Types of Anxiety Neurosis

The Diagnostic and Statistical Manual of Mental Disorders classifies anxiety disorders into the following categories:

Specific phobias and social anxiety disorders are the commonest of all these types. Post-traumatic stress disorders and generalized anxiety disorders are next commonest. Often these conditions remain underdiagnosed because patients generally do not approach the physician or the psychiatrist for the treatment of these complaints.

Panic disorder with or without Agoraphobia

Panic attacks are characterized by an intense feeling of terror which generally strikes suddenly and is incapacitating to the patient. These episodes may last for variable periods and attain a peak by 10 minutes generally. Rarely, they may last up to one hour. In between the attacks, the patient is constantly worried about getting another panic attack and hence avoids situations that may provoke a panic attack. Common symptoms of a panic attack are as follows:

Panic attack symptoms:

Patients generally seek medical advice considering this to be some medical crisis only to be told that this problem is psychological and not medical. Many patients often seek another opinion but they are told the same thing again. Such people land up self-medicating themselves which is harmful in the long run. 

The patient may suffer from discrete panic symptoms but this would be termed as a Panic disorder only when the attacks become frequent and the patient develops a fear of getting another attack or fears the consequences of the attack.

Panic attacks may occur as such or may be accompanied by Agoraphobia. Patients with agoraphobia are afraid of places or situations in which they might have a panic attack and be unable to leave or to find help. Such patients generally fear to be in places where they anticipate that they may get a panic attack and they may not be able to help themselves in the event of an attack. In clinical settings, agoraphobia is usually not a disorder by itself but is typically associated with some form of panic disorder.

Acute stress disorder

This is a condition that is precipitated by exposure to a stressful or traumatic event recently and the response is of intense fear, helplessness, or horror. After such an event the patient experiences a sense of emotional numbness has reduced awareness about the surroundings (as if in a daze) and is often unable to recall an important aspect of the trauma. The patient persistently re-experiences the traumatic event and tries to avoid anything that reminds him of the trauma.

There are also marked symptoms of anxiety or increased arousal (e.g. irritability, poor concentration, difficulty in sleeping, hypervigilance, exaggerated startle response, restlessness, etc). This causes many difficulties in functioning normally at home and at work. The patient gets these symptoms generally within a few days to about 4 weeks after the stressful event. This phase may last anywhere up to 4 weeks.

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is an anxiety disorder that develops after exposure to a traumatic or frightening event. Symptoms of this disorder generally develop about 3 months or later after the stressful or traumatic event. These symptoms usually last for more than a month. Some patients recover within 6 months whereas some of them may develop a chronic course lasting for years.

The trauma can be in the form of natural disasters, war, violence, accidents, etc. A few months after the traumatic event, the patient typically experiences strong feelings of fear, horror, and helplessness. The patient repeatedly relives the traumatic event in the form of flashbacks and nightmares. Often there is a feeling as though they are re-experiencing the trauma all over again. Flashbacks are generally triggered by certain situations which bring back memories of the traumatic event. In some patients flashbacks can even occur spontaneously or without any recognizable trigger.

The patient begins to avoid situations or experiences that remind them of the original trauma and this can lead to a fairly severe restriction in their activity. Sleep disturbances, depression, feeling detached or numb (derealization), easy startling are commonly experienced. Often there are feelings of loss of pleasure or interest in previously enjoyable activities (anhedonia). Women appear to be at greater risk than men for developing PTSD after traumatic experiences.

Social phobia

Social Anxiety Disorder or social phobia is characterized by marked and persistent fear in one or more social situations. A person suffering from a phobia will avoid or will be extremely distressed in social settings and this is the major difference between a shy person and a social phobic. A shy person may be uncomfortable in social situations, but his symptoms are not disabling.

Basically, a social phobic has fear of negative evaluation and he is intensely worried that he will do or say something that will make others think poorly of him. They tend to think that they are less socially competent than others. They often believe that everyone notices the smallest mistakes which they make and may greatly exaggerate the severity of the negative judgments about those mistakes. When an event such as a presentation or a party is unavoidable for such a person, he may worry for days or even weeks prior to the event. Common things that make a social phobic anxious are public speaking, informal conversations in small or large groups, dating, interacting with authority figures, eating, writing, or other public performances.

Heredity may predispose a person to develop social phobia but in most cases, it requires a trigger from the environment for the full-blown development of the disorder.

Specific phobias:

Fear of various things is a common phenomenon but an excessive, persistent, and irrational fear of certain things or situations is termed as a phobia. When the phobia is about some specific object or situation, it is termed a specific phobia. The individual is often not able to find out the rationale behind this fear but he just cannot seem to face these or overcome these fears.

Some common things which cause such phobias are listed below:

Animals: Spiders, lizards, cockroaches, rats, dogs, snakes, insects, etc are a few of the most common animals to which patients report phobias.

