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IT is impossible, in a single chapter, to enter into a full discussion of fears and phobias. Elsewhere I have made a more thorough study of these subjects2.
One of the most common fears met with is the dread of the dark. There is, no doubt, a good biologic background for this fear. Our forest ancestors had reason to look upon the dark, with all its unseen dangers, as something to stand in terror of. The dark meant wolves and a hundred and one other dangers. In our own day, however, children are needlessly frightened and made afraid of the dark by means of ghost stories, tales about haunted houses, witches, etc. Experience goes to prove that children are absolutely unafraid of the dark if they never have suggestions of fear, with reference to night, made to them.
Fear of the water is another common phobia. I have a patient, a woman forty years of age, whose husband wants to go to Europe this summer, but she simply will not go. She has never even been in a row-boat on a small pond. She has lived in Chicago all her life, but has never been out on Lake Michigan. These fears of water are probably suggested by parents who so early warn the children to stay away from the water. Of course, boys sometimes overcome this fear, go into the water, and learn to swim. It is highly probable that our fear of water comes from an early bath, in which we were submerged and half strangled, and that the fright so produced has led to a fear complex associated with water, from which we never fully recover in later life. Someone has suggested that the fear of water in our day may be induced by the sputtering sound heard when water is turned on in the bathtub, a sound which may have a terrifying influence on young infants.
The fear of stifling is another common phobia - the fear of closed places. I know a woman who, when a child of six, was locked up in a closet by her nurse as punishment; she never forgot the experience. It required over a year of persistent training for her to reach the point where she could sit with comfort in a theater or ride in a closed car. She was all right when riding in an open car, but in a closed car she was seized with panic, fear, and a suffocating feeling. Victims of this phobia cannot go into a church, a restaurant, a shop, without suffering.
Some people are afraid of microbes, and wash the door-knobs every time a visitor comes; I have a patient now who will not eat food unless it comes in the original package, and she must open it herself; whether it is a box of soda-crackers, or a box of oranges, she must take the food out of its original package.
I have come to believe that many of our fears are suggested in dreams. We dream about some terrifying experience, wake up, forget the dream, and yet subconsciously retain the fear that it aroused; this dream-fear becomes attached to the mind, and we transfer it to some later idea which arises in the consciousness, and thus a new fear is born in the mind.
Of late years we are coming to meet with eugenic fears. Young people read books on heredity and become obsessed with the fear that they are not worthy to marry and reproduce themselves. Of course, the fear of insanity is always present with us. W hat is more natural, when the mind is not working right and the feelings are vague and bizarre, than to think that we are going crazy? It should be remembered in this connection that it is only sane people who feel they are going insane. Those who are really "off" mentally never fear it. They may think the rest of us are crazy, but they always believe themselves all right.
And then we have patients who complain of difficulty in identifying themselves with themselves. They sometimes walk down the street and are seized with the strange feeling that they are not themselves. There is the very common fear of being alone - a fear largely due, I think, to the tendency of mothers to keep their children too close by their sides. When children are young and helpless, of course, they must be looked out for; but when they grow older the mothers must see that they are taught to stay alone without fear. Kidnapping stories also contribute to the nourishment of this fear.
We must remember that the sissified boy is largely a product of training. He was not born that way. He grew up that way because of being tied too close to his mother's apron strings. In this connection it is well to remember that awkwardness is largely the result of being kept out of society. Allow children to grow up with plenty of people around them, and they will not be awkward or easily embarrassed.
Let it be emphasized that fear is suggested to the growing child; he is not born with it. Even little chickens are not born with the fear of water. They learn that after they are hatched. Professor Pavlov clearly demonstrated this conditioning of fear by training his dogs by means of his famous sham feeding, so that he could obtain a certain sort of digestive juice merely by showing the dogs food, or even by associating food with the ringing of a gong. That fear is largely suggestive is shown by the fact that while people living in the West are afraid of cyclones, those in the New England States are not.
