Anxiety & Neurotic Disorders

Anxiety disorders are hard to tell apart if you learn them as symptom lists, because the symptom list is nearly identical in all of them.

Palpitations, sweating, tremor, dry mouth, breathlessness, chest tightness and a sense of impending doom are the physiology of autonomic arousal, and that physiology is the same whether the trigger is a spider, a crowded lift, an intrusive thought or nothing at all.

Two questions separate them.

What is the anxiety about? Panic is about the body itself. Phobia is about a specific situation. Generalised anxiety is about everything. Obsessive-compulsive disorder is about an intrusive thought. Post-traumatic stress disorder is about a past event pushing into the present.

How does it behave in time? Sudden and unprovoked, cued and predictable, continuous and free-floating, or triggered by a memory.

A third idea governs treatment and is the most useful sentence in the chapter.

Avoidance is what converts anxiety into disability. Escaping a feared situation reduces anxiety immediately, which powerfully reinforces the escape, and prevents the person from ever learning that the feared outcome does not occur. Every anxiety disorder is maintained this way, which is why exposure is the active ingredient of every effective psychological treatment.

1. The Grid

2. Panic Disorder

A panic attack is a discrete episode of intense fear with autonomic symptoms that peaks within about ten minutes.

Panic attacks are not the disorder. They occur in many conditions. Panic disorder requires recurrent unexpected attacks plus at least a month of persistent worry about further attacks or a significant behavioural change because of them.

The mechanism is a catastrophic misinterpretation of normal bodily sensation. A slightly fast heartbeat is read as an impending heart attack, which produces adrenaline, which speeds the heart further, which confirms the interpretation. The fear of the symptom generates the symptom, which is why explaining this loop is itself therapeutic.

Agoraphobia is not fear of open spaces but fear of situations from which escape would be difficult or help unavailable if panic occurred. That definition explains why patients avoid queues, buses, cinemas and bridges, which have nothing obvious in common except entrapment.

What must be excluded

Panic is a diagnosis that should never be made without considering physical mimics, particularly at first presentation.

Thyrotoxicosis, arrhythmia, hypoglycaemia, phaeochromocytoma, asthma, and substance effects including caffeine, stimulants and alcohol or benzodiazepine withdrawal all reproduce the picture.

Age is the most useful discriminator. A first panic attack after 45, or attacks with atypical features such as loss of consciousness, focal neurology or true chest pain on exertion, deserves investigation rather than reassurance.

3. Phobias and Social Anxiety

Specific phobia is marked, disproportionate fear of a defined object or situation, with avoidance, lasting six months or more.

The treatment is graded exposure, and it works well. Exposure must be prolonged enough for anxiety to fall while the person remains in the situation, because leaving early strengthens the avoidance it was meant to break.

Social anxiety disorder is fear of scrutiny and of humiliating oneself. It differs from shyness by the degree of impairment and by the avoidance it produces, and it commonly presents late because patients regard it as personality rather than illness.

Blood-injection-injury phobia is the exception worth knowing. It produces a biphasic vasovagal response with bradycardia and fainting rather than the tachycardia of other phobias, so applied tension, deliberately tensing muscles to raise blood pressure, is used instead of relaxation.

4. Generalised Anxiety Disorder

Excessive, difficult-to-control worry about multiple everyday domains, present most days for at least six months, with restlessness, fatigue, poor concentration, irritability, muscle tension and disturbed sleep.

The distinguishing feature is that the worry rotates. As one concern resolves, another takes its place, so the content changes while the process continues.

Comorbidity is the rule rather than the exception, and depression is the commonest partner. Generalised anxiety disorder with comorbid depression carries a worse prognosis than either alone, so screening for depression is part of the assessment.

5. Obsessive-Compulsive Disorder

An obsession is a recurrent intrusive thought, image or urge that is experienced as unwanted and as the person's own, and which causes distress.

A compulsion is a repetitive behaviour or mental act performed to neutralise the obsession or prevent a feared outcome.

