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Journal of Affective Disorders 56 (1999) 83–94www.elsevier.com/ locate / jad

Invited review

Anxiety disorders: a conceptual history

*G. Berrios

Department of Psychiatry, University of Cambridge, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ, UK

Received 5 January 1998; received in revised form 21 December 1998; accepted 19 February 1999

1. Matters historiographical According to the first, these are all linguistic con-structions (e.g. Sarbin, 1964, 1968) whose content

When writing on how the so-called ‘anxiety fully changes from generation to generation, accord-disorders’ came to be constructed, the historian faces ing to the second, clinical categories reflect stable,three difficulties: identifying the object of research, platonic objects more or less fixed in their ontologychoosing the appropriate historiographical approach, (like plants or animals); the third, to be followed inand setting limits to the data domain. this paper, is that most ‘clinical’ categories (and the

The object of research is not as clear cut as it phenomena related to ‘anxiety’ is one of them) havemight seem. For it would be a bad historian who a neurobiological substratum but that the experientialsimply accepted ‘official’ definitions, for example, and behavioural signals they generate are culturallyDSM IV: ‘The following disorders are contained in formatted at a very early stage. In practice, thisthis section: Panic Disorder Without Agoraphobia, means that the historian must assume such categoriesPanic Disorder With Agoraphobia, Agoraphobia not to be fixed for ever but undergo secular changesWithout History of Panic Disorder, Specific Phobia, in form and content which should depend both onSocial Phobia, Obsessive–Compulsive Disorder, change in biological programming and societalPosttraumatic Stress Disorder, Acute Stress Disor- change (Berrios, 1996a). Lastly, the object of inquiryder, Generalized Anxiety Disorder, Anxiety Disorder and the historiographical approach will determine theDue to a General Medical Condition, Substance- boundaries of the data domain: in the case of theInduced Anxiety Disorder, and Anxiety anxiety disorders this should certainly go beyond theDisorder . . . ’ (emphases in original) (American minutes of the DSM IV Work Group who drafted thePsychiatric Association, 1994). The reason for not section on Anxiety Disorders.accepting this list as the object of research is that,from an important perspective, writing on the historyof the DSM IV definition of anxiety disorders is not 2. Matters historicalthe same as writing on the history of the anxietydisorders in general. This ‘important perspective’ None of the clinical phenomena or ‘symptoms’relates to up to three historiographical assumptions now included under the various ‘anxiety disorders’ isas to the nature of clinical (nosological) categories. new. What has changed is their relative emphasis, the

permutations and combinations in which they are*Tel.: 1 44-1223-336-965; fax: 1 44-1223-336-968. clustered up, and their social meaning. Reported in

0165-0327/99/$ – see front matter 1999 Elsevier Science B.V. All rights reserved.PI I : S0165-0327( 99 )00036-1

84 G. Berrios / Journal of Affective Disorders 56 (1999) 83 –94

the Bible under the term pachadh, the symptoms of cated to the heart, ear, gut and brain. In other words,abnormal fearfulness were already differentiated up to the middle of the 19th century, they were takenfrom the reverential ‘fear of the Lord’ of the true at face value and treated as real ‘physical’ com-believer (Hastings, 1909, p. 261). The same phenom- plaints. Consequently, the primary sources for theena can also be found nicely catalogued in Burton’s historical study of the anxiety disorders during this(1883/1620) Anatomy of Melancholy. In both cases, period are medical textbooks; indeed, their study andthe experiential element remains more or less the ‘treatment’ only became part of the remit of ‘psychi-same. What changes in these reports, both in relation atry’ at the very end of the 19th century.to each other and to the present is their social The historian will find that the symptoms ofmeaning and conceptual wrapper. Whilst in Biblical ‘anxiety’ are listed under two headings. Subjectivetimes such experiences were part of the dynamic ones (i.e. those felt as ‘psychological’ experiences)relationship between men and their God, in Burton included fear, emotional worries, feelings of terror,they become behavioural curiosities, and in the 18th depersonalisation, etc., and occasionally mental actscentury they are medicalized into becoming diseases such as obsession-like thoughts concerning the safetyin their own right (e.g. hyperventilation became a of others, fear of dying, etc. On the other hand, thedisease of the lungs, palpitations one of the heart, ‘objective’ symptoms of anxiety (also calledetc.). The first half of the 19th century witnesses the ‘somatic’ and later on ‘anxiety-equivalents’) in-culmination of the process of medicalization. A good cluded abdominal pain, nausea, vertigo, dizziness,

´example is La medicine des passions, ou les passions palpitations, dry mouth, hot flushes, hyperventilation,´ ´considerees dans leurs rapports avec les maladies, breathlessness, headache, restless legs, and other

les lois et la religion published in 1844 by Descuret bodily experiences sometimes indistinguishable from(1868) where the author dedicates a chapter to fear complaints caused by physical disease.as a medical problem. According to biology, personality, culture, social

