Bound for Calmness: Voluntary Rope-Tying Behavior in Late-Life Generalized Anxiety Disorder

Original Source: Journal of Clinical Psychiatry, all rights reserved. —

Late-life generalized anxiety disorder (GAD) with panic attacks may present with atypical somatic and behavioral symptoms, creating diagnostic confusion with psychosis, delirium, akathisia, or neurocognitive disorders.¹ We report an elderly patient with severe anxiety who repeatedly sought rope restraint during episodes of overwhelming inner restlessness because he experienced temporary relief after immobilization.

Case Report

A 71-year-old married Hindu farmer from rural India, educated up to middle school and living in a joint family, presented in January 2026 with a 1-year history of gradually progressive symptoms beginning around February 2025. He developed excessive and difficult-to-control worries regarding health, finances, family welfare, and future security, along with insomnia, psychomotor restlessness, and persistent concerns about incomplete bowel and bladder evacuation. From mid-2024 onward, he experienced recurrent episodes of severe inner distress lasting 30–45 minutes, occurring once or twice daily, characterized by pacing, inability to remain seated, and fear of serious illness. During these episodes, he consumed 4–7 L of water daily and reported temporary relief afterward. Most notably, he repeatedly requested family members to tie him to the bed with ropes, describing immobilization as the only measure that made him feel calm internally. There was no history of suicidal behavior, self-harm, psychotic symptoms, or exposure to dopamine-blocking medications associated with akathisia.

Psychosocial evaluation revealed longstanding marital discord, emotional loneliness despite living within a joint family, and prominent fears related to dependency, aging, and death. Mental status examination showed anxiety, restlessness, and marked somatic preoccupation. Speech was coherent and goal-directed. No delusions, hallucinations, formal thought disorder, delirium, or cognitive impairment were detected. The Mini-Mental State Examination² score was 28/30. Routine blood investigations, serum electrolytes, endocrine evaluation, and urological assessment were unremarkable except for benign prostatomegaly, for which tamsulosin 0.4 mg/day was started. A diagnosis of GAD with panic attacks was made according to International Classification of Diseases, Eleventh Revision criteria (6B00 and MB23.H).

The patient underwent 4 weeks of inpatient multidisciplinary management. Escitalopram was titrated to 15 mg/day with short-term lorazepam support during the initial phase. Jacobson progressive muscle relaxation was introduced. Occupational therapy focused on structured daily activities to reduce bodily preoccupation. Family sessions addressed emotional communication, reassurance-seeking behavior, and caregiving responses. The Hamilton Anxiety Rating Scale³ score decreased from 40 to 17 over 4 weeks, with complete resolution of rope-tying requests and marked reduction in excessive water intake. A relapse-prevention plan emphasizing family support, structured routine, social engagement, and regular follow-up was discussed before discharge.

Discussion

This case demonstrates an unusual manifestation of late-life anxiety in which voluntary physical restraint functioned as a maladaptive coping strategy during episodes of overwhelming autonomic and emotional arousal. Unlike restraint associated with psychosis, delirium, or behavioral dyscontrol, the patient consciously sought immobilization because it produced subjective relief from unbearable internal restlessness.⁴ The behavior appeared more consistent with an anxiety-related self-soothing phenomenon than psychotic disorganization. Recognition of the underlying anxiety disorder prevented diagnostic mislabeling and allowed effective biopsychosocial intervention.

A PubMed search (1950–May 2026, English language) using the terms voluntary restraint, self-restraint, rope-tying, containment behavior, anxiety, generalized anxiety disorder, and elderly yielded no comparable geriatric case reports. Awareness of such atypical anxiety presentations may help clinicians avoid diagnostic delay and facilitate appropriate treatment in elderly patients presenting with unusual behavioral symptoms.⁵

Article Information

Published Online: October 22, 2026. https://doi.org/10.4088/PCC.26cr04280
© 2026 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2026;28(5):26cr04280
Submitted: May 18, 2026; accepted July 16, 2026.
To Cite: Prakash O, Koner S, Khanna A, et al. Bound for calmness: voluntary rope-typing behavior in late-life generalized anxiety disorder. Prim Care Companion CNS Disord 2026;28(5):26cr04280.
Author Affiliations: Department of Geriatric Mental Health, Institute of Human Behaviour and Allied Sciences (IHBAS), New Delhi, India (all authors).
Corresponding Author: Om Prakash, MD, Professor of Psychiatry & Head, Department of Geriatric Mental Health, Institute of Human Behaviour and Allied Sciences (IHBAS), New Delhi, India ([email protected]).
Financial Disclosure: None.
Funding/Support: None.
Patient Consent: Consent was obtained from the patient to publish the case report, and information, including dates, has been de-identified to protect patient anonymity.
Additional Information: Artificial intelligence (ChatGPT, OpenAI) was used solely for English-language editing to improve grammar, clarity, readability, and overall presentation of the manuscript. The authors independently prepared the manuscript, interpreted the clinical findings, conducted the literature review, and are fully responsible for the scientific content, accuracy, and conclusions. All authors reviewed and approved the final version of the manuscript.

Journal of Clinical Psychiatry, all rights reserved.