Two features are diagnostically decisive.

The thoughts are recognised as one's own, which distinguishes obsessions from thought insertion in schizophrenia, where the patient believes the thought is placed there by an outside agency.

The compulsion relieves anxiety temporarily and therefore maintains the disorder. Each time checking reduces distress, the association between doubt and checking strengthens, and the doubt returns sooner and stronger.

Insight is usually preserved, though it varies, and its presence does not exclude the diagnosis.

Treatment

Exposure and response prevention is the core psychological treatment, and its name states its logic: expose the person to the trigger and prevent the neutralising act, so that anxiety falls on its own and the link is broken.

Selective serotonin reuptake inhibitors are first-line pharmacologically, but at higher doses and for longer than in depression, often twelve weeks before response is judged. Clomipramine is effective but less well tolerated.

6. Post-Traumatic Stress Disorder

Four symptom clusters follow exposure to actual or threatened death, serious injury or sexual violence.

Intrusion: flashbacks, nightmares, intrusive memories. Avoidance: of reminders, thoughts and conversations. Negative alterations in cognition and mood: guilt, detachment, distorted blame. Hyperarousal: startle, hypervigilance, irritability, poor sleep.

Symptoms lasting less than a month constitute acute stress disorder.

Three points about treatment are examinable and are often got wrong.

Trauma-focused cognitive behavioural therapy and eye movement desensitisation and reprocessing are first-line, ahead of medication.

Single-session psychological debriefing immediately after trauma does not prevent post-traumatic stress disorder and may increase it. This is a genuine reversal of intuitive practice, and the evidence is consistent enough that routine debriefing is no longer recommended.

Benzodiazepines are not effective and may worsen outcomes, in addition to carrying dependence risk in a population with high comorbid substance use.

7. Dissociative and Somatic Presentations

These are common in Indian practice and are frequently mismanaged.

Dissociative disorders involve a disruption of the normal integration of consciousness, memory, identity or motor control, arising in the context of psychological stress.

Dissociative convulsions are the presentation most often confused with epilepsy. Useful distinguishing features include gradual onset and offset, asynchronous and side-to-side movements, eye closure with resistance to opening, preserved awareness during bilateral motor activity, an absence of tongue biting on the lateral tongue, absent postictal confusion, and a normal serum prolactin after the event.

None of these is individually decisive, and the two conditions coexist in a significant minority, so the presence of one does not exclude the other. Video electroencephalography is the definitive investigation.

Possession states and trance disorders are recognised in classification systems and must be interpreted against cultural background, since experiences that are normative in a community are not pathological.

Somatic symptom disorder is defined by distressing physical symptoms with disproportionate thoughts, feelings and behaviours about them. The modern definition deliberately does not require the symptoms to be medically unexplained, which is an important change: a patient with genuine disease can also have somatic symptom disorder.

Illness anxiety disorder is preoccupation with having a serious illness with minimal or no somatic symptoms.

The management principle is the same in all of these. Repeated investigation to reassure is counterproductive, because it confirms the patient's fear that something serious is being sought, and each normal result reassures only briefly. Regular scheduled appointments with a single clinician, limited investigation and explicit acknowledgement that the symptoms are real work better than escalating tests.

8. Two Conditions Grouped Here by Convention

Adjustment disorder

An emotional or behavioural response to an identifiable stressor, beginning within about three months of it and out of proportion to what would be expected, but not meeting criteria for another disorder.

The distinguishing feature is proportionality and duration rather than the presence of distress. Normal distress after a real loss is not a disorder, and calling it one medicalises ordinary human response.

It is a diagnosis worth making nonetheless, because it identifies people who benefit from brief support and monitoring, and because it carries a raised risk of self-harm that is easily underestimated when the label sounds mild.

Body dysmorphic disorder

Preoccupation with a perceived defect in appearance that is not observable or appears slight to others, with repetitive behaviours such as mirror checking, camouflaging or reassurance seeking.

