To most psychoanalytic psychotherapists, anxiety is not just another symptom, nor is it a cluster of a range of disorders. Rather, it is a central phenomenon in the complexity of the psyche. To begin with, it is an affect—a more or less consciously experienced emotion. To the person experiencing it, it is an unnerving sensation—a signal that all is not well, that some kind of danger lurks— it borders on fear without a distinct object to fear. It may or may not have the physiological attributes of fear: tachycardia, palpitations, shortness of breath, gastrointestinal distress, muscle tension, insomnia, and more. Not understanding the psychic source of these symptoms may allow the anxiety to grow into overt panic—fear of death or catastrophic loss of control, the source of many needless trips to emergency rooms and negative cardiac work-ups.
The eruption of anxiety into such distressing symptoms is a signal that defensive measures to ward it off have failed. Yet managing anxiety is an important task for everyone. Some degree of anxiety is normal in many situations—before an examination, before giving a speech, before a first date. Anxiety in a manageable degree can be a positive motivation to be more alert, more prepared, more focused and effective, just as it can impair performance when it is not managed well and it becomes overwhelming and paralyzing.
Psychoanalytic Approach To Treating Anxiety
The trail that leads to anxiety starts long before the stage where it becomes disabling. Perhaps there is a genetic predisposition, an innate low threshold for anxiety, since anxiety disorders run in families. Perhaps there has been difficulty in the early development of the neural pathways that manage and control anxiety. This may be attributed to interference with attachment and emotional regulation in parent-child interactions early in life when critical steps in brain development are occurring. Psychologists contend that early life experiences as well as genetic makeup contribute to the formation of each individual brain, particularly its regulatory systems.
In one of his most important papers, Freud set forth a hypothesis of how anxiety plays a pivotal role in the development of symptoms. The locus of action is what psychoanalysts call the "ego," shorthand for the wide-ranging collection of executive functions that record sensation, process information, access memory, form assessments, reach decisions, and command motor activity. Most important for purposes of understanding anxiety is the ego function of regulating affects.
In Freud’s model as elaborated by later psychoanalytic studies of young children, the ego of a child experiences anxiety in a variety of situations related to the stage of infant and child development. In work with adult patients, it is not hard to discern these various types of anxiety. In-depth psychoanalysis may relate them to difficulties in early childhood attachments.
Having experienced great distress from anxiety at various stages in life, the ego develops defensive measures to reduce the pain. It establishes an early warning system, sensing the potential for anxiety through small sensations of “signal anxiety,” which prompt evasive mental activity. Thus avoidance of anxiety becomes the primary motivator of psychological defense mechanisms.
Some defense mechanisms are associated with particular symptom profiles. Examples are intellectualization and undoing evident in the rituals of in obsessive-compulsive disorder, or displacement and avoidance in phobias. By and large, defense mechanisms are unconscious, as are the impulses or thoughts that are warded off. Rarely are people fully aware of the multiple motivations and internal forces that result in final resolutions or actions.
Inherent in this formulation is psychic conflict—various parts of the personality that are at odds with each other or with the individual’s perception of external reality. Love and hate towards the same person create ambivalence. Sexual desire confronts moral prohibition or concern about realistic consequences. Chest pain and shortness of breath are at odds with a narcissistic vision of oneself as being in perfect health.
The powerful advantage of psychodynamic therapy is its openness to free association and exploration in partnership with the patient, without preconceptions as to the particular nature of the patient’s difficulty. Under the influence of the life-long human drive to mastery, many patients deeply desire to understand the source of their anxiety, to confront their unrecognized inner conflicts and environmental challenges, and to grow beyond the need for years of dependence on medication to regulate their emotional states.
With these patients, exploring their multiple emotions and motivations, recognizing ingrained ideas and compulsions to repeat traumatic situations, and accepting the presence of forbidden thoughts and feelings all lead to dealing with conflictual states of mind in a more conscious way with less of the nameless dread and anxiety that comes from not knowing or understanding.