During the second half of the 19th century also class, etc. subjects may present these symptoms instarts the psychologization of the manifestations of different combinations. When repetitive and stableanxiety. By the 1890s, the very symptoms that once enough, they began to be called syndromes and evenhad been independent physical diseases became diseases. Combinations of subjective and somaticclustered up (e.g. by Freud) into a clinical condition symptoms may mimic heart disease (Krishaber,(anxiety-neurosis) whose integrating force was no 1873), inner ear disorder (Benedikt, 1870), stomachlonger a brain lesion but semantics (a sexual link). upset (Johnson, 1840) or neurological disease (Gow-Looking back, there was nothing prima facie ‘natu- ers, 1907). On occasions, such clusters may be calledral’ about the claim that experiences so disparate had ‘nervous’ but it would be anachronistic in theall to be manifestations of the same cause, namely extreme to interpret this word before the 1850s asthe unifying construct called ‘anxiety’. So, to state having anything to do with ‘psychology’. The termthat this move towards integration was the sole nervous meant ‘organic and not localized’, andconsequence of a new 19th century conception of the related directly to the nerves and brain in the senseautonomic nervous system (Clarke and Jacyna, that Thomas Willis had introduced during the 17th

˜´1987) is not the full explanation. As it will be shown century (Lopez Pinero, 1983; Hare, 1991).below, other forces, concepts and expectations were It would seem, therefore, that a proper historicalalso at work. account of the anxiety disorders should deal with

questions such as: (1) why were such ‘symptoms andsigns’, often dissimilar in appearance, brought to-gether under the same banner? (2) Was this the result

3. Data domains of clinical observation or of theoretical and socialpressures? (3) Were these states considered as ex-

Before the late 19th century synthesis took place, aggerations of ‘normal’ psychological phenomena, orhowever, the ‘symptoms’ of anxiety are found in as ‘morbid’ forms? (4) How relevant to their con-medical nosologies scattered in the sections dedi- ceptualization were late 19th century theories of

G. Berrios / Journal of Affective Disorders 56 (1999) 83 –94 85

emotion and new views on the ‘ganglionar’ (au- Bossuet used it to refer to ‘pressure on the heart’tonomic) nervous system? (Rey, 1997). Consistent with this secular usage, as

´The history of anxiety can be studied from a late as the middle of the 19th century, Littre andmetaphysical, social, poetic and even religious per- Robin (1858) defined angoisse as ‘feelings of close-spective; this paper will focus on its ‘medical’ ness or pressure on the epigastric region, accom-aspects. Lastly, and to avoid confusion, the historiog- panied by a great difficulty in breathing and exces-raphical technique will be used of separately study- sive sadness; it is the most advanced degree of

´ íng the history of the word, concepts and pertaining anxiety’ (p. 77) and anxiete as ‘troubled and agitatedbehaviours. state, with feelings of difficulty in breathing and

pressure on the precordial region: inquietude, anxietyand anguish are three stages of the same phenom-

´ ´4. The terms anxiete, angoisse and equivalents enon’ (p. 93). A similar development is found in theEnglish language and the famous Sydenham Lexicon

´ Éy’s (1950, p. 386), view that anxiete gained its defines anxiety as ‘a condition of agitation andmedical meaning in France at the end of the 19th depression, with a sensation of tightness and distresscentury needs rectification as there is evidence that in the præcordial region. This feeling, or rather itsby the second half of the 17th century the term marked expression in the features, forms a dangerousalready had a ‘psychological’ meaning (i.e. it re- symptom in acute diseases’ (Power and Sedgwick,

`ferred to subjective experiences) (Furetiere, 1701/ 1879–1899).1690); and that ‘by 1750 it was in wide use in Lewis (1967) has analysed the way in which themedicine’ (Rey, 1997, p. 87). For example, anxietas etymology of terms such as anxiety, anguish, and

ís used by Boissier de Sauvages, Linne, Vogel, and angor influenced the clinical conceptualisation of theSagar to describe paroxysmal states of ‘restlessness’ anxiety states. To this it must be added that, whilstand inquietude (Cullen, 1803); and panophobia, the dichotomy ‘anxiety-anguish’ has little clinicalvertigo, palpitatio, suspirium, palpitatio melan- meaning in Anglo-Saxon psychiatry, as it has beencholica and oscitatio (all redolent of anxiety and hinted at above it found a comfortable niche inpanic attacks) are found scattered amongst many France, Germany, and Spain where Angoisse, Angst,diseases in the work of Continental nosologists. It is and Angustia (respectively) refer to the moreimportant to notice that none of these clinical somatic, paroxysmal and more severe forms of

ćategories was ever considered as pertaining to the anxiety (Lopez Ibor, 1950).vesanias (i.e. the category used by 18th century Interestingly enough, during the middle of thenosologists to refer to the ‘mental’ disorders). 19th century, the language of psychiatry in Germany