One of our common dreads is the fear of crowds, or of large open spaces. There are any number of persons who will not go across an open place at night - some even dread doing it in the daytime; others, when they get into a crowd, show severe terror, not only by their expressed fears, but by certain physical symptoms, such as pallor, chilliness, palpitation, muscular rigidity, pain in the back of the neck, dizziness, and even nausea.
We have many occupational fears or phobias: people become afraid of certain things connected with their occupations. I remember the case of a man who was compelled to sign his name to a very important document in the presence of a large assemblage of business men, at a time when he was very tired. He became very self-conscious just before attempting his signature, and his hand grew so stiff and cramped that he was barely able to complete signing his name. Immediately a fear complex was mobilized in his mind, and for fifteen years he was never able to sign his name in public. If he attempted it, he was always seized with cramps that made it impossible to carry through the undertaking.
Stammering belongs to this same group. Most people who are troubled with stuttering also blush easily: both are manifestations of the same disorder. Most stammerers are also hyper-conscientious, and they are sometimes best helped, not by some of the many apparently successful stammering cures, but by concentrating the attention on improving oral mobility - on trying to get more completely relaxed and vigorous jaw action.
There is simply no end to the fears that can come to obsess the human mind. I have a middle-aged woman on my hands now who has developed a literal dirt mania. She is making life miserable for herself and her family, trying to keep things neat, clean, and in order. I suppose back of all this in her mind is the fear of microbes, the fear of disease. In this connection we might mention victims of all sorts of food phobias - intelligent men and women who have developed a fear complex regarding some class of foods.
Fear of altitude is a very common difficulty along this line. Many persons are afraid to climb ladders, to ascend high buildings, or even to stand upon high mountains if there is anything in the nature of a precipice near by. We know how some people develop a fear of cats, especially of black cats. I once had a patient who told me that many times she had to tear off her veil in order that she might be able to spit three times before a black cat got out of sight.
Other nervous people develop a dread of being stared at. If anyone looks at them they become inordinately self-conscious, and, of course, sooner or later they are driven out of society. They are unable to appear in public. They simply have to stay at home, because, the moment anyone glances at them, they feel they are being stared at.
We are all familiar with the various hoodoos - Friday the 13th, thirteen at a table, walking under a ladder, breaking a looking-glass; these are not just jokes with some people, they are real phobias, actual fears. We have a group of fears that are connected with air. Some persons are afraid of good fresh air. If it is cool and blows on the face, they are sure they are going to catch cold. They have a draft phobia. Others fear that they are not going to have sufficient air, and that if left alone they might faint or possibly die, and this runs on into the dying spells which we have elsewhere discussed.
Many hypochondriacs fear disease. They are constantly inventing new diseases, and it is only necessary that they find a new almanac, read the health column of the daily papers, or get hold of some of our modern health books, in order to be able to dig up half a dozen new ailments.
Others are afraid of storms; thunder and lightning strike terror to their souls. I know of a nervous mother who, the moment a storm breaks on the community, gathers her children about her and engages in solemn performances that are calculated to fill these young minds with fear of storms for the rest of their lives.
Some nervous individuals develop a phobia about sharp points, scissors, knives, razors, etc. I recall the case of a man, thirty years of age, who shudders almost with convulsions if he sees one of those wavy-edged bread-knives. But, like many other fears, these phobias and dreads can be analyzed and in the vast majority of cases banished.
We also have those nervous people who fear changes. When young, they even were afraid of growing up. They dread responsibility; they will not travel unless absolutely forced to move from one place to another. There has come under my observation a woman, now seventy years of age, who hasn't left the town she lives in for forty-five years. She will not even drive out in the suburbs in an automobile. A case was recently reported of a man who lived so near Niagara Falls that when the wind was blowing just right he could hear the roar of the rushing water; yet he was forty years of age before anyone could induce him to go far enough from home to view the Falls.
And last, but not least, we have the fear of fear - phobophobia. Many times our nervous friends wake up to the realization that they are victims of fear, slaves to their various dreads, and even tho they break themselves of many of these phobias, they still live in constant fear of fear.
