Idea Transcript
Sectional
Proceedings
of the Royal Society of Medine
Vol89.5X
Section of jpzcbtatrp President-T. A. Ross, M.D. [January 12, 1937]
Observations on Heredity in Neurosis
By R. G. MCINNES, M.R.C.P.E., D).Psych. No one who works with neurotic patients can fail to be impressed by the frequency with which a family history of nervous or mental disorder is given in these cases. I think it must be fairly general experience that the doctor engaging himself in this kind of work commences his career with a predominant orientation towards the importance of psychological explanations and the relief of symptoms by purely psychological means; and indeed with much justification, for at present these are almost the only specific instruments we possess which are practically effective. But, as experience is gained, I think the conviction grows that much of the neurotic problem lies neither in the nature of the symptoms nor in the manner of their production, but in the bare fact that under similar conditions some people suffer neurotic breakdown and others do not. In other words, the operation of a constitutional factor begins to engage the attention of the physician and to loom ever more large in his speculation. Freud, in his New Introductory Lectures, says: " The neuroses are serious, constitutionally determined affections which are seldom restricted to a few outbreaks but make themselves felt as a rule over long periods of life or even through its entire extent. Our experience, that we can influence them to a far-reaching degree if we can get hold of the historically precipitating causes and the incidental accessory factors, has made us neglect the constitutional factor in our therapeutic practice." Elsewhere in the same book he mentions a constitutional instinctual endowment and speaks of hormonic action as possibly supplying the quantitative variations of instinct which are encountered in the course of analytic work. In all except those cases in which the exogenous factors have been overwhelming, the existence of some degree of constitutional predisposition is generally recognized. Of what it consists, how it is transmitted or acquired, we do not know. The manner of its operation we may be able to learn. It was with such thoughts in mind that I began to survey the neurotic case material which passed through my hands in the Jordanburn Nerve Hospital, Edinburgh. In the course of these observations it was noticed that certain differences, which might be of importance, existed between the family histories of anxiety neurotics, hysterics, and normal people. MAY-PSYCH. 1
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Fifty cases of anxiety neurosis, 30 cases of hysteria, and 75 controls, form the material of the investigation with which this paper deals. The criteria for admission to the series were first, that an adequate account of parents and siblings should be available, and second, that the cases should conform to a more or less rigid classification. Unfortunately it was not found possible without the aid of field workers to obtain reliable family histories beyond the first degree of relationship, but in some respects this is an advantage. By this I mean that the family histories in all these cases were taken in the ordinary course of clinical work and before this investigation was thought of; this removes the possible objection that one finds what one is looking for. Furthermore, with a very few exceptions, the clinical histories and data from controls were taken by myself, a procedure which may make for uniformity. The family histories of the controls were, of course, taken later. To begin, then, with an examination of the anxiety group. The clinical criteria for admission to this group were the occurrence of anxiety manifestations, consisting of palpitation, sweating, trembling, subjective feelings of fear, phobias such as claustrophobia, agoraphobia, &c., anxious preoccupation and the like. Cases showing conversion symptoms were not included, and likewise depressions with concomitant anxiety were not considered. Some anxiety neuroses show a mild secondary depression, however, which is commensurate with the disability and discomfort which the neurosis entails. Cases showing only this type and degree of depression, in addition to their anxiety symptoms, were not debarred from the series. Of the 50 cases of anxiety neurosis 23 (i.e. 46%) had normal parents-that is to say, parents in whom no history of psychosis or neurosis was recorded. 14 (i.e. 28%) had one parent in whose case there was recorded a history of either chronic or
occasional neurotic anxiety. Where symptoms were recorded indicating the presence of anxiety sufficiently marked to give rise to spontaneous mention or to obvious objective manifestations, in that instance the relative was considered as a positive example of anxiety. The anxieties of the involutional type are not included in this conception.