Át the beginning of the 19th century, Landre- and England was not yet ready to assimilate the´ ´Beauvais (1813) defined anxiete as: ‘a certain subtle semiological distinctions rapidly developing in

malaise, restlessness, excessive agitation’ suggesting French psychiatry. Thus, where Guislain (1852) hadthat these states may accompany ‘acute’ and written craintes and frayeurs (p. 45), Griesinger

´‘chronic’ diseases. In Landre, anxiety becomes a (1861) translated Shrecken oder Angst (p. 169), andsyndrome with both subjective and somatic com- Robertson and Rutherford, the English translators ofponents, and which can accompany diverse diseases Griesinger (1867) used ‘shock or anxiety’. This drift(see below). in meaning (as the translations moved from frayeur

Angoisse, in turn, appears early in the European to Angst and to anxiety), reflect the changes ofvernaculars as a translation of the Latin Angustus emphasis that took place in the second half of the(‘narrow’). However, by the beginning of the current 19th century. For whilst Guislain (1852) was onlymillennium, the metaphorical force of the term referring to acute fears, Griesinger (1861) introducedbecomes salient and, for example, by 1080 the Angst, a term that with Kirkegaard (1980/1844)French word angoisse meant tourmenter (Rey, acquired a meaning that went beyond ‘fear’ (Jolivet,1997). Throughout, however, the term tended to refer 1950) to re-incorporate the old religious dimensionto the somatic components of suffering; for instance of ‘anguish’ (McCarty, 1981).


As a compromise, the term ‘nervousness’ became with the old concept of neuroses as defined by Willisavailable during the middle of the 19th century to and Sydenham during the 17th century; on this see

˜´refer to the subjective aspects of anxiety. Rather Lopez Pinero (1983) and Hare (1991)). The secondtypically, an anonymous (1860) English reviewer of shift concerned the suggestion by Krishaber (1873)

´Bouchut’s (1860) book on Nevrosisme, although that the symptoms of anxiety alone might constituteaccepting that there was ‘no good alternative in the a separate disease principally related to the car-English language’, complained of the ‘vagueness of diovascular system. The third pertained to the viewthe term’. Zeldin (1977) has also suggested that by Axenfeld (1883), Leroux (1889), Westphal‘nervousness’ was increasingly recognised as a com- (1872a,b) and Benedikt (1870) that a subset ofplaint after the 1850s (p. 833). Krishaber’s symptoms, to wit those related to a

subjective experience of dizziness, motor instability,fear and depersonalization might be a disease of the

5. Anxiety-related behaviours inner ear. Let us study these three important contri-butions in turn.

Irrespective of the name these states travelledunder (i.e. of the history of the words) or of how

´they were explained (the history of the concepts), 6.1.1. Morel and delire emotifbehavioural disorders recognizable as ‘anxiety-re- Morel (1866) was perhaps the first one firmly tolated’ can be found in the literature of the ages suggest that pathological changes (i.e. a neurosis of)(Errera, 1962). Altschule (1976) also reminds one the ganglionic (autonomic) nervous system could

´that Arnold, Locke, Battie, Mead, Smith and Crich- give rise to symptoms which he called delire emotifton described medical states of inquietude and (an inaccurate translation of which is ‘emotionaluneasiness (pp. 119–124). As mentioned above, delusion’). Analysis of his clinical reports shows thatbefore the 1820s, the manifestations of anxiety are he was focusing on a novel group of patients, onefound included under many nosological rubrics. For which until then had not been the preserve ofexample, Pinel (1818) lists them under ‘epilepsy’ (p. alienists, namely those whose presentation included80), melancholia (p. 85), rabies (particularly of the permutations and combinations of subjective com-‘spontaneous’ variety) (p. 156), and the ‘motility plaints such as fear, anxiety, phobias and obsessionsneuroses’ (p. 159) and Georget (1820) discussed the (on the latter see Berrios, 1989) and objectivesigns of anxiety in the section on ‘general and complaints referring to the skin, and the cardiovascu-sympathetic symptoms’. lar, gastrointestinal or nervous system. Indeed, at

least two of his patients showed classical ‘panicattacks’ with ‘generalized anxiety disorder’ (in

6. Guiding concepts and frames anachronistic diagnosis, and on account of their age,these patients are likely to have been suffering from

6.1. ‘Organic’ approaches a primary depressive illness).Morel’s contribution is important for, to explain a

Three important shifts in the conceptualization of clustering of symptoms which, until then, have beenthe symptoms and signs of anxiety took place during considered as unrelated, he imaginatively combinedthe second half of the 19th century (Rosenberg, available knowledge on the ‘ganglionar system’1989). One concerned Morel’s view that, however (thereby complying with the anatomo-clinical modeldifferent in phenomenology, the various mani- of disease) with the useful metaphor of ‘sympathy’festations of anxiety (together with other ‘non-psy- of functions put forward by Willis two centurieschotic’ symptoms) might result from a common earlier (Clarke and Jacyna, 1987). By asking whatsource, and that this was a neurosis (that is a symptoms might pathological changes of the ‘gang-pathological change) in the autonomic nervous sys- lionar system’ give rise to? he also complied with thetem; this shift suggested the creation of a new and aetiological classification he had proposed 6 yearsbroad concept of neuroses (one that has little to do earlier (Morel, 1860).


