03 · Anxiety, obsessions, trauma and bodily distress

3.1 Identifying the central fear

Negative reinforcement: escape relieves distress, so escape becomes more likely next time. “Negative” means removing something unpleasant; it does not mean punishment. Immediate relief can maintain long-term fear.

3.2 Generalised anxiety disorder

GAD = difficult-to-control worry across several life areas. Restlessness, irritability, muscle tension, poor concentration and sleep disturbance commonly accompany palpitations, tremor, sweating, dry mouth and gastrointestinal discomfort.

ICD-11: more days than not for at least several months. Distress/impairment and exclusion of better explanations are also required.

Mimics include hyperthyroidism, hypoglycaemia, arrhythmia, caffeine/stimulants and alcohol/benzodiazepine withdrawal. Thyroxine, salbutamol and corticosteroids may contribute. Weight loss despite appetite, heat intolerance and tremor deserve a thyroid differential.

Treatment: education and supported self-help, then high-intensity CBT/applied relaxation or medication according to preference. High-intensity therapy commonly means 12–15 weekly sessions. NICE favours sertraline initially on cost-effectiveness grounds, noting off-label use for GAD. An alternative SSRI/SNRI follows inadequate response; pregabalin is considered when these are not tolerated, with dependence and respiratory-depression concerns. Benzodiazepines are for short crises.

3.3 Panic attacks and panic disorder

A panic attack is an abrupt surge of fear, peaking within minutes. Symptoms include palpitations, sweating, tremor, breathlessness/choking, chest discomfort, nausea, dizziness, temperature changes and tingling. The interpretation may be “I am dying”, “losing control” or “going mad”.

Depersonalisation means detachment from oneself; derealisation, an unreal world. In anxiety, these usually remain recognised as feelings rather than literal changes in reality.

Panic disorder needs recurrent attacks, including unexpected ones, followed by continuing concern or maladaptive behaviour. Attacks confined to social scrutiny may belong to social anxiety. ICD-11 requires persistent concern or avoidance, for example over several weeks.

Why panic causes physical symptoms

Sympathetic activation increases pulse, sweating and tension. Hyperventilation lowers CO₂, producing respiratory alkalosis, dizziness, tingling and sometimes hand spasm. Catastrophic interpretation increases fear and further arousal. Symptoms are real; new or changing chest symptoms still need proportionate medical assessment.

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Interoceptive exposure deliberately tests feared bodily sensations. Agoraphobia also needs situational exposure. NICE describes 7–14 hours of CBT. An SSRI is another option; cautious initiation limits early activation. Continue effective medication for at least six months after the optimal dose is reached.

Benzodiazepines, sedating antihistamines and antipsychotics are not routine panic treatments. Paper-bag rebreathing is unsafe if a medical cause has been mistaken for panic.

3.4 Agoraphobia, social anxiety and specific phobia

Agoraphobia: several situations where escape/help may be difficult if embarrassing or incapacitating symptoms occur: transport, queues, crowds, being out alone. Avoidance, intense endurance or dependence on a companion all count. It can occur without panic disorder; ICD-11 allows both diagnoses.

Social anxiety: fear of scrutiny and negative evaluation, including blushing, trembling, seeming boring or visibly losing control. Anticipatory worry, self-focused attention and post-event rumination maintain it. Introversion without fear or impairment is different.

NICE prefers individual disorder-specific CBT. Clark and Wells treatment addresses internal attention, self-imagery and safety behaviours; experiments test predictions. Sertraline or escitalopram are options if medication is preferred. Beta-blockers may reduce peripheral symptoms but do not treat the full syndrome.

Specific phobia: disproportionate, impairing fear of one stimulus, such as animals, heights or injections. A frightening incident does not establish PTSD without its full syndrome. Blood–injury–injection phobia can cause vasovagal fainting; applied muscle tension may help alongside exposure.

3.5 Obsessions and compulsions

Obsessions are recurrent, intrusive, usually unwanted thoughts, images or urges. Themes include contamination, responsibility for harm, sexual/religious taboos, doubt and symmetry. They generally feel self-generated: hating a thought differs from believing someone inserted it.

Compulsions are repetitive acts or mental rituals performed because of an obsession or rigid rule. Include silent prayer, counting, memory review and reassurance, not just washing/checking. Some rituals seek a “just right” feeling rather than prevent a named catastrophe.

OCD requires time-consuming symptoms or significant distress/impairment. Over an hour daily is an example threshold, not a prerequisite in every case. ICD-11 sets no minimum duration. Insight ranges from good to absent: an isolated delusional-intensity obsessional belief does not automatically mean schizophrenia.

Depression, tics, anxiety, BDD, eating disorders and skin-picking may coexist. Hoarding disorder has its own category.

Why ERP works

Exposure and response prevention means approaching an agreed trigger while reducing overt and covert rituals. The person learns to tolerate distress and uncertainty without neutralisation. Eliminating every unwanted thought is not the goal; suppression may increase its salience.