In 14 of the 50 cases there was a history of anxiety in one parent. Of these 14 cases: In 1 instance the other parent showed anxiety. In 1 instance the other parent was asthmatic. In 1 instance the other parent was melancholic. Of the remaining 13 cases in whose parents, although no history of anxiety is recorded, yet some other abnormality existed8 gave a history of indefinite nervous disorder in one parent. 2 gave a history of asthma in one parent. 1 gave a history of hypochondria in one parent. 4 gave a history of alcoholism in one parent. To recapitulate: In the parents of the 27 cases in which some parental abnormality was recorded there were15 instances of anxiety. 8 instances of indefinite nervous disturbance. 4 instances of alcoholism. 3 instances of asthma. 1 instance of melancholia. 1 instance of hypochondria.
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897
Altogether in the whole anxiety group there were 2% cases showing psychosis and 34% of cases showing neurosis including 28% cases showing anxiety neurosis in the parentage. 18% showed a disorder too indefinite to classify (see Table I). TABLE I.-PARENTS. Percentage of
NMUROSIS
PSYCHOSIS
Anxiety neurosis
...
NEUROSIS or PsYCHosis of siliiilar type in the parentage
cases showing
in the parentage
Illness
cases showing
Percentage of
Percentage of cases showing
in the parentage
2
34
Hysteria ...
...
6.6
20
Controls ...
...
2.6
14.6
28
6.6 Anxiety
8
Hysteria 1.3 Considering now the siblings of this group of 50 cases of anxiety neurosis In 25 (i.e. 50%) of the cases there was some abnormality in the siblings. In 23 (i.e. 46%) of the cases there was a history of neurosis or psychosis in the siblings; in 21 cases (i.e. 42%) neurosis, and in 2 (i.e. 4%) psychosis. Of these 21 cases, in 14 the siblings showed anxiety, i.e. in 28% of the total (see Table II). TABLE I1.-SIBLINGS. cases showing NEUROSIS in siblings
PSYCHOSIS in siblings
Illness
Percentage of cases showing NEUROSIS or PsYcHosis of similar type in siblings
Percentage of
Percentage of cases showing
Anxiety neurosis
...
4
42
Hysteria ...
...
3.3
16.6
Controls ...
...
2.6
18-6
28
6.6
Anxiety 12
Hysteria 1.3 The total number of siblings of the whole group was 189. Of these 42 showed some neurotic or psychotic taint, i.e. 22%. Of these 28 were examples of anxiety, i.e. 14%. Taking now the siblings of the 23 patients whose parents were normal. There was a total of 95 siblings. In these there were 3 examples of anxiety, 2 of melancholia, 2 of neurasthenia, 2 of mental defect, 2 of epilepsy, 1 of asthma, and 1 of chorea. This leads to the observation that in 23 families in which the parents were said to be normal, there were 36 out of 118 children with some taint, and of these 26, i.e. 22%, suffered in some degree from neurotic anxiety. Considering now the 14 cases in which one parent suffered from anxiety, there were 68 siblings. Of these there were 18 examples of anxiety, 2 schizophrenics, 1 chorea, and 1 melancholia. This means that in 14 families in which one parent showed neurotic anxiety, 32 out of a total of 82 children, i.e. 39%, also showed neurotic anxiety (see Table III). TABLE III.
Anixiety group Those
Percentage of siblings showing anxiety
withi
Whole grouip
norlilal parents
14
3.15
Those with
anxiety in one parent
26
Continuing the examination of this group of 14 cases in which one parent showed anxiety, and assuming for the moment that there may be some hereditary transmission, there were 18 instances of mother-daughter transmission, 9 instances of father-daughter transmission. 5 instances of mother-son transmission, .2 instances of father-son transmission. MAY-PsYCH 2 *
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Proceedings of the Royal Society of Medicine
Altogether, 23 instances of transmission from the mother, and 11 instances of transmission from the father. These figures agree in the main with Mott's findings for the psychoses in general. The next part of the inquiry is concerned with a consideration of the possible effects of parental anxiety on the clinical course of the illnesses in the cases under review. The following table gives a comparison of the results: TABLE IV.-SHOWING THE EFFECT OF ABNORMALITIES IN THE PARENTAGE ON THE OUTCOME OF ANXIETY NEUROSIS. Parentage
Percentage recovered
Percentage relieved
Percentage i.s.q.