When it comes to the management of these fears and dreads, they are all dealt with according to certain general principles, which I will more fully outline at the end of this chapter.
There came to me a few years ago an ex-police officer, a big strapping fellow, who would go down a dark alley any night and shoot it out with half a dozen burglars, but who, as a result of a long emotional strain, experienced a partial nervous breakdown. He was several months recovering, but when he did get well there was one of his many fears that lingered on, behaving after the fashion of a residual fear. He simply would not go anywhere alone. He would find some excuse for getting out of any errand that required him to go anywhere by himself. He had to do considerable traveling for a year or two, and so he hired an old chum to go along with him. Finally he was cured, but it required more effort to conquer this one phobia than all his other fears, and he wasn't cured by reasoning, talking, explanation, or rationalization, as he was of his other fears. This one he had to go right out and defy; he had actually to go through all the misery, and suffer all the physical manifestations, of the fear which accompanied his going any place alone.
I have a case - an army officer, who had a breakdown after the World War. He made a slow recovery; he had little help of a psychic nature, but after two or three years he was fairly well except that he continued to have the fear of crossing bridges or going up in high buildings. For several years after he was really a well man he could not accept a position because he simply would not go up in a high building, and would rather take a licking than cross a bridge; and he happened to live on the North Side of Chicago, which necessitated his crossing the Chicago River to get down town. So years went by and he began drifting back into his old neurotic obsessions; but finally he decided to consult a physician and try to get to the bottom of his trouble. As a result he is all but over his phobia. But, tho he soon reasoned himself out of his other worries, it has taken him about a year and a half to conquer this one. Even now he shudders sometimes when going over the bridge, even in an automobile or on the bus, and gets a panicky feeling at the thought that he is on the sixteenth floor of a skyscraper. The worst is over, however, and he is undoubtedly going through to the complete mastery of this residual fear.
Definite dreads are aroused only when we are compelled to face something our experience has taught us greatly to fear, and we can do much to recondition our emotional reaction to these dreads by carefully analyzing them, and by teaching ourselves not to be afraid of the thing we fear; eventually we can hope to be delivered from such dreads.
Many of the things which we dread in adult life are those which made painful impressions upon our minds in childhood, but such fears can usually be banished by analyzing and explaining them. As someone has said, "A dreadful certainty is better than an uncertain dread".
In this connection let me emphasize the fact that unusual timidity is nearly always traceable to some disagreeable environmental influence, some situation which was so timed and framed as to take us by surprise or otherwise to upset our normal reaction behavior.
Unwise teaching in childhood often lays the foundation for a chronically guilty conscience. Victims of such teaching grow up with the idea they are guilty of something - first of this and then of that - and later on they may drift into melancholia and become so depressed as to think they have committed the unpardonable sin. Freud thinks this sort of melancholia is a grown-up form of Narcissism. We first worship ourselves, and later on, when we are cured of that, we get sick and indulge in a sort of glorified pity for ourselves.
Most people dread social disapproval. Any and all things which might lead to criticism on the part of their fellows they dread to do. It has been, said, "It is better to be dead than to be out of fashion".
Bashfulness is a form of fear, and in most instances it has its origin in unwise management of children during their first years in school in connection with class recitations. It is this embarrassment, this fear of reciting, that causes so many children to wish to leave school and go to work. An only child is always more subject to embarrassment and bashfulness of this sort. It is a great misfortune to be raised alone.
Most college breakdowns are due to fears and dreads, often aggravated by loss of sleep from overmuch social activity; but as a rule the victims of such breakdowns have brought an embarrassment complex with them to college, and the nervous symptoms which later appear are but an effort to get away from their embarrassment and to avoid emotional conflict from the feeling of having run away from school. Getting sick gives them a good reason for retiring with dignity. Some college students are also greatly bothered with the queer and sometimes sudden self-consciousness of ego - a stage which all developing minds go through more or less.
