Freud described a clinical entity, anxiety neurosis, which he distinguished from hysteria and psychoneurosis. Dos Santos reviews at length the history of the concept and Freud's elaboration of it. The main themes of Freud's descriptions involved general excitability, floating anxiety, and anxiety attacks with somatic manifestations
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which may be cardiac, respiratory, vasomotor, etc. Dos Santos is impressed with the accuracy of Freud's early clinical descriptions, and argues for the continued applicability of the phenomenological descriptions of the clinical entity. In Freud's view this was an actual neurosis that disturbs the libidinal economy only. Dos Santos does not agree with this purely economic explanation that led Freud to stress the role of contemporary sexual dissatisfaction and the accumulation of toxins. For Dos Santos, structural and genetic aspects are also inseparably involved.
There is a characteristic ego structure in patients with anxiety neurosis. Dos Santos stresses the experience of fragmentation or dissolution of the ego at the times of "crises of anxiety" as described by Freud. The anxiety has an organizing character similar to that of phobia or hypochondria. Rather than neurotic manifestations, however, there is a "brutal regression" of the ego, establishing an anxiety neurosis with a predominantly pregenital makeup. The ego is unable to contain the amount of excitation which invades the psychic apparatus at the time of crisis, and the anxiety comes to have a catastrophic character, in which it is as if all the mechanisms of defense suddenly disappeared. Dos Santos believes that this inability to contain excitation can be linked with the early difficulties such patients have in organizing their anxietydreams as infants, dreams that in normal development become organizers of aggression and symbolizations of the primal scene, preparing the entry into latency. The apparent cause of the anxiety attacks often seems to be some event, such as an accident or a sunstroke, presented with logical, scientific, and "human" evidence. But a structural similarity exists between the explanations presented by individuals from "primitive" cultures and those from a Western "scientific" culture, for both involve rationalizing defenses. In essence, both evoke a sort of fetish, whether scientific or animistic, and both attempt to attribute the illness to an exogenous factor.
Phobia and hypochondria are often the eventual outcomes of anxiety neurosis, representing attempts to displace dreaded fears to the exterior, and so to contain them outside the body. In the phobic or obsessional individual, anxiety intervenes in a chronic state of malaise and in difficulties of a purely psychological character. In contrast, the crises of an anxiety neurosis frequently come upon the individual in a state of apparent health, and the anxiety is experienced in its somatic components. For this reason, an anxiety neurosis is to be viewed as a chronic psychosomatic disorder. These individuals are characterized by what Dos Santos calls an "incomplete hysterical structure." They have not completed the work of the oedipus complex and do not have a "solid" superego to draw upon. Their ego lives always in an infantile fear of confusing the parents in unconscious fantasies of bisexuality, incest, and castration. Their sexual relations are "simulated," not fully genital, and pursued as an antidepressive measure. The partner is not a true displacementobject, but an external attempt at displacement, modified by the eroticized projection of imagoes and parental fantasies linked to bisexuality. Dos Santos gives examples from his work with children in treatment, in order to illustrate his hypotheses. In his experience, individuals who are subject to anxiety neurosis require a preliminary stage of work in which an elementary reorganization of the ego occurs, permitting it to recuperate from the narcissistic wounds caused by the traumatic quantity of anxiety. In this first phase of analysis, the patient has to rely on the image of the therapist to permit himself or herself to pass beyond the state of anxiety, and to approach a hysterical organization more susceptible of a standard psychoanalytic approach.
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Wilson, E., Jr. (1992). Revue Française De Psychanalyse. XLIX, 1985. Psychoanal. Q., 61:146-147