6.1.2. Krishaber ex-soldier who, on crossing la Place de la Bastille,Six years later, Morel’s views found expression in suddenly felt shaky, dizzy, with vertigo and ex-

Maurice Krishaber’s work, a Hungarian ear-nose- perienced the irresistible need to run; he becamethroat specialist, working in France (Dechambre, suicidal and had to be admitted after trying to gas1889) who reported 38 cases of ‘cerebro-cardiac himself. Retrospective diagnosis of this case suggestsneurosis’ (Krishaber, 1873). After criticising the an agoraphobic syndrome secondary to severe de-inadequacy of clinical categories such as nervous- pression (p. 208). Weill (1886) also wrote on the

´ness, protean neuropathy, spasmodic state, etc., vertiges des nevroses which accompanied epilepsy,Krishaber suggested that the new disease included insanity, neurasthenia and the cerebrocardiac neuro-symptoms affecting sensation, movement, and car- pathy of Krishaber and include ‘anguish, palpita-diovascular function, and proceeded to differentiate tions, and headaches’ (p. 64). Even Gowers (1907),it from hysteria, hypochondria, chlorosis, other cere- who was a thoroughly ‘organicist’ writer, reportedbrovascular syndromes and toxic states. He then two cases in their 30s with ‘pseudo-aural vertigo’suggested that the new illness was due to a who had attacks of giddiness without other features

´ `pathological instability of the blood vessels and of Meniere’s disease and got better (p. 68).hence it might be treated with caffeine. His 38 In his review, Leroux (1889) reported that, ac-

`patients showed a high prevalence ( . 80%) of cording to Lasegue, vertige mental or Schwindel (asanxiety, light-headedness, vertigo, palpitations, tin- described by Westphal, 1872a,b), ‘was one of thenitus, tremor, gastrointestinal symptoms (nausea, central symptoms of agoraphobia’ (on this see also

`indigestion and diarrhoea), intolerance to noise, Legrand du Saulle, 1876). Lasegue also listed diag-photophobia and inability to concentrate. nostic criteria: (a) somatic symptoms often precede

Instead of encompassing all symptoms putatively the eruption of acute anxiety which is out ofrelated to the ganglionar system under the one proportion with the former, (b) the anxiety is over-category (as Morel had done), Krishaber cleverly powering, of sudden onset, and seems often to haveselected only those seemingly representing a ‘labili- no precipitant, and (c) once started, it must follow itsty’ of the cardiovascular system. His new ‘neurosis’ full course (Leroux, 1889). Leroux also suggestedwas narrower, stable and clinically recognizable and that when vertigo accompanied lypemania (i.e. de-provided internists with a god-sent explanation for pressive illness) it included: ‘sensations of over-anxiety symptoms and for a while caffeine became a whelming pre-cordial and epigastric anxiety, addedpopular treatment. Krishaber died young but his to a feeling of impending fainting and collapse withviews remained influential, particularly in relation to weakness of the legs. There was also the sensationthe view that primary organic changes in the au- that the ground sunk, and perception became misty.tonomic nervous system may give rise to sensations Anguish was the predominant component of thewhich are secondarily read as emotions, namely what attack, showing as pallor, dyspnoea, and cold sweat-later became the ‘James-Lange theory’ (Gardiner et ing. The subject cannot reason any more. He knowsal., 1937). that there is no danger but is incapable of controlling

his worry. He may become paralysed or act in an6.1.3. Vertigo and anxiety uncontrolled manner . . . ’ (pp. 168–169). A clearer

The experience of vertigo had been known since description of panic attacks cannot be found. It isClassical times, but during the 19th century new also likely that Haltenhof’s (1887) cases of ‘paralys-accounts were produced of its nosological meaning. ing vertigo’ were anxiety attacks. Grasset (1901)For example, under vertige nerveux, Axenfeld also refers in his treatise to the ‘vertigo of neuras-(1883) included cases of subjects experiencing dizzi- thenia and hysteria’ (p. 203).ness in social situations or after ‘over-exertion’ ofthe intellect (p. 268). Likewise, in his award-winning 6.2. Agoraphobiastudy on vertigo in the insane, Millet (1884) alsoreported cases where vertigo was clearly part of a The ‘organic’ view of some of the manifestationspanic attack; the most illustrative being that of an of anxiety also developed in other directions. For


example, Benedikt (1870) related the dizziness of first, connected with fear, includes all manifestationspanic attacks to ‘pathology of the inner ear’, and implying in any degree whatsoever the fear of pain,Westphal (1872a,b) explained agoraphobia as a from that of a fall or the prick of a needle to that ofvertigo of similar origin. (In his autobiography, illness or death. The second is directly connectedBenedikt (1906) complained that he had been the with disgust, and seems to me to include the forms‘first to describe the condition of Platzschwindel’ but which have sometimes been called pseudophobia