Environmental: Fear of water, heights, fire, storms, darkness, etc

Situational: Fear of going in elevators, closed places, crowded places, tunnels, bridges, etc

Fear of injections, injury, the sight of blood, etc are a few common phobias; such patients usually faint at the sight of blood or injury.

Usually, for many individuals, the phobic stimulus is easy to avoid. When the feared object is easy to avoid, people with phobias may not feel they need treatment. In certain cases, however, specific phobias can become impairing or individuals may go to excessive lengths to avoid exposure to the feared object or situation. In these cases, treatment is recommended. This is particularly important, as individuals with a single Specific Phobia are likely to develop additional phobias of similar objects or situations over a period of time.

Specific phobias tend to run in families and very often family members have fear of similar objects or situations i.e. a common “theme” of fear. In general, phobias appear in adolescence and adulthood. Adult-onset phobias tend to show a more stable course, with only a small percentage of these disappearing without treatment.

Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions and compulsions. Obsessions and compulsions are unreasonable and in excess and they cause marked distress to the patient.

Although Obsessive-Compulsive Disorder usually begins in adolescence or early adulthood, it may begin in childhood. Generally, the onset is gradual, but occasionally acute onset has been noted in some cases. The majority of individuals have a chronic waxing and waning course, with exacerbation of symptoms that may be related to stress.

Obsessions include the following:

• Recurrent and persistent thoughts, impulses, or images that are intrusive and inappropriate and cause anxiety or distress
• Thoughts, impulses, or images that are not simply excessive worries about problems in real life
• The patient makes attempts to ignore or suppress these thoughts or tries to neutralize them by thinking about other things
• The patient recognizes that these thoughts, impulses, or images are the product of his mind and not imposed from outside

Compulsions include the following:

• Repetitive behaviors, such as washing hands repeatedly, ordering, and checking locks and doors again and again, etc. The patient feels driven to repeat these actions and these must be carried out in order to relieve the anxiety.
• Any other typical behavior or mental acts that the patient carries out in order to reduce distress or anxiety.

The point to be noted is that the patient realizes that these obsessions and compulsions are unreasonable and in excess (except in the case of children). These obsessions and compulsions cause marked distress to the patient are time-consuming (taking more than an hour daily) and cause marked interference in the patient's routine functioning. For e.g.: the patient may be obsessed with cleanliness and may spend hours daily washing and taking repeated baths. He may be spending a lot of time washing his hands because he feels that they get dirty even if he does not do anything to dirty them. Compulsions are not really connected to the things which they are designed to neutralize. They are meant to reduce the anxiety or distress of the patient and not to provide any pleasure or gratification.

The most common compulsions involve washing and cleaning, counting, checking, requesting or demanding assurances, repeating actions, etc. When attempting to resist a compulsion, the patient may have a sense of increased anxiety or tension that is often relieved by yielding to the compulsion. In the course of the disorder, after repeated failure to resist the obsessions and compulsions, the patient may give in to them; he no longer experiences a desire to resist them and may incorporate the compulsions into his or her daily routines.

Generalized anxiety disorders

The onset is generally around childhood or adolescence but cases with late-onset anxiety symptoms are also seen. Generalized anxiety disorder is characterized by excessive anxiety and worry. This occurs for most of the days for at least 6 months, about a number of events or activities. Generally, anxiety is about work, daily events, or performances. The patient finds it difficult to control the anxiety about various things and this is often associated with a few or most of the following features:

• Restlessness
• Irritability
• Difficulty in concentrating
• Sleep disturbances (difficulty in falling asleep, frequent waking in the middle)
• Easy fatigue

The anxiety causes significant distress and impairment in various areas of functioning. The course of generalized anxiety disorders is chronic and usually gets worse during periods of stress. The intensity, duration, or frequency of the anxiety and worry is far out of proportion to the actual likelihood or impact of the feared event. The person finds it difficult to keep worrisome thoughts from interfering with his daily activities and has difficulty stopping the worry. During the course of the disorder, the focus of worry may shift from one concern to another. In children suffering from Generalized Anxiety Disorder, there is a tendency to worry excessively about their competence with their friends or the quality of their performance.

