionally (in relation to eliciting and maintaining events)" (Hallam 1989, 102).
The subjective meaning of a particular feeling state should in other words primarily be derived from behavior patterns and the contexts in which these behavior patterns develop (cf. also Zane 1989). Classification of verbal report may be a too limited approach to serve as an entry to the scientific understanding of the subjective dimension of anxiety.

This is not meant to detract from the merits of verbal report in the clinical situation. Here, however, the hazards of isolation and decontextualization can be neutralized, particularly by the carefully conducted clinical interview and by focusing on the biographical embeddedness of the patient's complaints. As has been said in the Introduction, pathological forms of anxiety must be seen as products of a learning history.

It is interesting to note how the earlier descriptions, which were often heavily loaded with psychodynamic terminology (cf. Meissner 1980, 702-704), have made room for descriptive precision, such as required by authoritative classification systems like DSM and ICD. This is not to say that these classification systems, in particular the successive editions of the DSM, are totally non-theoretical. A category like panic disorder can not even be thought of without the numerous pharmacological and challenging studies which laid the basis for its existence as a separate diagnostic entity. Ultimately, phenomenological description and theoretical explanation can not be kept apart.

If all this is taken into consideration, one can only conclude that we are in need of a conceptual framework in which different approaches to the phenomenon of anxiety are ordered systematically according to their viewpoint (molecular, physiological, behavioral, cognitive, social, and subjective) and to their level of abstraction (from pure description to approaches with a high level of abstraction). With such a conceptual framework it would be possible to diminish the gap between mere description of subjective mental states on the one hand and explanation by high level theoretical constructs on the other hand.

Throughout this chapter we have been concerned with the non-transparency of the feeling of anxiety. Many authors challenged the view that this non-transparency must be attributed solely to biological causation. Psychoanalysts and cognitive therapists pointed out that meaningless and objectless anxiety may become meaningful and transparent in the course of psychotherapy. Anthropological psychiatrists went a step further by stating that anxiety, rather than being exclusively related to internal or external danger, must be conceived as the counterpart of the human urge for self-realization. Anxiety, ultimately, refers to a domain which is beyond that of emotion. This insight should not be played off against other approaches, in particular the biological approach. For the frustration of the urge for self-realization is expressed in all domains of human functioning, the biological domain included.


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