´that Westphal never acknowledged this). However, (Gelineau). Such are the fears of contact, the horror¨this may not have been so as in 1832 Bruck reported of blood, and of innocuous animals, and many

in Huffeland’s Journal the typical case of a ‘priest strange and causeless aversions’ (p. 212). Ribotwho complained of severe vertigo and anxiety as (1911/1886) also suggested that the ‘state in whichsoon as he was outdoors’ and who only felt better the patient fears everything, and where anxiety,when he had ‘a solid top or roof over his head’ instead of being riveted on one object, floats as in a

´(Lopez Ibor, 1950, p. 25). dream . . . ’ (p. 214) i.e. generalised anxiety, shouldWith his usual clinical acumen, Legrand du Saulle be called panophobia. Devaux and Logre (1917)

(1876) was the first to realize that the feelings protested that the term should be ‘pantophobic asreported by these subjects were not, in fact, those of panophobia, in good etymology, refers to the wor-

´objective vertigo but of ‘fear that they might lose shipping of the god Pan’ (p. 35). Pitres and Regisbalance’: ‘by the term peur des espaces I refer to a (1902) also offered a good analysis of panophobie

´ ´particular neuropathic state, characterised by a feel- which rather aptly they called emotivite diffuse (pp.ing of anguish and terror, without loss of conscious- 20–34).ness, which occurs in an open space, and which is In the event, it is Freud’s work that is considereddifferent from vertigo . . . ’ This psychological dis- as crucial to the separation of phobia from obsession.turbance has not been described in France, except by In a paper published in French Freud (1953a/1895)Perroud’s writing on agoraphobia in 1873. The term, wrote: ‘two components are found in every obses-accepted by Cordes (1872) and Westphal (1872a,b) sion: (1) an idea that forces itself upon the patient;seems to me to be too narrow for it does not cover (2) an associated emotional state. Now in the groupall the many symptoms of the cases described. of phobias this emotional state is always one ofPatients may fear spaces, but also streets and ‘morbid anxiety’, while in true obsessions othertheatres, travelling by public transport, boats and emotional states such as doubt, remorse, anger, maybridges’ (pp. 405–406). occur in the same capacity as fear does in the

However, the nosological status of ‘agoraphobia’ phobias’ (p. 129) (on this see also Sauri, 1979).remained confused at the time. Some, like Gros(1885), suggested it might be a form of ‘psychosis’; 6.3. Brissaud and l’angoisseothers, like Dagonet (1894), regarded it as a her-

´editary, sui generis, mental disorder. Hartenberg Eduard Brissaud was a neurologist with psychiat-(1901a), in turn, proposed that agoraphobia was a ric interests (Freeman, 1970). His staunch organiclearned problem in which anticipation played a major views on the issue of the psychogenesis of hysteria,role (p. 692). Others took an intermediate position; caused a long-lasting breach between him and Char-for example, Westphal believed that ‘subjects with cot. Brissaud (1890) was equally firm in believingphobias and obsessions inhabited the same clinical that anguish was not psychological in origin, and thatborderland (Grenzgebiet) between neuroses and psy- its somatic symptoms resulted from brain stemchoses’ (Leguil, 1979, p. 91). lesions. Anxiety, on the other hand, was subjective

Up to this period, no clear distinction was yet and of cortical origin (p. 410). He expressed thesebeing made between phobias and obsessions al- views repeatedly. For example, at a meeting of the

´ ´though Ribot (1911/1896) tried to separate them. Societe de Neurologie in 1902, he forcibly did soAfter criticising the coining of countless ‘pseudo- when asked to comment on the case of a docker whoGreek’ terms to name each of the specific phobias, showed anguish without anxiety (angoisse sans

´ ´he suggested that there were only two groups: ‘the anxiete ), i.e. ‘after more than a hundred attacks of


severe chest pain, [the patient] remained philosophi- 1895) himself acknowledged, ‘adduced hardly anycal, lived from day to day, and had never developed examples and quoted no statistics’ (p. 108).either sadness (tristesse) or panic (terreur)’ Freud’s suggestion of a ‘sexual aetiology’ for the

¨(Souques, 1902). Late in the same year, he did ‘anxiety-neurosis’ was criticised by Lowenfeld; andlikewise at the 12th Congress of French Alienists and stung by these comments Freud (1953b/1895) re-Neurologists at Grenoble when he confronted Lalan- plied: ‘I do this because the writer . . . is one whosene (1902): ‘Anguish (l’angoisse) is a brain stem judgement probably has great weight with the medi-

´ `phenomenon ( phenomene bulbaire), anxiety is a cal public, and because of a mistaken conception´ ` ¨cortical phenomenon ( phenomene cerebral): anguish which Lowenfeld imputes to me; and also because I

is a physical disorder that expresses itself in a wish at once to combat the idea that my theory is tosensation of constriction, of suffocation; anxiety is a be overthrown so very easily by the first casual andpsychological disorder that expresses itself in feel- impromptu objections’ (p. 109).ings of undefinable insecurity’ (Brissaud, 1902). In fact, Freud’s view that the anxiety states should

This organic view of anguish lasted in French constitute a separate condition received little chal-psychiatry up to the Second World War. Thus it can lenge as the terrain had already been prepared by

´still be found in the Claude and Levy-Valensi (1938) Krishaber, Ribot, and others. It should be kept inmajor monograph on anxiety (p. 24). It was only mind that, at this early stage in its history, ‘anxiety-towards the end of the War that, in another classic neurosis’ was considered (by Freud included) as awork on L’Angoisse, Boutonier (1945) challenged a disease of the nervous system: ‘The nervous systemtheory that had remained alive for ‘its clarity and reacts to an internal source of excitation with asimplicity were more apparent than real’ (p. 18). neurosis, just as it reacts to an analogous external

one with a corresponding affect’ (Freud, 1953b/1894, p. 102). At the time, Freud believed ‘anxietyneurosis’ to be a form of ‘actual neurosis’, i.e. of an

7. The construction of the modern syndromes acquired and reactive condition unrelated to child-hood events’ (Laplanche and Pontalis, 1973, pp.

7.1. Anxiety neurosis 10–12). Indeed, important alienists agreed withFreud’s nosological view. For example, Hartenberg

By the early 1890s, the ‘neurasthenias’ had be- (1901a) who only took issue with the ‘sexual aetiolo-come so large that they threatened to engulf all the gy’ and preferred as explanation the older mecha-‘neuroses’. Started in the USA, but taken over with nism of Morel and Krishaber: ‘anxiety neurosisenthusiasm by European physicians (less so by originates in the sympathetic nervous system’ . . .alienists) (Wessely, 1995), the category neurasthenia ‘the term anxiety neurosis is useful to differentiateincluded most, if not all, the symptoms of anxiety. from neurasthenia a distinct group of symptoms thatFreud (1953b/1894) then published his classical represent a ‘primary disorder of the emotions’ andpaper arguing that ‘anxiety-neurosis’ should include: which can provide an explanation for the develop-‘general irritability, anxious expectation, anxiety ment of phobias’ (p. 699) (for an excellent treatmentattacks, and [somatic] equivalents such as car- of these issues see May, 1968; Levin, 1978).diovascular and respiratory symptoms, sweating, But there was also disagreement. For example,

´tremor, shuddering, ravenous hunger, diarrhoea, ver- Pitres and Regis (1902) in their famous Les Obses-tigo, congestion, paræsthesia, awakening in fright, sions et les Impulsions wrote: ‘during recent yearsobsessional symptoms, agoraphobia, and nausea’. German authors have described what they callThese complaints were to be found in various anxiety-neurosis. According to Hecker, this disordercombinations and resulted from either a ‘grave would include all the symptoms of neurasthenia —hereditary taint’ or from a ‘deflection of somatic the latter term being now reserved for simple spinalsexual excitation from the psychical field, and an irritation. On the other hand, Freud considers an-abnormal use of it, due to this deflection’ (p. 97). xiety-neurosis as an independent disorder character-Mostly theoretical, this paper, as Freud (1953c / ised, in its pure form, by nervous over-excitement,


chronic anxiety and anxious attention, attacks of Attack . . . ’ (American Psychiatric Association,acute and paroxysmal anxiety with dyspnoea, palpi- 1994).tations, profuse sweating . . . ’ (p. 250). Pitres and Next to nothing has been written on the history of

´Regis were referring to E. Hecker whose 1893 paper these phenomena and often the impression is givenhad been duly acknowledged by Freud: ‘I believed that social phobias were only recognised and definedthat this conception of the symptoms of the anxiety in 1966 (Liebovitz et al., 1985) or that there is aneurosis had originated with myself until an interest- major gap in the historical record between Hippoc-ing paper by E. Hecker came into my hands, in rates, Burton and the present (Marks, 1969, p. 152).which I found the same idea expounded with the In fact, two great books on social phobias (‘Timidi-most satisfying clearness and completeness. Al- ty’) were published at the turn of the century. Onethough Hecker recognises certain symptoms as equi- was by Dugas (1898a), better known for his contri-valents or incomplete manifestations of an anxiety bution to depersonalization (see below); an introspec-attack, he does not separate them from neurasthenia tive study, this work is based on the classical 19thas I propose to do’ (Freud, 1953b/1894, p. 77). century psychology tradition.

