At age 44 and physically fit, he feared imminent death

History: Learning to worry

Mr. A, 54, is a hotel manager who has struggled with anxiety since childhood. At that time, he suffered primarily from incessant worries. Even then, he knew that his concerns were irrational, but he could not suppress them. Mild illness stirred up thoughts of his own death and then even the possibility of his parents’ death. Water coming from a tap evoked images of disasters from a future global water shortage.

In the classroom, his elaborate concerns about his teachers’ evaluations of him paralyzed him emotionally. While trying to manage this inner turmoil, even his obvious intelligence could not compensate for his time off-task in school, and a subsequent decline in his grades brought about the scrutiny he had dreaded, further exacerbating his anxiety.

By his teenage years, Mr. A developed classic compulsions, such as checking locks and engaging in counting rituals. In his 20s, he also found himself repeatedly returning home to confirm that he had turned off appliances. Over time, the doubt intrinsic to these compulsions only grew, and ultimately the associated anxiety became unbearable. Mr. A turned to increased alcohol use and even a brief experiment with heroin.

After self-medication brought no relief, Mr. A finally sought professional treatment at age 26. Although the compulsions caused the greatest burden, they were the most readily treated symptoms. His behavior-based psychotherapy led to full remission of his most overt symptoms. This treatment also helped alleviate some of his more circumscribed obsessions, but the diffuse worry proved to be more intractable.

After psychotherapy, just as in his childhood, Mr. A still worried about an ever-changing array of subjects. He worried about finances, his own physical health, and his wife’s well being. He worried about his relationship with his customers, as well as his supervisor’s assessment of him. Any physical symptom set off fears that he had cancer. In response to his memory of engaging in low-risk sexual behaviors in his distant past, he struggled to resist thoughts that he had AIDS. He stayed in excellent physical condition, combining strength training with 6 hours of aerobic exercise weekly. Still, he could not escape the nearly constant fear that his death was imminent.

In your view, what single diagnosis best explains Mr. A’s symptoms? What other conditions are you considering—or would you have considered earlier in his life?

Dr. Carter’s observations

The childhood history highlights a major controversy: psychiatric treatment of inattentive children who are not performing well in school. We psychiatrists are accused of sloppy diagnostic overuse of attention-deficit/hyperactivity disorder (ADHD) when “it’s just boys being boys,” and even of conspiracy in overmedicating children with psychostimulants. In my adult psychiatry practice, I more commonly see the consequences of missed cases of ADHD, rather than overdiagnosis, when, after successful treatment in adulthood, “underachieving” men struggle with a new view of their childhood “failures.”

The current case illustrates the need for careful evaluation of inattention. As an adult, Mr. A articulates his anxiety, but as a child, physically active yet silently worried, it would have been easy for an observer to misunderstand the source of his inattention.

The history in his adolescence and early adulthood emphasizes anxiety symptoms. With morbid themes, we must consider the possibility that the anxiety is a component of depression. Pervasive somatic concerns in particular can indicate major depression with psychotic features, a frequently missed diagnosis.

While Mr. A expresses concerns about AIDS and cancer—common themes in delusional depression—his core pathology is excessive worry, the essential feature of generalized anxiety disorder (GAD). Previously, Mr. A met criteria for obsessive-compulsive disorder. His concerns about scrutiny of his behavior also raise suspicion of social anxiety disorder. The complete differential diagnosis would include somatoform disorders, and we should note the comorbid substance abuse history.

So how many diagnoses does Mr. A have?

The disparate symptoms listed in the criteria for GAD cause some to doubt its validity as a true diagnostic entity. The overlap between the criteria for major depression and GAD (Box 1) raises other legitimate concerns.

But when we focus on pathologic worry as the defining feature of this disorder and recognize the associated emotional and physical symptoms, I think the diagnosis of GAD captures the essence of Mr. A’s presentation. Yes, he met criteria for OCD, and he has features of other disorders, but his current anxiety and physical symptoms are best explained by a unifying diagnosis of GAD.

Box 1