Normal ... ... One parent showing anxiety .. Indefinite nervous disorder in parentage
42 30
43
47 42
14
63
17
8.6
A follow-up inquiry was made to render these results more valid. There was a large number of untraceables, and the smallness of the groups makes one hesitate to draw conclutions, but as far as the evidence goes it seems to indicate that there is no substantial difference in the outcome between the group with parental anxiety and the group which is free from it. On this basis one might argue that the presence of anxiety in the parents was not necessarily a bad prognostic factor, and vice versa. It is a common observation that in taking the history of neurotic patients one frequently obtains accounts of previous symptoms of a neurotic nature. Many of these occur in childhood, and it seems that there might be some correlation between their presence at an early age and the presence of parental anxiety. It has to be remembered, of course, that nearly all children at one time or another may have fleeting fears-such as fear of strangers, fear of being alone, and fear of the dark, which, although essentially neurotic, are so universal as to be almost considered normal. The following figures do not include states of this kind: TABLE V.-SHOWING INCIDENCE OF NEUROSIS IN THE CHILDHOOD OF ANXIETY NEUROTICS. Pare_tage Normal
Percentage of cases with nenrotic or temperamental abnormality of any kind in childhood Percentage of cases showing definite anxiety neurosis in childhood
Anxiety in one parent
60.8 64
43-5 50
Here, although there is a slight predominance of neurosis in the childhood of the group with anxious parents, it is not sufficiently marked, and the numbers are not large enough, to justify any conclusions. I would like to consider now for a moment the question of causation. The assigning of causes in the anxiety states is difficult and depends, to some extent at least, upon the individual predilections of the physician. He may be definitely Freudian in his beliefs, or he may adhere to some other school of psycho-pathology, the teachings of which form the basis of this psychotherapeutic effort. It is beyond the scope of this paper to discuss these points, but I feel that psycho-analytic theory offers the only satisfactory explanation of mechanisms in the neurosis, and it has been my own experience that it provides a measure of understanding not attainable by other means, and without which psychotherapy tends to be irrational. The theories of the therapist may not go so deep, however, and he may regard neurotic anxiety as simply the outcome of a disproportion between demand and capacity. Whatever be taken as the actual source of anxiety, however, it is a matter of clinical observation that certain situations, frequently related to the sex life of the individual, are prone to act as the apparent cause of what we clinically recognize
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as anxiety neurosis. It may be that the nature of the precipitating situation has some relation to the occurrence of anxiety in the parentage of anxiety neurotics. The following table sets forth the findings:TABLE VI.-SHOWING THE APPARENT CAUSES OF ANXIETY NEUROSIS. Percentage Incidence of Causes
Parents Cause
Marital incompatibility ... Unsatisfactory intercourse ... Masturbation ... ... Coitus interruptus Conflict over sex attachment Separation from sexual object Worry over illegitimacy ... Influenza ... ... ... ... Childbirth ... ... War service
Oral sepsis
...
Domestic strife ... Business worry Failure of vision No cause assigned
...
... ... ... ... ... ... ... ... ...
normnal 26 13 -
8.4 8.4 8.4 4.2 4.2 4-2
... ...
...
-
...
Anxiety in one parent
7-1 -
7-1 21 14.2 28.4 -
Indefinite
nervous disorder in parentage
7.6
16-3 -
30.7 7.6 7.6 -
7.1 7.1
-
84
-
...
...
-
...
..
-
7.6 7.6
...
...