It sits close to obsessive-compulsive disorder and responds to the same treatments, namely a selective serotonin reuptake inhibitor and exposure with response prevention.

Its clinical importance is that these patients seek cosmetic and dermatological procedures rather than psychiatric help, are rarely satisfied by them, and carry a high risk of suicide. A patient requesting repeated procedures for a defect the clinician cannot see should be assessed rather than operated on.

Assessing anxiety in Indian practice

Two contextual points change how these disorders present and are often missed.

Anxiety is frequently expressed somatically. Patients present to physicians with palpitations, giddiness, burning sensations or non-specific weakness rather than describing worry, partly because physical complaints are more acceptable and partly because the somatic symptoms genuinely dominate the experience. A patient with repeatedly normal cardiac investigations who remains convinced something is wrong is often describing panic disorder.

Culture-bound presentations are recognised and must not be pathologised carelessly. Dhat syndrome, in which a young man attributes fatigue and weakness to semen loss, is best understood as a somatic idiom of distress and usually coexists with depression or anxiety, which is what should be treated. Possession states occurring within a shared religious framework are not in themselves disorders.

The general principle is that the content of a symptom is shaped by culture while the underlying process is not, so the assessment asks how much distress and impairment the experience causes rather than whether the belief matches the clinician's own framework.

9. Treatment Principles Across the Group

Selective serotonin reuptake inhibitors are first-line pharmacotherapy across almost all of these disorders. Onset takes weeks, and anxiety may worsen transiently in the first days, which must be warned about or the patient stops the drug.

Cognitive behavioural therapy with exposure is at least as effective as medication and has more durable benefit, because it changes the maintaining mechanism rather than suppressing the symptom.

Benzodiazepines have a narrow legitimate role. They work immediately, which is precisely the problem: rapid relief is powerfully reinforcing, tolerance develops, and dependence follows. They also block the anxiety reduction that exposure depends on, so they undermine the treatment that would work. Short courses in crisis are defensible; maintenance treatment of anxiety disorders is not.

Propranolol helps the peripheral autonomic symptoms of performance anxiety, such as tremor and palpitations, but does nothing for the cognitive component.

10. Worked Examples

Example 1. A 52-year-old man has his first ever episode of sudden palpitations, sweating and chest tightness lasting fifteen minutes, with a sense he was going to die. He is otherwise well. A colleague diagnoses panic disorder and reassures him. Comment.

The reassurance is premature. Panic disorder requires recurrent unexpected attacks plus at least a month of persistent worry or behavioural change, so a single episode does not meet the criteria in any case.

More importantly, a first panic attack after the age of 45 should prompt exclusion of physical causes before a psychiatric label is applied. Thyrotoxicosis, arrhythmia, hypoglycaemia, phaeochromocytoma and substance effects including stimulants and alcohol withdrawal all reproduce this picture exactly, because the symptoms are simply autonomic arousal. Chest tightness in a man of this age also requires cardiac assessment on its own merits.

Example 2. A 28-year-old woman washes her hands until they bleed, knows it is unreasonable, but says the thought of contamination will not leave her. Explain the mechanism that keeps this going and the treatment that targets it.

The obsession is the intrusive contamination thought, recognised as her own and as unreasonable, which distinguishes it from thought insertion. The compulsion is the washing.

The maintaining mechanism is negative reinforcement. Washing reduces the anxiety generated by the obsession, and that immediate relief strengthens the association between the intrusive thought and the act, so the urge returns sooner and more intensely. She never has the opportunity to learn that anxiety would have subsided on its own and that the feared contamination would not occur.

The treatment that targets this directly is exposure and response prevention: deliberate contact with the feared trigger while the washing is prevented, allowing anxiety to fall without the ritual. A selective serotonin reuptake inhibitor at higher dose than in depression, judged over about twelve weeks, is first-line pharmacologically.

Example 3. After a bus accident, a hospital plans a single group debriefing session for all survivors within 48 hours to prevent post-traumatic stress disorder. Comment on this plan.