´Pitres and Regis (1902), in turn, believed that The second, and perhaps more important of theanxiety-neurosis was: ‘only a syndrome and hence two, was by Hartenberg (1901b) and includes a fullmay be found grafted, whether acutely or chronical- clinical, theoretical and aetiological discussion of thely, upon any neuropathic or psychopathic personality phenomenon. A disciple of Ribot, to whom he paid. . . It is associated with neurasthenia and melan- warm tribute, Hartenberg declared himself a positiv-cholia but can also be seen in other neuroses and ist psychologist, more ‘interested in behaviour thanpsychoses . . . There is, therefore, no independent in the soul’. Like Ribot, he believed both in thedisorder called anxiety-neurosis’ (my emphasis) (p. predominance of the ‘affective life’ and in the251). A similar criticism was voiced at the Grenoble ‘James-Lange’ theory of emotions. HartenbergCongress of 1902 by Lalanne (1902) who also (1901b) believed that timidity resulted from a combi-presented his oft-quoted historical account. The nation of fear, shame, and excessive embarrassment

´views of Pitres and Regis were defended by a young engendered by social situations, and that the disorderCapgras (1903) who also reported two cases in their could seriously impair psychosocial competence by

`support. causing attacks (acces) of fear. He studied both theDisagreements on the nature of the anxiety dis- subjective and objective manifestations of timidity

orders gave rise to a plethora of treatment ap- (e.g. tremor, unsteadiness of gait, dizziness, blushing,proaches; their study is beyond the scope of this etc.). But he also analyzed the timid personality andpaper (see Dubois, 1905; Dejerine and Gauckler, its tendency to isolation, misogyny, pessimism,1911; Thomas, 1913; Levy, 1917; Janet, 1919a; sadness, pride, irritability and suppressed anger.Berrios, 1996b). Hartenberg (1901b) distinguished between predis-

posing (inherited vulnerability), determinant (phys-ical, social or psychological defect — real or im-

7.2. Social phobias agined), and occasional (learning situations) causesof timidity. He conceived of timidity as a dimension

Social phobia remains a confused construct whose which ranged from minor shyness to the severe fearsmeaning oscillates between avoidance personality of the socially phobic; and believed that the bestdisorder and specific social fears: ‘The essential treatment was re-assurance and self-administeredfeature of Social Phobia is a marked and persistent behavioural therapies.fear of social or performance situations in whichembarrassment may occur (Criterion A). Exposure to 7.3. Paroxysmal anxiety attacksthe social or performance situation almost invariablyprovokes an immediate anxiety response (Criterion Although an expert in nutrition, Heckel (1917)B). This response may take the form of a situational- managed to write one of the great works on laly bound or situationally predisposed Panic nevrosse del’angoisse, particularly on its formes


paroxystiques (i.e. panic disorder). The monograph, history of ‘depersonalization’ see Sierra and Berrios,in fact, had been completed before the Great War 1996, 1997).started. In 12 chapters, issues ranging from history totreatment are fully covered. The first three chapters

´ áre dedicated to semeiologie (i.e. clinical presenta- 8. Other viewstion) which Heckel divided into paroxysmal andinter-paroxysmal. Then physical signs, mechanisms, 8.1. Morbid emotivityand causes are discussed. The paroxysmal states

´ ´Heckel classified according to the predominance of Fere (1899) published La Pathologie des Emo-cardiovascular, respiratory, digestive, neurological, tions in 1892. A disciple of Ribot and collaborator ofsensory or endocrinological manifestations. The as- Binet, he pursued an experimental approach in thesociation of each is then explored in its relationship study of emotions and their disorders. Of the 22to generalised anxiety, obsessions, phobias, impul- chapters of his book (covering all available knowl-sions, and tics. edge on emotions), five are dedicated to ‘morbid

´ émotivity’. By this crucial concept, Fere (1899/7.4. Depersonalization 1892) meant an emotivity ‘characterised by reactions

badly adapted to the interest of the individual or theThe term ‘depersonalisation’ was coined by species . . . [it] presents itself in two forms: (1)

Dugas. Like many others writers featuring in this diffuse and permanent morbid emotivity as apaper, he had trained under Ribot and believed that pathological character, and (2) systematic morbidboth in psychiatry and education the emotions were emotivity induced by special conditions always the