13
7.1
15.3
These figures are derived from numbers which are too small to justify conclusions. There is the suggestion however that those whose parents are neurotic are more likely to break down under sexual deprivation of a purely physical kind. On the other hand the well-endowed seem to be less able to stand general marital incompatibility. The marked predominance of sexual causes is noticeable over the three groups. Before leaving the consideration of the anxiety group I might mention that a comparison of the kinds of situations which give rise to anxiety in those with and those without previous manifestations yielded no definite differences. Further, in correlating the outcome of anxiety states with the occurrence of pre-neurotic symptoms we find that 33 out of 50 cases had shown previous symptoms. Of these 42.4% recovered; 42-4% were improved; 15.2% were in statu quo. Of the remaining 17 who showed no previous symptoms 47 % recovered; 47 % were improved; 6% were in statu quo. The group without previous symptoms, therefore, shows slightly more favourable results. HYSTERIA GROUP Turning now to the second part of the investigation, namely the group of 30 cases of hysteria, I have to describe the criteria for admission to this group. This is a difficult matter, and it would be impossible to give a comprehensive list of symptoms under this heading. In general, however, the cases in this group all showed conversion symptoms of some kind such as seizure, anaesthesias, paralysis, aphonia, and the like. In addition, there was in these cases an absence of anxiety amounting in some instances to the affective indifference generally supposed to be characteristic of the hysteric. Of the 30 cases in this group 20 had parents in whom no abnormality was recorded, 10 had one or other parent in whom some abnormality was noted. Of these 10 cases with one abnormal parent, there were: 2 in which the parental abnormality was hysteria-6-6%. 2 in which the parental abnormality was anxiety neurosis, 1 in which the parental abnormality was epilepsy, 1 in which the parental abnormality was cyclothymia, 1 in which the parental abnormality was asthma, 1 in which the parental abnormality was stammer, 2 in which the parental disorder was indefinite.
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These figures are perhaps too small to give significant percentages when con-
sidered by themselves, but in comparison with the previous anxiety group, it is to be noted that whereas 28% of the anxiety cases had one anxious parent, only 6.6% of the hysteria cases had a hysterical parent. The percentage of cases in which
some form of neurosis occurred in the parentage of the hysteria group was 20 (8ee Table I, p. 25). In considering the siblings of the hysteria group, it was found that the number of cases in which the siblings were abnormal was 7 out of 30. Of these, in5 cases there was neurosis (i.e. 16.6%) and in 2 cases the siblings showed hysteria (i.e. 6.6%). In one case there was psychosis in the siblings (i.e. 3.3%). Comparing these figures with the corresponding results for the anxiety group, we recall that in 46% of the anxiety cases there was neurosis or psychosis in the siblings, and that of these, 28% showed anxiety neurosis. The difference is perhaps sufficiently substantial to be noteworthy (see Table II, p. 25). The total number of siblings in the hysteria group was 117. Of these 8 were recorded as having shown some abnormality. These were: 2 instances of anxiety neurosis, 2 instances of schizophrenia, 1 instance of melancholia, instance of neurasthenia, instance of mental defect, instance of enuresis. Four of these could probably be classed as neurosis, giving a percentage occurrence of neurosis in the siblings of this group of hysterics of 3-3. In comparing these figures with those of the anxiety group, we find that there were 189 siblings, and of these 22% (as against 6.6%) showed neurosis or psychosis and 14% (as against 3.3%) showed neurosis of a similar type. TABLE VII.-SHOWING THE PERCENTAGE INCIDENCE OF ANXIETY NEUROSIS AND HYSTERIA IN THE SIBLINGS OF EACH GROUP. Anxiety Hysteria grotup controls group .. 4.5 1.7 14 Percentage incidence of anxiety neurosis in siblings ... ... ... Nil 1.1 Percentage incidence of hysteria in siblings
383
