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Robert Heinlein

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What is mental illness?



-          Anxiety disorders-

-          What is normal anxiety?

. We tend to get anxious and fearful when sensing some immediate and realistic danger. For example, having a big dog barking and running at us make us fear about dog bite.

. In such situations, we tend to fight the threat or flight from this. For example, if we see a big dog coming at us, will be fearful and possibly flight from there. Next time, simply hearing a dog bark arouses fear in us and our body gets ready for any eventuality.

. This gets possible through our body physiology whereby body prepares us for flight by diverting blood to leg muscles so that we can run, making our heart beat faster so that more blood gets pumped to legs and so on. All these changes arouse the perception of fear in us. This gets manifested through fast heartbeat, rapid breathing, dryness of mouth, feeling of losing control, giddiness etc. Once the threat is not there, body returns back to normal and fear disappears.

. We tend to have a mental picture of fearful situation through our various life experiences. Such as sometimes during childhood we get told by elders that snake is a dangerous animal, one should avoid height, one should not go to hospital as it could cause infection etc. Sometimes one’s individual life experience such as meeting a road traffic accident, seeing someone killed in front of them could make a person fear such situation.

. As one grows, the person learns the reality of their fear and feels comfortable dealing with them.

. Thus our body has an ‘alarm system’ which prepares and protects us to deal with dangerous and fearful situation.



-          What is abnormal anxiety or anxiety disorders?

. Anxiety disorders are a group of disorders when body’s ‘alarm system’ gets activated unnecessarily or without any apparent danger. One could say that the ‘alarm system’ gets falsely activated without person able to control it. This makes the person fear situations where the ‘alarm’ is falsely activated. For example, if a person feels alarmed at a crowded market place or while travelling in a bus or while in hospital, a sense of panic might set up in the mind while in these situations with no apparent cause known.  They might develop attacks of panic if they confront these situations which make them feel that they might die if facing such situations. Some people feel that they have become ‘mentally crazy’ as they couldn’t explain their reason of fear to self. Sometimes a desperate search for answer makes them associate their fear with some remotely related events.

. People developing such fear normally manage them by avoiding these situations. For example, someone having a fear of panic attack in a crowded market would not go outside alone, or they will ask for someone to come with them or they may simply not leave the house.

. Depending on type of fearful situation, anxiety disorders could be of following types

-Panic disorder – fear of dying, going mad or suffering some other personal catastrophe/dangers

              - Social phobia – fear of making a fool of oneself in social situation such as public speaking, speaking in a classroom, participating in a family get together such as birthday etc, eating in a restaurant.


             -Obsessive–compulsive disorder – fear of contamination, of having harmed others, of doing

something terrible, repeated doubts


-Agoraphobia – fear of being in a place from which escape is difficult such as bus, train, aeroplane, crowded market, lift


-Post-traumatic stress disorder – fear of re-experiencing the traumatic event such as road traffic accident, victim of any crime, brutally assaulted by someone etc.


-Generalised Anxiety Disorder- excessive and unreasonable worry about the future, one’s health, or one’s relationships, finances etc.


. Apart from excessive fear and worry associated with certain situations or circumstances, other associated symptoms include avoidance of feared situation, withdrawal from such situations, and use of alcohol or benzodiazepam tablets to feel relieved of anxiety.


. The associated bodily symptoms include fatigue, chest pain, headache, nausea and joint pain, light- headedness, dizziness, choking, derealisation and depersonalisation, tachycardia, paraesthesia,cold sweats, muscle tightness, tiredness, and nausea.


.Anxiety isonly pathological when it is excessive in relation to the threat, persistent, and causes significantdisability and handicap.


What are the treatments for anxiety disorders?


-          Each anxiety disorder is unique even if having same diagnosis. For example, two persons getting the same diagnosis of agoraphobia may require different treatments.

-          The treatment is guided not only by diagnosis but formulation of individual case. Through formulating the case, the psychiatrist tries to answer the question ‘why this person is having this problem at this point of time?’.

-          In formulating, a detailed history is obtained and the information is synthesised to get a full understanding of the illness on the lines of biological factors, psychological factors and social factors which might cause or protect from anxiety.

-          If the anxiety disorder is only treated with medication, the response rate is likely to be around 50-60% even if multiple medications are combined.

-          Medication treatment may reduce the symptom of anxiety but the person might not be able to manage anxiety on it’s own with perceived fear of the need to take the medication lifelong.

-          An example of formulation is as follows-

A young woman remains severely disabled by her obsessive–compulsive symptoms despite six months of pharmacological treatment and a course of exposure with response prevention. Her symptomsimprove after her psychiatrist takes a careful history and arranges counselling to address hermarital problems.


-          Various form of psychological treatments known to be effective for anxiety disorders are behavioural therapy, cognitive behaviour therapy, mindfulness based techniques.


Why people suffering from anxiety disorders should get treatment from psychiatrists?


-          Most of the general physicians and neurophysicians don’t have expertise in accurately formulating the cases of anxiety disorders.

-          Their treatment primarily depends on prescribing medications which may not help by more than 50-60%. This means person continue to suffer despite some relief in anxiety.

-          Some doctors rely on long-term use of benzodiazepines to treat anxiety disorder which can lead to addiction of these drugs.

-          Most of the anxiety disorders are co-morbid i.e the person might suffer from more than one anxiety disorders. This may get miss out if the doctor doesn’t explore the patient’s symptoms or rely primarily on patient’s presenting complaints.

-          In many cases, anxiety disorders occur together with alcohol related problems or personality issues such as anxious avoidant personality traits which need to be addressed separately.

-          The goal of treatment should be functional recovery rather than symptom reduction. For functional recovery, psychological intervention is required which is obviously better done by psychiatrist.


What are the challenges of treating anxiety disorders?


-          Only partial response to treatment with medications.

-          Need to treat with multiple medications

-          Sensitivity to side-effects if medications are not used carefully

-          Patient’s difficulty in accepting the partial response to medication and not co-operating with psychological interventions

-          Patient’s fear of need of lifelong treatment, frequently changing their doctor, fear of discussing their fear with doctor openly, relying on relaxing remedies such as alcohol, gutkhas, tobaccos, addictive medications etc.




Services we offer-


-          Second opinion on difficult to treat cases of anxiety disorders


-          Specialist advice on patients with poor response to medication treatment


-          Individualised case formulations for anxiety disorders


-          Holistic approaches to treatment of anxiety disorders