Pure, anxious-depressive, and panic anxiety attacks: A Freud-inspired case series

Freud described three types of anxiety attacks: pure anxiety attacks (PAA), characterized by sudden affective surges without ideation or somatic symptoms; anxious-depressive attacks (ADA), involving ruminative, self-critical thoughts; and panic attacks (PA), dominated by autonomic arousal. Although PA has been extensively documented, PAA and ADA have received limited clinical attention. In this retrospective case series, we reviewed outpatient clinic charts and descriptively classified recorded anxiety episodes by their predominant features, which enabled us to identify attacks lacking prominent physical symptoms. Two Japanese outpatients illustrate how these subtypes can manifest and shift within the same individual. Case A showed a temporal progression from PA to PAA and then ADA, each phase marked by distinct features. Case B initially presented ADA, followed by episodes of PA and PAA, sometimes alternating rapidly within a single episode. These observations suggest a shared psychodynamic origin expressed through somatic, cognitive, or affective channels depending on individual and situational factors. Distinguishing PAA and ADA from PA is clinically significant, as these subtypes lack the somatic arousal that typically guides diagnosis and may show different responses to psychological versus pharmacological strategies. Our findings highlight less recognized non-somatic variants that might otherwise be overlooked in clinical practice and point toward more tailored therapeutic approaches.