SSRIs help without depression. Benefit may take up to twelve weeks, often at the higher end of the licensed dose range. Continue effective treatment for at least a year, then review after sustained remission.

Before escalating, check adequate exposure and hidden rituals. Options include combined treatment, another SSRI, clomipramine and specialist review. Antipsychotic augmentation is a specialist strategy, not initial treatment. Clomipramine adds anticholinergic, cardiac and overdose risks.

3.6 PTSD and complex PTSD

ICD-11 PTSD has three clusters after an extremely threatening or horrific event:

• Re-experiencing in the present: vivid memories, nightmares or flashbacks feel as though the event is happening again.

• Avoidance: deliberately avoiding reminders.

• Current threat: hypervigilance or exaggerated startle.

Symptoms persist for at least several weeks with impairment. Repeatedly analysing why the event happened is not sufficient re-experiencing. Insomnia, irritability, guilt, detachment and poor concentration often accompany the core syndrome.

A perceptually vivid flashback with reduced awareness of the surroundings does not by itself establish psychosis. Consider experiences outside flashbacks and the overall course.

Complex PTSD = PTSD plus emotion-regulation difficulties, enduring negative self-concept and relationship difficulties. Repeated/prolonged trauma is common, but symptoms determine diagnosis. Overlap with borderline patterns cannot be settled by one symptom or abandonment concerns alone.

In the first month after trauma, clinically important symptoms may justify monitoring or trauma-focused treatment according to severity. Routine compulsory single-session debriefing is not recommended. Established PTSD is treated with trauma-focused CBT or EMDR; EMDR combines structured trauma processing with bilateral stimulation. NICE's specific adult EMDR recommendations concern non-combat trauma, not a universal ban for combat-related PTSD.

If medication is preferred, consider an SSRI such as sertraline, or venlafaxine. Do not routinely prescribe to prevent PTSD. Complex needs may require more sessions and work on safety, engagement and regulation. Substance use should be addressed alongside PTSD, not automatically exclude therapy.

3.7 Health anxiety and bodily distress

Health anxiety concerns a feared disease: a headache means a tumour. Checking, searching and reassurance briefly reduce fear; some people avoid healthcare instead. ICD-11 calls it hypochondriasis (health anxiety disorder) within obsessive-compulsive and related disorders, with poor insight available as a qualifier.

CBT addresses attention, catastrophic interpretation, checking and reassurance. Planned consistent reviews can reduce crisis consultations. New indications still justify investigation, and real illness can coexist.

Bodily distress disorder centres on distressing symptoms and excessive attention to them, persisting for several months with impairment. Symptoms need not be medically unexplained; the response may be excessive relative to an established disease. Pain remains real.

3.8 Body dysmorphic disorder

BDD: preoccupation with absent or slight appearance flaws, repetitive behaviour/mental acts and significant distress or impairment. Look for mirror checking/avoidance, comparison, camouflage, repeated photographs, skin manipulation and seeking procedures. Beliefs that others stare or laugh can belong to the syndrome.

The concern is appearance, rather than disease in health anxiety. Social fear centres on the supposed defect. Assess weight/shape concerns for an eating disorder. Delusional conviction confined to the appearance concern still permits BDD.

Consequences include depression, isolation, self-harm, suicidal thinking, damaging skin treatment and attempted self-surgery. Cosmetic changes often leave the preoccupation intact; suspected BDD in someone seeking procedures needs specialist assessment.

CBT with ERP and SSRIs are core treatments; combine them for severe impairment. NICE names fluoxetine, including delusional-intensity beliefs, although BDD use is off-label. Absent insight does not make antipsychotic monotherapy the routine answer.

3.9 Functional neurological and dissociative symptoms

FND symptoms are genuine and involuntary. Motor, sensory or seizure-like symptoms arise from altered nervous-system functioning; ICD-11 calls this dissociative neurological symptom disorder. A psychological stressor is not required, and neurological disease can coexist.

Diagnose using positive clinical features, not just normal tests. Hoover's sign shows weak voluntary hip extension improving during resisted flexion of the opposite hip. Tremor entrainment is another positive sign. Interpret both in context.

Normal pupils/fundi do not exclude every organic cause of visual loss: ophthalmic assessment still matters. Functional seizures require distinction from epilepsy and syncope using witness accounts, recordings and specialist assessment where needed.

Possible benefits from illness do not prove deception. “Primary/secondary gain” is not a diagnostic test.

Treatment combines a clear explanation with symptom-specific rehabilitation: physiotherapy retraining automatic movement, occupational/speech therapy and psychological work when indicated. Treat comorbid depression, anxiety, trauma and pain. There is no universal FND drug; chronic symptoms can improve without a guaranteed rapid recovery.

Dissociation also includes depersonalisation/derealisation and autobiographical memory gaps. Unresponsiveness needs a medical/neurological differential, including catatonia; a stressor does not establish dissociative stupor.