Anxiety due to medical causes

Anxiety may be a symptom of a number of medical conditions as well and hence it is necessary to rule out these conditions before we testify the patient is suffering from an anxiety disorder. A few of them have been listed below:

1) Neurological illnesses

It can cause symptoms similar to those found in anxiety disorders and hence these illnesses must be ruled out before concluding the symptoms to be that of anxiety disorders. Following are a few of the examples of such neurological disorders:

• Cerebral vascular insufficiency: Transient Ischemic Attacks (TIA) lasting from 10-15 seconds up to an hour (brief blocks in the blood vessels of the brain causing temporary loss of brain blood supply)
• Anxiety states and personality changes following head injury
• Infections of the central nervous system
• Degenerative disorders of the nervous system
• Alzheimer's dementia 
• Multiple sclerosis: Maybe marked early on by vague and changing medical complaints
• Huntington's chorea: May present early as anxiety or other functional disorder before the movement disorder is evident. It always has a positive family history
• Toxic Disorders
• Lead Intoxication: loss of appetite, constipation, and colicky abdominal pain followed by irritability and restlessness
• Mercury intoxication: from contaminated fish
• Manganese intoxication: from industrial exposure
• Organophosphate insecticides (similar to nerve gas): from chemical or insecticide exposure
• Partial complex seizures

2) Endocrine disorders

It also frequently presents with symptoms of anxiety and these can be the differential diagnosis of anxiety disorders. Common examples would be: 

• Hyperthyroidism (increased thyroid hormone) commonly presents as anxiety and is one of the most common endocrine abnormalities. Most common in 20 to 40 years old women.
• Adrenal hyperfunction or Cushing's syndrome: This has a variety of causes, including tumors of the pituitary or adrenal glands or from steroids given to treat other illnesses. Anxiety is a common feature as also abnormal hairiness, acne, change in fat distribution, decreased menstruation in women, and impotency in men.
• Hypoglycemia (decreased blood glucose): Usually associated with a history of diabetes and insulin or other hypoglycemic medications. Rarely does this occur from an insulin-secreting tumor?
• Hypoparathyroidism (decreased parathyroid hormone): Almost always associated with a history of thyroid surgery. It often presents with overwhelming anxiety, either with or without personality changes.
• Menopausal and premenstrual syndromes.

3) Cardiopulmonary disorders:

Often presents with shortness of breath, rapid breathing, complaints of chest pain, chest pain that are worse with exertion.

• Angina
• Pulmonary embolus
• Arrhythmias (irregularities of heartbeat)
• Chronic obstructive pulmonary disease (COPD)
• Mitral valve prolapse (generally harmless)

4) Pheochromocytoma (epinephrine secreting tumors)

Substance-induced anxiety disorders

Substance-induced anxiety is commonly missed out because very often the physician may not take a detailed note of the medication that the patient has been continuing for long and these medicines may be the culprits in inducing anxiety symptoms in the patient. Common medications and drugs which can induce anxiety symptoms are as follows:

Non-psychotropic medications:

• Sympathomimetics (often found in non-prescription cold and allergy medications): epinephrine, norepinephrine, isoproterenol, levodopa, dopamine hydrochloride, dobutamine, terbutaline sulfate, ephedrine, pseudoephedrine
• Xanthene derivatives (asthma medications, coffee, colas, over-the-counter pain remedies): aminophylline, theophylline, caffeine
• Anti-inflammatory agents: indomethacin
• Thyroid preparations
• Insulin (due to hypoglycemic reaction)
• Corticosteroids
• Others: nicotine, ginseng root, monosodium glutamate

Psychotropic medications:

• Antidepressants (including MAO-inhibitors), drugs for the treatment of attention deficit disorders (on rare occasions cause anxiety-type syndromes)
• Tranquilizing drugs: benzodiazepines (paradoxical response most common in children and in elderly), antipsychotics (akathisia may present as anxiety)
• Anticholinergic medications can cause a delirium which, in early stages, may easily be confused with anxiety: scopolamine and sedating antihistamines (found in over-the-counter sleep preparations) antiparkinsonian agents, tricyclic antidepressants, antipsychotics

Other Drugs:

• Caffeine-intoxication or withdrawal
• Nicotine-withdrawal even more than acute intoxication
• Stimulants-cocaine, amphetamines, etc.
• Alcohol or alcohol withdrawal

Drug withdrawal is a common cause of anxiety symptoms. A large number of drugs can cause withdrawal states with symptoms of anxiety or even agitation. All sedative-hypnotics, tricyclic anti-depressants, and anticholinergics can cause withdrawal symptoms. 

A totalistic view of anxiety disorder

A holistic study and review of the type of anxiety and its causes are required for treating the disease at a deeper level. In Homeopathy, there are different medicines for specific types of anxiety or fear. For example, if one has a fear of closed or narrow spaces (claustrophobia), the drug could be Argentum nitricum, while for anxiety before performance or examinations could need Gelsemium. Likewise, anxiety and depression following a dissapointment in love may need Natrum muriaticum, while anxiety due to loss in business may need Aurum metallic, as examples. Likewise, the obsessive-compulsive trait may need a different group of medicines, while anxiety related to thyroid disorders may need another approach. 

Written & Approved by-

Dr. Rajesh Shah

M.D. (Hom.)