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Shorn of the psychologic components of apprehension and fear, the anxiety attack consists essentially of an excessive autonomic discharge Some of the autonomic symptoms are duplicated by chromaf n tumors, hyperthyroidism, and the menopause The prominence of chest discomfort and respiratory distress during an acute anxiety attack may be mistaken for myocardial ischemia, in which case the patient is often subjected to a series of studies of cardiac function Another form of the illness in which dizziness, a vague dif culty with visual clarity, and fear of losing consciousness are the most prominent features may be mistaken for a neuro-otologic problem ( panic-vertigo, page 258) In contrast, numerous other symptoms such as headache are relatively infrequent, and the diagnosis should be suspect if headache is a prominent feature (Chronic headache may be part of chronic anxiety state or anxious depression.

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) Loss of consciousness, incontinence, and clonic or myoclonic movements do not occur Other medical diseases that are brought to mind by particular elements of an anxiety state are pulmonary embolism, cardiac arrhythmias, hypoglycemia, hypoparathyroidism, alcohol, drug, and nicotine withdrawal, and especially complex partial seizures Strict adherence to the diagnostic criteria of these disease states readily permits their differentiation from acute anxiety, but diagnosis may be dif cult if the symptoms of anxiety are very brief or persist for hours or days on end Of greater importance is the relationship of anxiety neurosis to other psychiatric illnesses, particularly to depression Symptoms of depression are frequently added to those of anxiety neurosis, and the majority of patients with depression have symptoms of anxiety Indeed, some psychiatrists believe that anxiety neurosis is accounted for mainly by a variant of depression.

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As has been mentioned, an anxiety state appearing for the rst time after the fortieth year usually proves to be primarily a depression The uncovering of paranoid symptoms in a patient with an anxiety state should always raise the question of depression, as should the presence of symptoms such as overwhelming fatigue, self-depreciation, and feelings of hopelessness and, of course, ideas of self-destruction As mentioned, a very small number of patients with a condition diagnosed as pure anxiety neurosis by competent psychiatrists have committed suicide Schizophrenia may also begin with prominent anxiety symptoms Here the diagnosis rests on nding the characteristic thought disorder of schizophrenia, which may emerge only after several interviews Hysteria may include anxiety symptoms, though they are seldom prominent, as do also phobic and obsessive-compulsive neuroses, but each has other distinguishing attributes..

These focal or segmental dystonias, in contrast to the generalized dystonic disorders described in Chap 4, are intermittent, brief or prolonged spasms or contractions of a muscle or adjacent group of muscles that places the body part in a forced and unnatural position When limited to the neck muscles, the spasms may be more pronounced on one side, with rotation and partial extension of the head (idiopathic cervical dystonia or torticollis), or the posterior or anterior neck muscles may be involved predominantly and the head hyperextended (retrocollic spasm, retrocollis) or inclined forward (antero- or procollic spasm, anterocollis) Other dystonias restricted to craniocervical muscle groups are spasms of the orbicularis oculi, causing forced closure of the eyelids (blepharospasm); contraction of the muscles of the mouth and jaw, which may cause forceful opening or closure of the jaw and retraction or pursing of the lips (oromandibular dystonia).

Myopathic Fatigue Not unexpectedly, fatigue and intolerance of exercise (ie, fatigue with mild exertion) are prominent manifestations of myopathic disease, in which muscles are weak to begin with Even in a disease such as myasthenia gravis, the muscles exhibiting fatigue are usually weak even in the resting state The classes of myopathic disease in which weakness, inability to sustain effort, and excessive fatigue are notable features include the following: the muscular dystrophies, congenital myopathies, disorders of neuromuscular transmission (myasthenia gravis, Lambert-Eaton syndrome), toxic myopathies (eg, due to cholesterol-lowering drugs), some of the glycogen storage myopathies, and mitochondrial myopathies One type of glycogen storage disease McArdle phosphorylase de ciency is exceptional in that fatigue and weakness are accompanied by pain and sometimes by cramps and contracture.

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