Some people make life miserable for themselves by indulging premonitions. They are always feeling that something is going to happen, and this can, of course, be developed to the point where it is a real anxiety neurosis. It helps a great many people to overcome their silly phobias and nonsensical dreads to learn how universal they are, how many persons are subject to one or more of these phobias. They simply represent fears we have carried over from nursery days. We grow up into a real world, but we have failed to slough off all our cradle dreads.
When our fears and phobias develop to the point where they lead us to do some act or engage in some motor reaction at the thought of the fear, we call such complexes "obsessions". The counting obsession is probably the most common of these complexes. A man goes down the street counting the money in his pocket. Others count the stripes in wall-paper; some people count the pipes in the organ at church. No matter where the victims of this obsession are, they must be counting something. Some people develop a fear of touching certain things, and others develop the contrary impulse to touch common objects. I saw a boy going down the street the other day stopping to honk the automobile horn in every open car he passed. I had a playmate in boyhood who always kicked every hitching-post he passed.
Then we have obsessions developed from the fear of committing a sacrilege; the victims must go through certain motions to make sure they have not committed a sin. I have a nurse at the present time who is all but driving herself crazy with this sort of obsession. It came over her one day during a church service and has been tormenting her for a number of years.
Probably the impulse to take things, the urge to steal, kleptomania, belongs to this same group. Individuals who have money in their pockets to buy a thing will steal it, and many times they steal things they don't need. The whole experience seems to be merely the yielding to an impulse, an obsession to steal.
A few years ago I had my attention called to the case of a young woman, a trained nurse, who had been raised in a splendid Christian home. She certainly had a saintly mother, a devoted father, and her brothers and sisters were thoroughly normal; but this girl was always given to impulsive acts. Her parents early noticed that if she was asked not to do a thing, that was the very thing she wanted to do. If she was walking through a public park and saw a sign "Do not pick the flowers", she never left the place until she had picked at least one. I presume the parents thought it was "cute" when she was very young.
When she was about seventeen this compulsion of thought or obsession took the form of stealing. She developed into a first-class kleptomaniac. There was no connection between her needs and her stealing. She seemed to delight particularly in stealing from the large department stores in Chicago where they have detectives. The greater the risk the bigger the kick she got out of it. There was some sort of supreme satisfaction which she derived from this life. There was adventure and risk, and she seemed thoroughly to enjoy it; but of course she was destined to be caught. The father paid the bills and she was let off, but within a year she was caught again, and again she got off; but by the third time the word had been passed along - her record was card-indexed - and this time she was sentenced to go to jail, but friends secured her parole. The year's probation that followed was spent in intensive psychic training, and it is hoped that this will effect a cure and save her and her family from further humiliation.
I remember meeting a young woman who could well afford to pay for her meals, who liked to go into a certain department store and see if she could get out without paying for her lunch. She kept a record of 136 stolen meals. She got by with these, but on the 137th she was caught. When I asked her why she did this, she replied, "I don't know. There is something in me that just compels me to do it, but I can't explain what it is".
In later years I have come to look upon these cases as specific forms of what would otherwise be regarded as obsessions, and I have been more successful in dealing with them since I have come to accept this view.
We have the same condition in the case of certain types of pyromaniacs - unbalanced individuals who yield to the urge to start fires. They can often give no reason for it. It is simply an obsession. It belongs to the same group as do our various tics, twitchings, and other minor motor obsessions. There are many theories as to the origin of these motor obsessions. No doubt the majority of them originate early in life. When very young some experience makes a profound impression upon the memory and is associated with a high degree of emotional excitement; these fears become the center of a complex involving motor reaction; the whole association, as we grow up, develops into an obsession.
Janet thinks that our obsessions arise from a limited action of the will, a chronic lack of decisiveness. He regards them as most likely to develop in wishy-washy individuals who allow the mind to get into a helpless, passive attitude - what he calls lack of psychic tension; and he thinks that this, in turn, is the result of stress and strain, or of psychic fatigue.
