Severe Generalized Anxiety With Persistent Presyncope and Avoidance

AGE: 29 Years, Male.
In May 2025, while accompanying father to the hospital emergency department for a finger bandage, a vasovagal syncope episode occurred on exposure to blood. The episode lasted approximately 30 seconds and was associated with shortness of breath, tachycardia, sweating, and vertigo-like spinning sensation upon regaining consciousness. The episode resolved spontaneously without residual weakness or confusion. The patient is a medical doctor (MBBS, 2021), accustomed to hospital environments and routine clinical exposure, making emotional or blood-related phobia an unlikely primary trigger. Following the incident, he remained asymptomatic for about one month, carrying out routine daily activities without limitation.

By June 2025, recurrent presyncopal episodes began to occur, characterized by:
● Dizziness and lightheadedness
● Excessive sweating
● Thirst and dry throat
● Heat sensation around neck and upper chest
● Abdominal discomfort and urgency to defecate
● Nausea
● Phantom smell sensations
● Shortness of breath or difficulty breathing
● Difficulty focusing and concentrating
● Feeling of chaos or loss of control

Common triggers included:
● Visual exposure to blood (in videos, pictures, or clinical settings)
● Loud noises, crowds, and enclosed or hot spaces
● Sudden body or head movements (turning, looking around)
● Walking, climbing stairs, or driving
● Being alone in a room
● Hospital or clinical environments

By October 2025, symptoms had worsened significantly. He became unable to stay alone, drive, or perform routine tasks without symptom provocation. Exercise tolerance markedly decreased—previously able to walk 30–40 minutes, now limited to less than 2 minutes before symptom onset. To prevent worsening, work, studies, and social activities were discontinued, and bed rest was maintained to avoid triggers.

During the past one month, new lower limb sensory symptoms developed while walking or standing, described as burning, cold-water-splash sensations in the legs accompanied by a mild internal shaking or trembling feeling. These sensations are intermittent but have increased in frequency and intensity recently.

Given the professional background and familiarity with medical settings, the persistence of these symptoms raises consideration of autonomic dysfunction (dysautonomia) in addition to anxiety or panic-related etiologies. However, based on the overall clinical pattern, triggers, and response to anxiolytic therapy, the presentation appears more consistent with a psychological rather than a physical cause.

Clinical Findings and Investigations

● Vitals: Generally within normal limits except during symptomatic episodes, when blood pressure fluctuates (occasionally elevated or reduced) and heart rate increases significantly.
● Orthostatic measurements: Blood pressure and heart rate recorded in lying, sitting, and standing positions per minute over 8 minutes remain within normal range, with no orthostatic hypotension or tachycardia observed.
● Blood glucose levels: Normal.
● ECG and Echocardiogram: Normal findings, no structural or electrical abnormalities detected.
● Ultrasound Abdomen: Normal except for fatty liver (hypoechoic pattern).
● Other physical and clinical examinations: No significant or relevant abnormalities identified.
● Height: 6 feet 1 inch (185 cm)
● Weight: 115 kilograms

Relevant Past History

In December 2016, following three consecutive flu infections and antibiotic therapy, a vasovagal syncope episode occurred in the washroom. Post-event, mild presyncopal symptoms (dizziness, fatigue, lightheadedness) persisted for approximately 2.5 years, resolving spontaneously by mid-2019 without medication or therapy.

In March 2025, a severe flu infection occurred, approximately two months prior to the May 2025 syncopal episode, possibly contributing to recurrence of autonomic or anxiety-related symptoms.

Diagnoses Considered

● Generalized Anxiety Disorder (GAD) – psychiatrist and neurologist
● Panic Disorder / Panic Attacks – neurologist
● Obsessive-Compulsive / Stress-Related Anxiety – internal medicine physician
● Possible Dysautonomia or Autonomic Instability – under consideration

Medications / Prescriptions

Neurologists:
● Escitalopram 5 mg once daily

Psychiatrist:
● Paroxetine 12.5 mg once daily
● Propranolol 10 mg once daily
● Alprazolam 0.5 mg once daily

Internal Medicine Specialist:
● Sertraline 100 mg twice daily
● Quetiapine 25 mg (½ tablet once daily)
● Propranolol 10 mg once daily
● Pantoprazole 40 mg once daily
● Cholecalciferol (Vitamin D3) 200,000 IU capsule once weekly

Current Status

Persistent presyncopal and autonomic symptoms triggered by minimal exertion or environmental stressors, accompanied by intermittent lower limb burning, cold, and shaking sensations on standing or walking. Blood pressure and pulse variability are observed during episodes but remain within normal limits under monitored conditions. Considering the medical background and the absence of structural or metabolic abnormalities, both anxiety-spectrum disorders and autonomic dysfunction remain possible explanations. Symptoms continue to significantly limit mobility, independence, and overall quality of life.

Currently taking escitalopram 5 mg once daily with mild improvement and increased calmness. However, significant avoidance behaviors persist due to fear of syncope or panic attacks—such as inability to go for a haircut, persistent fear of being in public places, and missing ongoing classes and internship due to fear of passing out in those settings.