Considering for a moment the families involved in the hysteria group: There were 20 families in which no parental abnormality was recorded. In these 20 families there were 105 children (including the hysterics). These yielded 4 additional instances of abnormality, i.e. 24 out of 105, or 22.8%. There were 10 families in which there was abnormality in one parent. In these families there were 42 children including the hysterics. These also yielded 4 instances of tainting, i.e. 14 out of 42, or 33.3%. Again, these results are perhaps not particularly significant in themselves, but when it is remembered that the family histories were taken before such an inquiry as this was considered, that they were with few exceptions taken by one individual, and that there seems no reason to suppose that the informants in one group were more reticent or less accurate than in the other, the differences between the hysteria group and the anxiety group with regard to the occurrence of a neurosis of similar type in parents and siblings, is worthy of comment. In the anxiety group it was found that in 36% of cases there was psychosis or neurosis in the parentage, and in 28% the neurosis was similar in type; while in the hysterics, in 26% of cases the parentage showed neurosis or psychosis, and in only 6.6% could the abnormality be said to be similar to that occurring in the patient (see Table I, p. 25). In attempting to discover some correlation between the heredity of this group of hysterics and the outcome of the illness, the following results were obtained:
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TABLE VIII. Outcome of hysteria
Parentage
Parents normal One parent abnormal
Percentage recovered
30 30
State on discharge Percentage Percentage improved I.S.Q. 45 25
40
30
On this basis there is no noteworthy difference in the outcome of the two groups; in fact their similarity is noticeable. As in the case of the anxiety group, an effort was made to determine in the hysterics the possible correlation between heredity and the occurrence of previous symptoms. Taking first the group of 20 hysterics with normal parents, we find that in 8, no previous symptoms were recorded. In 12 of the cases, some previous abnormality was recorded. This represents a percentage of 60, as compared with a percentage of 60-8 in the corresponding group of the anxiety cases. Further, it was noted that of these 12, four showed previous symptoms which were predominantly hysterical in type, i.e. a percentage of 20 as compared with a percentage of 43*5 of the anxiety cases where previous anxiety was noted. Turning now to the group of hysterics in which one parent showed some abnormality, it was found that in 2 cases no previous abnormality was recorded. In 8 of 10 cases in which the parentage was normal, some previous neurotic abnormality had occurred in the patient. This represents a percentage of 80 which compares with a percentage of 64 in the anxiety group with abnormal parents. Although the groups are small, and on this ground there must be hesitation in drawing conclusions, the figures in both groups point to the greater occurrence of neurotic trends in children with neurotic or psychotic parents. This is, of course, in accordance with clinical impression, but the figures further suggest that anxiety neurosis shows a greater tendency to run true to type than does hysteria. In pursuance of further study of the hysterical group an attempt was made to trace a possible relationship between the occurrence of previous neurotic manifestations and the outcome of the illness for which the patients were in hospital. In the group of 30 hysterics, 20 had shown some previous symptoms. Of these: 6 recovered (i.e. 30%) ; 8 were improved (i.e. 40%) ; 6 were unchanged (i.e. 30%). Of the remaining 10 cases with no previous symptoms: 5 recovered (i.e. 50%); 4 were improved (i.e. 40%) ; and 1 remained unchanged (i.e. 10%). Again the groups are small, but the tendency is towards a more favourable prognosis in those cases without previous neurotic history. To complete the investigation of the hysterical group and to make further comparison with the anxiety cases, a survey of the apparent causes of breakdown was made. Again it must be emphasized that the allocation of single formal causes in such a group of cases is a matter fraught with difficulty and open to criticism; but again it can be cljiimed with some justification that there are certain situations or kinds of situations, involving either through soma or psyche, the emotional life of the individual, which are clinically observed to be the frequent apparent cause of neurosis and which can often be expressed in a phrase as the main factor in the precipitation of the illness. For example, it is common to find that jealousy of a brother or sister is the obvious cause of a series of hysterical seizures. The basis of the attitude of jealousy is, of course, another matter and would involve a theoretic discussion of psychopathology which is outwith the scope of this paper. The presenting emotional situation, therefore, is for present purposes of comparison, taken as the main cause of the illness. In considering the hysterical group on this basis, the following facts emerge Taking first the group of 20 whose parents were normal, we find that the causes were as follows: In 5 cases jealousy of brother or sister.