Freud thinks obsessions come on as the result of imperfect repression of some wish, and when the obsession is marked or involves a group of muscles he is inclined to regard it as "conversion hysteria" - the displacement of the repressed wish or fear.
Another group of obsessions is illustrated by those individuals who become possessed of some idea which they pursue almost to the point of monomania. Take, as an example, the anti-vivisectionists. They become so obsessed with this idea, that they will believe any stories of cruelty to animals that gossip may pass along, especially if they involve a doctor or a medical student. Unquestionably some highly neurotic reformers in other fields allow their pet ideas to develop into obsessions; this statement, however, is in no wise intended to belittle the motives which underlie these otherwise queer reform complexes.
No matter whether we are dealing with generalized fear, definite dreads, or the anxiety neuroses, the methods of management are fundamentally the same.
Fear, if long entertained and over-indulged, engenders selfishness, and when it actuates crowds it may induce panic, as is so well known in case of fires and shipwrecks. An effort should be made to explain to the victims of fear that the purpose of this animal emotion is to lead us to forethought and prudence, to make us realize the difference between fear thought and forethought. It is impossible to overcome fear by direct opposition. Scolding by parent, teacher, or physician is of no avail. Affirmation on the part of the patient is equally useless. It does no good for the patient to say "I am not afraid" when his psychic censor tells him he is.
The best method of managing fear is to take the following course:
We must not, of course, overlook the possibilities of substitution on the one hand, and so-called sublimation on the other. Minor dreads can easily be swept out of the mind by greater and superior passions, as is so well illustrated in the case of stage fright which is overcome by the desire to perform before others and to receive applause. When the mind is saturated with the desire to do right and is dominated by a love for truth - both superior complexes - it is equipped to sweep out fear. There is that "perfect love which casteth out all fear".
All victims of fear must learn to travel on the sunny side of the street; to look on the bright side of things; but they must not forget that merely wishing is useless. The mind must engage in logical thinking. There must be produced an actual psychic reaction. There must be bona fide conceptual work done in the task of recognizing the psychic factors that compose the fears, and then the patient must indulge in the logical reaction of ridicule and contempt, must laugh at himself for having been so foolish as to be made sick and unhappy by such psychic fictions.
If it be suggested that this leads to introspection, let me explain that neurotic patients are already victims of introspection. They have been spying on themselves for years. They are experts at listening in on their own feelings, but there has been an introspection of illogical fear and self-pitying anxiety. What they need now is to sublimate it, exalt it into fearless self-analysis, accompanied by a passion for the truth, a willingness to face the facts, and a determination to be logical and sane in their reaction to these fears when once they are explained. And in this connection, it might be well in our social contacts with neurotics to find some other form of salutation to take the place of the common "How are you to-day?" Of course, we might train the neurotics to treat this as a moral gymnasium and react by saying, "Fine, absolutely fine; couldn't be better".
When fear is translated to dread, and when it becomes chronic and severe, we may speak of it as an anxiety state. Because anxieties are usually the fruition of other and preceding chronic worries and dreads, and because there is often such a complexity of factors, together with the unwillingness of most anxiety patients honestly to seek to discover and face the facts, it is often very difficult to run down these anxieties to their original sources.
So few people are willing frankly to state to the physician and to admit in their own consciousness those experiences which they regard as discreditable, and they are also so largely enamored of their own feelings and fears, that it is hard to get them down to logical reasoning about the possible causes of their trouble; but when we do get to the bottom we nearly always find that they were suggestible to some sort of influence, that they were vulnerable to some trifle of their environment.
It is remarkable how many people who are sane, sensible, and logical in, say, their business life, are easy of deception in other domains of their mental existence. I know of an efficient engineer who is, nevertheless, utterly useless at a spiritualistic séance. He hears and sees everything the medium hears and sees. I have a friend, an attorney, who is logical and altogether reliable and sensible when pleading before a jury or addressing the judge, but who, when he is home and has an ache in his stomach or toe, is subject to any sort of quackery that the most blatant charlatan might propose. He is always trying out some new fake remedy or shyster cure. It is hard to understand how human beings can be so sane at one time and so silly at others.
