Introduction to

Anxiety and Fear-

Related Disorders
• Anxiety disorders are among the most common
forms of psychiatric disorders, characterized by
excessive fear, anxiety, and related behavioral
disturbances. Unlike psychotic disorders, they do
not involve hallucinations, delusions, or gross
disturbances of thought and perception. Instead,
they represent an exaggerated response of the
mind and body to stress or anticipated danger.
Anxiety vs fear
• Fear: Emotional response to a real or perceived imminent
threat.
• Anxiety: Anticipation of a future threat, usually associated
with feelings of apprehension, tension, or uneasiness.
• Both fear and anxiety are normal protective responses.
They prepare the body to deal with danger (“fight or
flight” response). However, when these responses are
excessive, disproportionate, prolonged, and impair daily
functioning, they become pathological and require clinical
attention.
Definition

• Anxiety disorder: A group of mental disorders

where the central feature is excessive fear and
anxiety, often accompanied by autonomic
hyperarousal, avoidance behaviors, and
psychological distress.
• According to ICD-11, these disorders are grouped
under “Anxiety or Fear-related Disorders”, replacing
the older term “Neurosis.”
Prevalence

• Global crude prevalence (1990–2017): 3.3%.

• In India (2017): 44.9 million cases.
• More common in females (2x higher).
• Onset: usually in 20s; risk high in childhood,
adolescence, early adulthood.
• Commonly seen in primary care settings.
Etiology ( causes )

• Multifactorial → genetic, biochemical,

psychological, behavioral, cognitive, personality,
environmental.
• 1. Genetic theory
• Runs in families.
• 15–20% first-degree relatives affected.
• Monozygotic twin concordance: ~80%.
• 2. Biochemical theory
• Neurotransmitter imbalance (esp. GABA).
• 3. Psychodynamic theory
• Failure of repression → anxiety.
• Phobia = displacement of fear from dangerous to
neutral object.
• 4. Behavioral theory
• Learned response via classical conditioning.
• Harmless object paired with stress → phobia
develops.
• 5. Cognitive theory
• Faulty cognitions, negative thoughts, irrational
beliefs → anxiety.
• 6. Other factors
• Personality (shy, perfectionist).
• Stressful/traumatic life events.
• Even positive events (marriage, new job, childbirth).
• Physical illnesses.
ICD-11 Classification
• 6B00: Generalized anxiety disorder
• 6B01: Panic disorder
• 6B02: Agoraphobia
• 6B03: Specific phobia
• 6B04: Social anxiety disorder
• 6B05: Separation anxiety disorder
• 6B06: Selective mutism
• 6B0Y: Other specified anxiety/fear-related disorders
Generalized Anxiety
Disorder (GAD, 6B00)
• Definition
• Excessive, unrealistic, persistent worry (free-
floating anxiety).
• Not limited to specific situation/object.
• Present most of the time, lasting several months.
• Clinical Features
• 1. Psychological
• Excessive worry, apprehension
• Restlessness, irritability, poor concentration,
forgetfulness
• Insomnia
• 2. Autonomic hyperactivity
• Palpitations, sweating, dizziness
• GI symptoms (nausea, abdominal distress)
• Trembling, dry mouth, shortness of breath
• 3. Motor symptoms
• Muscle tension, aches, shakiness
• Fatigability, chest/back pain
• Symptoms → must last months, cause impairment,
not due to another illness or substance.
Diagnosis

• Based on ICD-11 criteria.