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In 4 cases physical and accompanying psychic trauma. In 3 cases dislike of occupation. In 1 case conflict over marriage. In I case worry over defective child. In 1 case trauma of sex assault. In 1 case conflict over sterilization. In 1 case fear of tonsillectomy. In 1 case fear of responsibility. 2 cases in which no definite cause could be assigned. In the group of 10 in which one parent was abnormal, the causes were: In 2 cases jealousy of brother or sister. In 1 case dislike of occupation. In 4 cases conflict over sex attachment. In 1 case fear of pregnancy. 2 cases in which the cause was indefinite. Although there is perhaps no very significant difference in the nature of these two groups, it is noteworthy that in the hysterical group as a whole, several situations appear repeatedly as assigned causes which have no place in the list of factors described in connexion with the anxiety group. In particular, the jealousy situation, which occurs seven times in a group of 30 hysterics, does not occur in relation to the anxieties at all. Similarly, dislike of occupation is peculiar to the hysterical group as a causal factor. From this it might be argued that the nature of the apparent cause of breakdown tends to be less subtle in the hysteric than in the anxiety neurotic. This, I think, is in accord with clinical impression and particularly with the general belief that, on the whole, hysterics are of comparatively meagre intellectual endowment.
CONTROL GROUP The third section of this survey is concerned with the control group. This consisted of 75 propositi, of whom 44 were females and 31 males, giving a relative percentage of 58-6 to 41*4. In the anxiety group the relative percentages of females and males was 62 and 38, and in the hysteria group 83 4 and 16*6. As far as possible the conditions governing the investigation of the control group were made to correspond with those under which information relating to the parents and siblings of patients in the two previous groups was obtained. That is to say, the data was procured in the course of a personal interview with the propositus during which the nature and purpose of the investigation was explained and the co-operation of the individual invited. In order to facilitate confidence, the anonymous principle was emphasized and preserved. The actual propositi were drawn partly from the staff of the Royal Edinburgh Hospital and partly from personal acquaintances of myself and my colleagues and friends. In this way a mixed group was obtained, corresponding in range of age, occupation, and social level, with the groups of patients suffering from anxiety neurosis and hysteria which formed the previous parts of this investigation. Considering first the parents of the controls, it was found that in 54 out of the 75 propositi both parents were said to be normal, i.e. 72%. Of the remaining 21 propositi, in 11 there was an account of neurosis in one parent, i.e. in 14.6% of the total, in 2 there was definite psychosis in one parent, i.e. in 2-6% of the total, in 8 there was an indefinite abnormal state, i.e. in 10-6 of the total; these were probably: 2 cases of asthma, 2 of cyclothymia, 2 of irritability of unknown origin, and 2 undefined. It is to be particularly noted that the number of propositi in whose parentage neurotic anxiety was recorded was 6 (or 8%).
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This is to be compared with the state of affairs relating to the anxiety neurotics in which, it will be recalled, 28% of the cases gave a history of neurotic anxiety in one or other parent. This difference is sufficiently large to be of some significance. Of the remaining 5 cases in which neurosis was recorded in the parentage, there was only one instance in which the neurosis was hysterical in type, i.e. in 1.3% of the total (see Table I, p. 25). In considering the siblings of the control group, it was found that the number of propositi in which the siblings were said to be normal was 53 out of 75 or 70.6%. The remaining 22 showed some abnormality in the siblings. The number of propositi in which neurosis or psychosis occurred in siblings was 16 out of 75, or 21.3% (see Table II). This compares with a percentage of 46 for the anxiety group and 19*9 for the hysteria group. It will be noted that this figure is lower than that for the control group. This is probably to be explained by the fact that in the control group the directed interest of the observer may have resulted in the more thorough discovery of family abnormalities. On this basis it might be suggested that the figures for abnormality in the control group are disproportionately high. If this is true, the differences between them and the figures for the other groups are probably less than that which exists in reality. Of the 22 propositi in whose case there was some abnormality in the siblings, In 2 instances the abnormality was psychosis (i.e. 2.6%), In 14 instances the abnormality was a neurosis (i.e. in 18.6% of the total), and in 6 cases the abnormality was too indefinite to classify (i.e. in 8%). Taking the group of 14 propositi in which neurosis occurred in the siblings, it was found that in 9 of these the neurosis was of the anxiety type, i.e. in 12% of the
total. This figure is to be compared with that of 28% of the anxiety group, in which the siblings also showed anxiety neurosis. In the case of 1 of the 14 propositi mentioned here, hysteria occurred in the siblings, i.e. 1.3% of the total, compared with 6.6% of cases in which hysteria occurred in the siblings of the hysteria group (see Table II). The total number of siblings of the control group was 176. The incidence of anxiety neurosis in this group was 4.5%, as compared with 14% in the siblings of the anxiety group. The incidence of hysteria in the siblings of the control group was 1.1%, as compared with 3.3 % in the siblings of the hysteria group (see Table VII). Finally, taking the controls as a closed group by themselves, it was found that there were 251 children of 75 matings, giving a total of 401 individuals. It was found that the percentage incidence of psychosis in the parents was 1*3, in the children 0 79, giving a percentage, over the total, of 1. The incidence of neurosis appeared to be higher, i.e. 7-3% in the parents, 6% in the children, and 6.4% over the total, i.e. 64 per thousand. This concludes the description of the data collected from the material investigated. For many reasons it would be unjustifiable to attempt to draw definite conclusions as to the possible hereditary transmission of anxiety states or hysteria. In the first place, the groups and subgroups are numerically small, although this defect is, to some extent, offset by the provision of controls. Apart from this, however, there is the difficulty at present of assessing how much of any constitutional neurotic tendency is genetically inherited, how much may be dependent upon intra-uterine toxic or other congenital factors, and how much is due to anomalies of libidinal development in infancy. The last of these possibilities again introduces psycho-analytic concepts. At this point I must make it clear that, although it is the purpose of this paper to draw attention to the constitutional factor in neurosis, the intention is not thereby to minimize the great importance of the psychogenic factor, but rather to range the
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two alongside each other in order to give a more balanced perspective of the neurotic problem. It has been my experience that there are many cases of neurosis arising out of psychic conflict in which the patients appear to have no constitutional predisposition. In such instances, the conflict is generally intense and activated by powerful exogenous stimuli. Recent cases of this nature probably offer the best hope of recovery with psychotherapeutic help, and one embarks on their treatment with optimism. At the other end of the scale there are cases in which the patients have shown a consistent tendency to break down under ordinary or even trifling strains and in which the physician can only employ the simplest therapeutic procedures. In such cases I think it is justifiable to postulate the existence of a constitutional neurotic tendency. Between these two extremes there are all grades of combination of factors, and it is my own opinion that judicious treatment cannot be instituted until these have been assessed as far as possible and each given its due place in the causation of the neurosis. The question arises as to what guides we have in reaching such an assessment, and it was with the idea of initiating a search for some standards, especially in relation to heredity, that this paper was written. Newman and Carter have demonstrated in studies on normal twins the influence of germinal factors in the production of emotional variations. The recent investigation of a series of manic depressive twins, by Rosanoff, Handy, and Plesset has thrown fresh emphasis on the importance of heredity in these conditions. The survey with which the present paper deals furnishes confirmatory evidence of the general feeling that neurotic patients are more heavily loaded than the general population, and, in particular, it suggests that in anxiety neurosis there may be a specific hereditary factor or group of factors which operate in some cases in producing the emotional disorder. Much work of a more detailed and extensive nature is required before this point can be established, and this paper represents only a tentative approach to the subject. I wish to express my indebtedness to Professor D. K. Henderson for permission to utilize the case material and for much valuable help and criticism, and to thank him and Dr. T. A. Ross, through whose kindness I was privileged to present this paper to this Section of the Royal Society of Medicine. REFERENCES CARTER, H. D. (1935), Character and Personality, 4, 61. FREUD, S. (1933), " New Introduct. Leot. on Psycho-Analysis ", London, p. 197. MOTT, F. W. (1910-11), Eugenics Rev., London, 2, 245. NEWMAN, H. H. (1935), Am. Naturalist, 67, 193.