It should not be done. Single-session psychological debriefing does not prevent post-traumatic stress disorder, and the evidence indicates it may increase the risk, plausibly by interrupting natural recovery processes and by exposing people to others' traumatic material at a time of high arousal.

What is supported instead is psychological first aid: ensuring physical safety, meeting practical needs, providing accurate information, reuniting people with family and social supports, and identifying those who are most distressed for follow-up.

Active treatment is offered to those who develop persistent symptoms, using trauma-focused cognitive behavioural therapy or eye movement desensitisation and reprocessing, which are first-line ahead of medication. Benzodiazepines should be avoided, since they are ineffective for this indication and may worsen outcomes.

Example 4. A 22-year-old woman has episodes of generalised shaking lasting twenty minutes, with eyes tightly closed, occurring only in front of family. She is fully oriented immediately afterwards. How would you approach this?

The features suggest dissociative convulsions: prolonged duration, gradual onset and offset, forced eye closure with resistance to opening, situational occurrence and absent postictal confusion. Absence of lateral tongue biting and a normal post-event serum prolactin would add support.

However, no single feature is decisive, and epilepsy and dissociative seizures coexist in a significant minority of patients, so the presence of one does not exclude the other. Video electroencephalography during a typical event is the definitive investigation.

Management then requires care in communication. The diagnosis is explained as real and involuntary rather than deliberate, since telling a patient the attacks are not genuine reliably destroys engagement. Antiepileptic drugs are withdrawn if there is no epilepsy, psychological factors are explored, and treatment is psychological.

Example 5. A 45-year-old man has attended six specialists in two years for abdominal pain with normal investigations each time, and requests another scan. What is the principle guiding management?

This is somatic symptom disorder, defined by distressing physical symptoms with disproportionate thoughts, feelings and behaviours about them. Note that the current definition does not require the symptoms to be medically unexplained, so the presence of genuine disease would not exclude it.

The guiding principle is that further investigation to reassure is counterproductive. Each new test confirms his belief that something serious is being sought, and the reassurance from a normal result lasts only days before doubt returns, so the cycle escalates while iatrogenic harm accumulates.

What works is a structured alternative: a single named clinician holding responsibility, regular scheduled appointments rather than symptom-triggered ones, explicit acknowledgement that the symptoms are real and disabling, investigation only on new objective indications, and a gradual shift of the consultation from finding a cause to improving function.

Summary

All anxiety disorders share one physiology, so symptoms do not separate them.

Ask what the anxiety is about and how it behaves in time.

Avoidance converts anxiety into disability, and exposure is the treatment for all of them.

Panic attacks occur in many conditions; panic disorder requires recurrent unexpected attacks plus a month of worry or behaviour change.

Panic works by catastrophic misinterpretation of normal bodily sensation.

Agoraphobia is fear of situations from which escape is difficult, not of open spaces.

A first panic attack after 45 demands exclusion of physical causes.

Blood-injection-injury phobia causes fainting, and applied tension replaces relaxation.

Generalised anxiety disorder has rotating worry content over at least six months.

Obsessions are recognised as one's own, unlike thought insertion.

Compulsions relieve anxiety temporarily and therefore maintain the disorder.

Exposure and response prevention is the core treatment for obsessive-compulsive disorder.

SSRIs in obsessive-compulsive disorder need higher doses and about twelve weeks.

PTSD has four clusters: intrusion, avoidance, negative cognitions, hyperarousal.

Trauma-focused CBT and EMDR are first-line, ahead of medication.

Single-session debriefing does not prevent PTSD and may worsen it.

Dissociative convulsions and epilepsy coexist in a significant minority.

Video electroencephalography is the definitive investigation for seizure-like events.

Somatic symptom disorder no longer requires symptoms to be medically unexplained.

Repeated investigation to reassure is counterproductive and escalates the cycle.

Benzodiazepines undermine exposure and cause dependence, so their role is narrow.