´ ´more important than the intellect. Dugas (1894) had same for the same individual’ (p. 360). Fere’scome across the phenomenon of ‘depersonalisation’ examples of diffuse emotivity correspond to Ribot’swhilst exploring the psychopathology of so-called panophobie and to current conceptions of general-‘false memories’: ‘In 1894, when dealing with false ised anxiety. Likewise, his instances of ‘systematicmemories, I had not yet knowledge of depersonalisa- morbid emotivity’ relate to states ranging from

´ ´tion. Not realising its novelty, I missed [the phenom- agoraphobia to specific phobias. Fere believed mor-enon] when I first met it’ (Dugas, 1898b, p. 424). bid emotivity to be constitutional, and his view mustSoon enough, however, he started writing on the be regarded as the origin of the idea of constitution

´ ´subject (Dugas, 1898c; Dugas and Moutier, 1911). emotive later on expanded by Dupre (1917).´The term Depersonnalisation was derived from an

expression taken from Amiel’s (1927/1883–1887) 8.2. JanetJournal Intime. In his personal diary, this Swissphilosopher had written: ‘Everything is strange to Janet was at the meeting point of two Frenchme, I can be outside of my body, of me as an psychological traditions and a foreign one. On theindividual, I am depersonalised, detached, away’ one hand, there was the positivism of Ribot, Taine,(my emphasis) (p. 288). ‘Depersonalisation’ was and Renan (who had been his teachers) and theintended to describe: ‘a state in which there is the spiritualist tradition of Maine de Biran, transmittedfeeling or sensation that thoughts and acts elude the to him by his uncle, the philosopher Paul Janet

´ ´ ´self (le moi sent ses pensees et ses acts lui echapper) (Prevost, 1973). On the other, there was the in-ánd become strange (lui devenir etranger); there is fluence of H.J. Jackson and his hierarchical approach

an alienation of personality; in other words a de- to psychological functions (Rouart, 1950).personalisation’ (Dugas and Moutier, 1911, p. 12). It In Janet’s model, feelings were secondary mentalis important to remember, however, that these au- states that guided the expression and termination ofthors are still using the concept of ‘personality’ in its behaviours (Fouks et al., 1986). Their effectiveness19th century sense (Berrios, 1993); ‘Personalisation depended on their energy ( force) and integrativeis the act of psychical synthesis, of appropriation or capacity (tension). Exaggerated energy or reducedattribution of states to the self’ (p. 13) (for a full integration led to a failure of feelings, and to the


release of primitive behaviours. Anxiety and anguish ness, vertigo, palpitations, and gastric bloating wereconsidered as separate diseases and were not thewere the main manifestations of such failure. Likepreserve of alienists but of general physicians.Freud, Janet believed that both behaviours were

Towards the end of the century, and very gradual-accompanied by somatic symptoms. However, hisly, the concepts of generalized anxiety, agoraphobia,interest was in the description of the ‘mental’ orsocial phobia, depersonalization and paroxysmal‘psychological’ component of l’angoisse which heattack of anxiety were described. The historicalstudied repeatedly (Janet, 1898, 1909, 1919a, 1926).factors that encouraged their construction are not theIn 1903, he proposed a rather wide clinical conceptsame in each case and have to do with the gradual´called psychasthenie under which he proceeded topsychologization of the neuroses, new organicinclude all the symptoms of anxiety and panic (Janet,models of psychoses, ideological changes brought1919b/1903, pp. 220–265).about by the tragedy of the Great war, and advancesin general medicine and neurology. For a while,8.3. Bergonzoli and the great integrationover-encompassing categories such as neurastheniaand psychasthenia threatened to engulf the inchoateBergonzoli’s (1915) great monograph constitutesanxiety disorders but became fragmented after thethe culmination of nearly a hundred years of ideas onGreat war.anxiety as a medical subject and is based on 356

Psychiatric views on the anxiety disorders werereferences. Stati ansiosi nelle Malattie Mentali in-changed by the Great war. Severe states of anxiety,cludes 12 chapters ranging from history to medico-shell-shock, temporal loss of motor, sensory andlegal aspects, and considers anxiety as a symptom, amental functions, either seen alone or in the wake ofsyndrome, and a disease in its own right. Bergonzolihead injury, responded to psychological approachesconcludes that the anxiety states are complex phe-and proved to be reversible. These clinical findingsnomena, with both mental and somatic mani-were interpreted as challenging the ‘organicfestations, found accompanying a variety of mentalparadigm’ and gave a fillip to psychological accountsdisorders. In spite of the frequent severity of itsof a number of disorders. The pendulum swung toosymptoms, there is no reason to create an autonom-far the other way, and interesting 19th centuryous entity, whether called anxiety-neurosis or an-observations concerning the neurobiology andxiety-psychosis. A disorder of constitution, bothheritability of some of the anxiety disorders werehereditary and degenerative, is at the basis of anxietylost. The recovery has just started.and its manifestations and hence it should not be

considered as a mere exaggeration of ‘normal’emotivity. The basis of the disorder is to be found in

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