Being in a state of anxiety

Being at a high risk of carrying the gene generates ambivalence. It yields a sense of opposites: carrier/non-carrier. These opposites leave the patient in an unprecedented situation. Caught up in this dualism, individuals might be overwhelmed by a sense of doubt—am I a carrier or not? Such doubt is redolent of obsessive ambivalence. It may overwhelm, disable, or inhibit individuals' thinking and acting.

When experiencing doubt, a patient needs to know their real genetic position. Doubt is often unbearable when dealing with the anguish of waiting and self-observation. Any change in behaviour, any abnormal movement, could be interpreted as a sign of disease: "Is anything getting out of my control? Am I forgetting any word, any work to accomplish, or any meeting? When this distressing question comes back to my mind: is it the beginning of the disease?" (Caniou, 1999, translated for this edition). Anything can trigger anxiety. However, we should not confuse a carrier's anxiety with a psychotic anxiety. It is not the kind of anxiety Pasche (1996) described as death anxiety among healthy patients with no external threatening sign. It is not a hypochondriac anxiety either: "the withdrawal from unconscious representations of an organ, a function, or their immobilisation can generate a void to be filled by disturbing physical sensations in the body" (Brusset, 2002, p. 64, translated for this edition). When repeatedly exposed to several family members' disability, individuals question their genetic risk. We might here be assisting in the emergence of a new clinical approach, with these unprecedented situations leading to new complaints and forms of anxiety.

The notion of anxiety proves to be a good tool to understand experience through a testing process. Minimal anxiety proves to be a protective signal, preparing individuals to learn the test result. Freud insisted on the positive side to anxiety, as being an anticipation and preparation for danger (Freud, 1916-1917, 1933a).

Fright, fear and anxiety are improperly used as synonymous expressions; they are in fact capable of clear distinction in their relation to

danger. Anxiety describes a particular state of expecting the danger or preparing for it . . . fear inquires a definite object of which to be afraid.

Fright, however, is the name we give to the state a person gets into

when he has run into danger without being prepared for it . . . there is

something about anxiety that protects its subject against fright. (Freud,

1920g)

In a presymptomatic testing situation, those three notions seem to be well represented. Anxiety is experienced while waiting for a possibly threatening result.

Fear of the results is experienced under knowledge that resolution of the uncertainty will come through an announcement of the result in binary form: carrier/non-carrier. Fear is based on excessive anxiety, with a primary danger "overwhelming the defensive ability of the body-ego" (Freud, 1923b).

If not prepared by the anxiety signal, an inflow of external energy would force the stimulus barrier and, thus, generate a trauma. "The Ego is concerned with its security. It uses anxiety sensations as a warning against any danger that may threaten its integrity" (Freud, 1940a). Accordingly, as a signal, anxiety is a self-protective and a self-organising mechanism for the ego. Such anxiety may be considered normal and necessary in the waiting context of genetic testing. By contrast, automatic anxiety would be a sign of distress and trauma, leading the ego to actual neurosis.

Prior to testing, successive consultations are used in order to helping trigger anxiety as a signal so as to reduce the pathogenic and traumatic effects announcement of the test results might induce. However, for two reasons, it would be illusory to believe that a result will have no traumatic effect. This is, first, because learning the results raises questions of identity, of filiation, and, particularly, of prediction as to the future. Second, anticipation does not spare individuals from suffering mental collapse, from coming adrift. When unprepared, individuals might feel fright, becoming overwhelmed by their instincts: it becomes impossible for them to frame such an unfathomable, unthinkable event.

Laplanche (1980) emphasises the paradoxical nature of the situation: "Fright continues, when we thought the individual would be prepared through the number of experiences he went through" (p. 58, translated for this edition). Anticipating does not completely prepare against fright, since the attack can be internal and can overwhelm the eg°.

Hence, anxiety has a dual status: its intentional aspect (as an alarm signal) is closer to fear. Its irrational aspect (which is automatic and attacks the subject from the inside) is closer to fright.

 
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