14.3 — Anxiety, Panic and OCD

These are the most treatable conditions in this Part, with recovery rates that would be considered excellent in most of medicine — and among the most under-treated, because people classify themselves as worriers and never go.

All of them run on the same mechanism (6.9): a threat prediction, avoidance of the thing feared, and therefore no correction of the prediction.

And all of them are treated by the same principle: approach the thing, stay, and let the prediction be corrected by evidence (2.6).

Generalised anxiety

Persistent, excessive worry across multiple areas, most days, for six months or more, which is difficult to control and comes with restlessness, fatigue, difficulty concentrating, irritability, muscle tension and disturbed sleep.

What it feels like: the worry moves. One thing resolves and the next arrives. There is always something, and the person frequently believes the worry is protective — that if they stopped, something would go wrong.

What helps: cognitive behavioural therapy, with strong evidence. Scheduled worry time (5.4). Dropping the safety behaviours — the checking, the reassurance-seeking, the over-preparation — which is the part that maintains it. Medication, where symptoms are significant.

Panic disorder

Recurrent panic attacks plus persistent fear of having another.

A panic attack is a sudden surge of intense fear peaking within minutes: pounding heart, sweating, shaking, breathlessness, chest pain, nausea, dizziness, tingling, feelings of unreality, and a conviction of dying or losing control.

The single most important fact: it is not dangerous, and it always ends. The physical sensations are the stress response (6.2) at full intensity, and the body cannot sustain it.

The loop that produces the disorder: the sensations are interpreted as catastrophic — this is a heart attack, I am dying, I am going mad — and the interpretation triggers more of the response. Then avoidance of any situation where an attack might occur, which spreads.

What helps, and this is one of the most effective treatments in psychiatry: cognitive behavioural therapy with interoceptive exposure — deliberately producing the sensations, by spinning, over-breathing, or running on the spot, until the body learns that the sensations are not dangerous. Recovery rates are high.

In the moment: long slow exhale (7.3). Name it — this is panic, it peaks in about ten minutes, it is not dangerous. Do not leave if you can stay, because leaving teaches escape.

And get a first attack medically checked — chest pain has other causes, and once cleared, stop seeking further reassurance, because the reassurance-seeking maintains it.

Social anxiety

Marked fear of social situations where you might be judged, with avoidance or intense distress, for six months or more, causing real impairment.

Not shyness (9.4). The line is impairment: turning down work, avoiding calls, not going to things, drinking to cope.

What maintains it: the safety behaviours. Rehearsing sentences, avoiding eye contact, sitting at the edge, having a drink first, saying little. Each one prevents you learning that you did not need it (6.9).

And self-focused attention. During a social situation, sufferers attend to their own performance — imagining how they appear — rather than to the other person. This makes performance worse and blocks the evidence that it went fine.

What helps: CBT, with strong evidence — specifically exposure plus dropping safety behaviours plus shifting attention outward. The instruction "pay attention to the other person rather than to yourself" is a real technique and it works.

Specific phobias

Excessive fear of a specific thing — heights, flying, needles, dogs, enclosed spaces.

The most treatable condition in this Part. Exposure therapy, done properly, works for the large majority, and it can be effective in a single extended session for some phobias.

The rules that make exposure work: graded — start well below the limit; stay until the anxiety comes down, because leaving at the peak teaches escape; repeated; and without safety behaviours.

If you have a phobia and have not treated it, this is the highest return available in the whole of Part 14.

Obsessive-compulsive disorder

Widely misunderstood, and it is not about being tidy.

Obsessions are intrusive, unwanted thoughts, images or urges that cause severe distress. Common themes: contamination, harm coming to someone, doubt about having done something, unacceptable violent or sexual thoughts, and a need for symmetry.

Compulsions are repetitive behaviours or mental acts performed to reduce the distress. Washing, checking, counting, repeating, arranging, seeking reassurance, mentally reviewing.

The key point about the thoughts: they are ego-dystonic — the person finds them horrifying and contrary to who they are. Somebody tormented by intrusive thoughts of harming their child is not a danger to that child; the distress is the diagnosis. This distinction matters enormously and it is frequently missed, including by sufferers, who conclude they are monstrous and tell nobody for years.

The loop: the thought arrives, the distress spikes, the compulsion reduces it, and the reduction reinforces the compulsion. Meanwhile the belief that the compulsion prevented disaster is never tested.

What helps: exposure and response prevention — deliberately encountering the trigger and not performing the compulsion. This is the specific treatment, it has strong evidence, and it is uncomfortable. Certain antidepressants at higher doses than for depression also help, and combination is common.

What does not help: reassurance, which is a compulsion by proxy (6.9), and analysing the content of the thoughts, which is a mental compulsion.

Health anxiety

Persistent fear of having a serious illness, despite reassurance.

Maintained by: body checking, symptom searching online, and reassurance-seeking from doctors and family. Each produces relief for hours and strengthens the loop.

What helps: CBT, with an explicit agreement to stop checking, stop searching, and stop seeking reassurance — including from the people around you, who need to be told to stop providing it kindly.

The common thread

Every condition here is maintained by the thing that provides short-term relief. Avoidance, safety behaviours, compulsions, reassurance, checking.

And every effective treatment involves deliberately giving those up while approaching the feared thing.

That is why treatment is uncomfortable, why it works, and why nothing else does.

What to do

Identify your safety behaviours — the things you do to make the feared situation tolerable — and drop one, deliberately, this week. This is the highest-value single action available for anxiety (6.9).

Stop seeking reassurance about the same thing. Notice how many times you have asked, and that the relief lasted minutes.

Approach rather than avoid, in small graded steps, and stay until it drops.

And get treatment, because these conditions respond to it better than almost anything else in this volume. In India, Tele-MANAS on 14416 is free and 24 hours and is a reasonable first call.

Next: 14.4 covers the condition where the memory itself is the problem.