As mentioned, the term anxiety neurosis was introduced by Freud to describe a syndrome of general irritability, anxious expectation, anxiety attacks, somatic accompaniments or equivalents of anxiety (breathlessness, chest pain, asthenia), and nightmares. In anxiety neurosis, this symptom complex constitutes the entire illness. However, parts of this constellation also appear with many other psychiatric diseases—bipolar disease, schizophrenia, hysteria, and phobic neurosis. Its closest link is with depression, which it resembles in another respect, namely, a strong hereditary factor, as pointed out by Cohen and White in 1949.
Anxiety disorder is a chronic state, some would say a disease, punctuated by recurrent attacks of acute anxiety or panic. The acute attacks are the hallmark of the disease and some psychiatrists are reluctant to make a diagnosis of anxiety neurosis in their absence. Because of the clinical features of panic attacks and particularly their episodic nature, simulating an acute medical condition, they are of special interest to neurologists and general physicians. While anxiety may be inferred from observing the activities of young children, and is reported as a form of nervousness by older children and adolescents, more often there are physical complaints at times of transition or stress during the day or year.
Panic attacks in their full form are prone to begin after this age and are almost as dramatic as seizures. They often begin with distressing feelings of dread and foreboding. The patient is assailed by a sense of strangeness, as though his body had changed or the surroundings were unreal. He is frightened, sometimes by the prospect of imminent death (angor animi) or of losing his mind or self-control. There may be a feeling of smothering. “I am dying” or “I can’t breathe” are characteristic expressions of alarm and panic. The heart races, breathing comes in rapid gasps, the pupils may be dilated, and the patient may sweat or tremble. The palpitation and breathing difficulties are so prominent that a cardiologist is often consulted. Some of our psychiatric colleagues identify breathlessness or a suffocating feeling as central to the diagnosis of panic (and attribute psychologic meaning to the symptom), but this is not sustained in our observations of affected patients. The symptoms abate spontaneously after 15 to 30 min, leaving the patient shaken, tense, perplexed, and often embarrassed. There is no confusion, and after the episode there is full memory of the event.
Most anxiety attacks are of lesser severity with complaints of apprehension, slight faintness, palpitations, or a feeling of postural instability referred to by the patient as dizziness. Breathlessness, vague chest or upper abdominal discomfort, a palpitating sensation as if the heart were beating too hard, and a generalized “washed out” feeling (asthenia) are other common symptoms. More than 50 years ago Cohen and White listed the following symptoms in order of frequency in the patients they observed: palpitation, 97 percent; easy fatigue, 93 percent; breathlessness, 90 percent; nervousness, 88 percent; chest pain, 85 percent; sighing, 79 percent; dizziness, 78 percent; apprehensiveness, 61 percent; headache, 58 percent; paresthesias, 58 percent; weakness, 56 percent; insomnia, 53 percent; unhappiness, 50 percent. What is evident from this listing is that the experience of anxiety is a polysymptomatic physical syndrome. This was the basis of the James-Lang theory of emotion—that the physical-sensory experience was the central one and emotion followed. It is not surprising, therefore, that many patients with chronic or recurrent symptoms first consult a physician not with a complaint of “anxiety” but with symptoms referable to the cardiorespiratory system or gastrointestinal system (dyspepsia, loss of appetite, or “irritable colon”).