The prognosis for affective illness with overt anxiety.

Not the least of our problems in psychiatry is the ubiquitous anxiety state. These patients are an unsatisfactory group because there seem to be no established indications for treatment, and it is rare to find anyone who is prepared to give an unequivocal prognosis. This is due in large measure to the fact that anxiety is a word having varying connotations, so that "anxiety state" is not a precise term. Even if anxiety is strictly defined there are still a number of different conditions having this symptom in common, and which may all therefore be reasonably called anxiety states. For this reason questions about the treatment of anxiety states have little real meaning, and it is easy to see how such methods as individual psychotherapy, group therapy, tranquillizers, modified insulin, and even electroconvulsive therapy, may all be mentioned at some time during the course of a discussion on this subject. Until we have a working classification and some agreement about the untreated prognosis for these illnesses, there can never be unanimity about the indications for treatment, or any useful evaluation of the treatments. This article is concerned with the classification of illness confidently diagnosed as affective (as opposed to schizophrenic or organic), and in which anxiety is the cardinal presenting symptom. Illness in which anxiety was incidental, but notpredominant,hasbeen excluded. It is probably because of this that patients, with one exception, are from the age group 20 to 35 years. It is imperative to be clear about the boundaries of the subject under investigation, and "anxiety" in this context refers to manifest, overt, or freefloating anxiety. This is variously described by the patient as a feeling of fear, panic, tension, or, more descriptively, as a sensation of being wrought up, or of expecting something unpleasant to happen. Physiological concomitants of fear are almost invariably present. Common ones are described as palpitations, rapid heart beats, missed heart beats, or a sudden empty feeling in the pit of the stomach. The less common are complaints of diarrhoea, 33E frequency of micturition, and a sudden sensation of dizziness or instability. The fear may be nameless, or secondary elaboration may occur so that anxiety becomes centred, for instance, on the idea of heart disease or death. Bodily symptoms may occasionally be the first or main complaint, but the feeling of acute anxiety is always present. This definition of anxiety excludes from the study all those anxiety states, anxiety hysterias, or organ neuroses in which somatic symptoms are unaccompanied by manifest anxiety or tension. All the patients considered were under my care and supervision from the onset of their illness. They were selected from among consecutive outpatients using the criteria listed below, and were seen in departments serving rural, urban, and metropolitan-suburban districts of Surrey and Sussex. Throughout the study the treatment was not definitive, and consisted of varying admixtures of superficial reassurance and amylo-barbitone, grain . It can reasonably b. described as expectant. The fundamental basis of classification was prognostic. In addition, it seemed to me that other reasonably objective criteria having possible predictive value could be set up based on the mode of onset, and the method of progression or course of the illness. Presenting symptoms were used for classification; some patients changed their symptoms as time passed, but they were not reclassified. The criteria are as follows: