Emotion › Abnormal Emotional Reaction

Anxious Foreboding

Anxious foreboding is a persistent, uneasy sense that something bad is about to happen, without the person being able to say clearly what that something is. It has the apprehensive quality of anxiety, but is oriented specifically toward an unspecified future misfortune rather than being tied to a particular object, situation, or already-present threat.

This has traditionally been described as a diffuse, forward-looking apprehension distinct from ordinary worry about a known problem, since the defining feature is precisely that the anticipated misfortune cannot be named or specified, only felt.

Recognition features

• A persistent sense that something bad or catastrophic is about to happen
• The anticipated misfortune is vague or unspecified, rather than a named, particular fear
• Carries the same apprehensive, uneasy quality as anxiety generally, but oriented specifically toward the future
• Not reliably tied to a specific object or situation, distinguishing it from a phobic pattern

Eliciting it at interview

• Ask: "Do you have a sense that something bad is going to happen, even if you can't say exactly what?"
• Explore whether the person can identify any specific feared outcome, or whether the sense of dread remains vague and unfocused however much they are asked to specify it
• Note how persistent and pervasive this sense is, and whether it colours the person's outlook generally

Distinguishing features

• Differs from a phobia in lacking any specific, identifiable trigger or object
• Differs from a panic attack in being a sustained background sense of dread rather than a discrete, rapidly peaking episode
• Differs from a delusion of persecution or catastrophe in that the feeling remains a vague sense of foreboding rather than a fixed, false belief about a specific threat

Common misconceptions

• That anxious foreboding must be based on some real, if unrecognised, threat; the feeling can arise and persist with no identifiable external basis
• That this is the same as ordinary worry; ordinary worry is usually attached to a specific, nameable concern, while anxious foreboding remains characteristically vague

Related phenomena

Abnormal Emotional Reaction · Anxiety · Morbid Anxiety

Diagnostically relevant to

Generalized Anxiety Disorder (links open the DSM-5 Learning Lab)

Practice this

For several weeks, a woman has carried a persistent sense that something bad or catastrophic is about to happen, though she cannot say what, or to whom, or when — it is not tied to any particular object, situation, or event, just a sustained, uneasy sense of dread hanging over everything. What is this? · A man describes brief episodes, several times a week, in which intense dread suddenly overwhelms him, peaking within a few minutes along with a racing heart and breathlessness, before subsiding completely and leaving him feeling entirely normal in between episodes. Before revealing the answer: is this anxious foreboding? · A patient describes fear about the future. Before revealing the answer, decide what distinguishes anxious foreboding from a panic attack. · A patient appears distressed and unsettled about their current experience. Before revealing the answer, decide what distinguishes perplexity from anxious foreboding. · You are assessing a patient for anxious foreboding. Before revealing the answer, decide what you would ask. · Explain why the vagueness of the anticipated misfortune in anxious foreboding is itself a clinically meaningful feature, rather than simply a patient's inability to articulate their fear clearly.

Illustration

For several weeks, a 52-year-old man describes an unshakeable feeling that something terrible is coming, even though his job, health, and family life are all, by his own account, entirely stable, and he cannot point to any single thing he is actually afraid of.

References

• Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 6, 'Disorders of Emotion'.