Since self-preservation is the first law of nature, it is only natural that human beings, when they have strange feelings in the stomach, or when the heart flutters, should be inclined to stop and inquire into the cause of these disturbances. It is natural, therefore, that the victim of a neurosis should feel anxiety when he is seized with such spectacular manifestations as palpitation, shivering, frequent urination, vomiting, exaggerated flushing of the face, a dry mouth, cold and clammy sweating, not to mention the more serious nervous manifestations, such as accelerated intestinal action, hysterical fainting, unconsciousness, and even catalepsy - muscular rigidity of the entire body. Little wonder that the mind becomes hypochondriac and more or less preoccupied with these nervous symptoms; and still more do we have trouble with anxiety if the religious nature becomes involved.
I believe that the roots of most of our anxiety states are to be found back in childhood. Many of them can be traced to the child's first separation from the mother, an event which should be so staged as to prevent the generation of inordinate anxiety. Still later anxieties are started in connection with unwise methods of punishment for trifling misbehavior.
Anxiety neuroses more often appear in the case of those individuals who are hereditary and constitutionally inferior, and this state of anxiety, with them, can very soon become habitual. Along with this mental anxiety will usually be found more or less continuous muscular tension, which often persists during sleep.
These obsessions, tensions, and anxieties constitute an extravagant waste of nervous energy and vital strength. Anxious people are always in a hurry, always "rushed to death"; they have all but forgotten how to relax. In time, the body comes to reflect the psychic state. An anxious mind is reflected in a tense body - at least for a time; later on there may appear fatigue, brain fag, and exhaustion.
Then we have those highly sensitive souls, those easily irritated temperaments, that suffer such exquisite torture at the hands of the rest of the careless and indifferent world. They habitually over-react to all the unpleasant stimuli of human existence. Their suffering may be mental or physical, or both. They just can't bear the idea of being hurt, they will not endure the thought of suffering pain - not even of the slightest degree. If conditions are at all unpleasant, these sensitive souls are wont immediately to withdraw to the seclusion of their grown-up nursery, where they can nurse their injured feelings and ponder over the inconsiderateness of the cruel world.
Such persons, when in the least irritated, are quick to utter expletives and indulge in oaths. They are also prone to resort to alcohol or drugs in an effort to soothe their wounded feelings.
Unquestionably the anxiety states may become chronic. The state of continuous apprehension may be carried to the point where we are justified in making a diagnosis of real and established anxiety neurosis.
Not long ago I came in contact with the case of a trained nurse from Michigan who was a typical victim of an anxiety neurosis. For years she had been given to worry. She was hyper-conscientious respecting her professional duties. She had worked hard, trying to support her aged parents and assist her brother through college, and while struggling along with these manifold burdens she experienced a severe emotional shock, a disappointment in love. She collapsed, and was almost a year in recovering from this nervous breakdown. When she returned to work, she seemed well, but her strength did not hold out. A few days' work completely fatigued her, and she began to worry about her future. Instead of worrying about some specific problem, as she formerly did, she now began to be affected by a profound and generalized anxiety, a vague and indefinite apprehension that all was not going to be well with her. This anxiety gradually grew worse, and had been in progress almost three years when I saw her. She would clasp her hands, sometimes even wring them, and in the most pathetic manner give expression to her profound but vague anxieties. The most definite expressions that could be secured from her were: "I know I shall never get well. I know something is going to happen. I feel absolutely certain that I am going to get worse. I know you can't do a thing for me. I appreciate your trying, but I know my case is hopeless". It required over a year of patient explanation and careful guidance to help this nurse, and even when she returned to work it required another year before she was anything like normal. This, of course, was a rather exaggerated case of anxiety neurosis. The average case merely presents anxiety regarding some physical symptom or group of symptoms.
The anxiety neurosis is an entirely different picture from melancholia. There is not that profound depression, although there may be an almost equally hopeless outlook. In the anxiety states the patient is afflicted with a more active form of apprehension as compared with the passive slump of melancholia; when allowed to run on for years, it is very difficult to help these cases.
In most cases of anxiety neurosis we have a very scrambled, tangled state of the emotions, sometimes impossible of complete analysis. They represent the more advanced chronic form of emotional mix-up. If the earlier emotional sprawls may be compared to isolated temperamental sprees, then this anxiety state is more in the borderland of emotional delirium tremens. It represents the cumulative miseries of long continued misadaptation and emotional conflict.
I recently saw one of these cases, a woman about forty years old, whose continuous wailing consisted merely in saying over and over, in one form or another: "I will never get well now after all I have done. It was all a great mistake. If you had taken hold of my case sooner, there might have been some hope, but now I am sure you will never be able to help me".
She was up and about the house, more or less active, but kept up a continuous stream of conversation, working her hands, and crying off and on; she constantly looked forward to getting help in spite of her pessimistic expressions. She was always appealing to be taken to a different doctor or some new sanatorium. While there was not much in common with the picture of melancholia, she was all but melancholic in her outlook, more especially in her day-by-day expressions. These anxiety cases are always appealing for help and are ever ready and willing to take treatment or follow out medical suggestions.
Here is another case, a woman fifty years of age, who presents this restless anxiety, but on examination is found to be suffering from arteriosclerosis. She has high blood-pressure, and while mental medicine has afforded her a little help, it does not cure her. In her case the nervous symptoms are in the main due to underlying physical and organic causes. The possibility of organic disease in the background of these anxiety states must be borne in mind.
I recall a middle-aged woman who developed an anxiety neurosis which was really of a religious order. She maintained that her soul was not right, that her relations with the Supreme Being were disturbed, but she was never able to explain this matter until we discovered that she was always made worse by going to church. Presently the fact was uncovered that about ten years previously she had experienced a profound emotional shock while attending service one Sunday morning, and thus a vague but very definite association of ideas grew up around religion, churches, and her whole spiritual life; it was not until this experience was uncovered and explained to her that her anxiety was in the least relieved. Up to this time no amount of reasoning, no effort to explain the foolishness of her anxiety, was of any avail. From this time forward, covering a period of about six months, she continued to improve and gradually overcame her anxiety.
I have many times seen the milder form of the anxiety state grow up out of adolescent bashfulness from the aggravation of the ordinary reticent, retiring type of personality.
A university teacher came to me not long ago, who, through over-conscientiousness about her work and all-around emotional suppression, was headed straight for a real anxiety neurosis. After the true nature of her trouble was explained to her she immediately began to improve. In her case the matter was taken in hand sufficiently early to avoid years of psychic misery and physical suffering.
A few years ago a business executive, about fifty years of age, became restless and apprehensive. He had enjoyed the best of health all his life; had never been particularly nervous; was unmarried; had been a hard worker; had never enjoyed much self-expression. He had largely devoted himself to supporting his parents and making a home for his two spinster sisters after the death of his parents. Within six months he had developed a full-fledged anxiety neurosis, the strangest of its kind I have ever seen. He resigned his position, and after spending two or three years traveling around, trying this and that, at last settled down to a program of emotional analysis and readjustment. He determined to master the art of living with himself as he was, and with the world as it is, and he has been largely successful; but he made little headway until we induced him to go back to work. His was one of those rare cases in which an anxiety state grows out of the gradual accumulation of the residue of continuous generalized emotional suppression.
A business woman, thirty-three years old, was sent to me with the diagnosis of an anxiety neurosis. The history seemed to point in that direction, and she certainly was exhibiting a continuous over-anxiety about herself in particular and the world's affairs in general; but her examination had not progressed far until it was discovered that she was suffering from exophthalmic goiter. While the thyroid gland showed little or no enlargement, her metabolism test, pulse rate, tremors, etc., all pointed clearly to toxic goiter. No amount of mental medicine would cure this patient. A surgical operation restored her to normal health within a few months.