• Screening tools:
• GAD-7
• Hamilton Anxiety Rating Scale (HAM-A)
• Zung Self-Rating Anxiety Scale (SAS)
• DASS-21 / 42
• RCADS (for children)
• Rule out: phobias, OCD, depression, schizophrenia.
Treatment Modalities

• 1. Pharmacotherapy
• Antianxiety (Benzodiazepines): alprazolam, clonazepam
• Antidepressants: imipramine, buspirone, SSRIs (sertraline,
escitalopram)
• Beta-blockers: propranolol (for palpitations)
• Usually continued for 9–12 months, then tapered.
• 2. Psychological Therapies
• Supportive psychotherapy: listening, reassurance, stress management.
• Behavior therapy:
• Relaxation techniques (muscle relaxation, yoga, pranayama,
meditation).
• Biofeedback.
• Cognitive therapy:
• Correct faulty thinking.
• Record anxiety levels, examine evidence for/against worries.
• Teach realistic problem-solving.
• 3. Lifestyle modification
• Adequate sleep, exercise, relaxation practices, avoidance of
stimulants.
• ---
• ✅ Course: Usually chronic, with insidious onset in early–mid 30s.
• ❌ Full remission uncommon.
• ⚠️Early onset → higher risk of functional impairment & comorbidi
Panic Disorder
• Definition
• Panic disorder is characterized by recurrent,
unexpected panic attacks.
• A panic attack is a sudden episode of intense fear or
discomfort, reaching a peak within minutes,
accompanied by prominent physical symptoms
(e.g., palpitations, breathlessness, chest pain) and
fear of serious consequences (e.g., dying, losing
control, going mad).
• Unlike phobic disorders, panic disorder is not linked
to specific situations or objects.
Prevalence and Incidence
• Lifetime prevalence: 1.5–2% of the population.
• More common in females (2–3 times higher than
males).
• Onset: Usually in early adulthood (20s–30s).
Clinical Features

• Recurrent panic attacks (discrete episodes of intense fear).

• Symptoms may include:
• Palpitations or rapid heart rate
• Sweating
• Trembling/shaking
• Shortness of breath
• Feeling of choking
• Chest pain
• Nausea/abdominal distress
• Dizziness/lightheadedness
• Chills or hot flushes
• Tingling/numbness in extremities
• Depersonalization/derealization
• Fear of losing control or “going mad”
• Fear of imminent death
• Persistent worry about recurrence of attacks.
• Avoidance behaviors → patients may avoid public
places, crowds, or unfamiliar environments.
• Significant impairment in personal, family, social,
occupational, or educational functioning
Diagnosis
• Based on ICD-11 criteria.
• Exclude organic/medical conditions and substance
effects:
• Blood glucose (rule out hypoglycemia)
• Thyroid function (rule out hyperthyroidism)
• Toxicology (rule out caffeine, amphetamines,
barbiturates, etc.)
• Must cause significant distress or impairment in
functioning.
Treatment Modalities
• 1. Pharmacotherapy
• Benzodiazepines: alprazolam, clonazepam (for acute relief).
• SSRIs: fluoxetine, sertraline, escitalopram (first-line long-term
treatment).
• Beta-blockers (propranolol): control palpitations not
responding to anxiolytics.
• 2. Behavioral Therapies
• Relaxation techniques (progressive muscle relaxation, guided
imagery).
• Breathing exercises (reduce hyperventilation).
• Listening to calming music.
• Cognitive Therapy
• Helps patient identify catastrophic thoughts (e.g.,
“I’m going to die”).
• Teaches realistic thinking and restructuring negative
thoughts.
• Identifies triggers and develops coping strategies.
• More effective for long-term prevention of relapse.
• 4. Patient and Family Education
• Reassurance: attacks are not fatal, resolve within
15–30 mins.
• Avoid excessive medical consultations.
• Do not restrict activities or avoid places
unnecessarily.
Phobic Anxiety Disorders

• A phobia is an irrational and persistent fear of a

specific object, activity, or situation that:
• Is disproportionate to the actual danger.
• Cannot be controlled by reasoning.
• Leads to avoidance behavior.
• Causes significant distress and impairment.
Types of Phobias (ICD-11
• 1. Specific Phobia (Simple Phobia)
• Fear of a specific object/situation (e.g., animals, heights, blood, closed
spaces).
• Onset: usually childhood (7–10 years).
• Exposure leads to immediate anxiety or panic attack.
• Examples:
• Acrophobia → fear of heights
• Claustrophobia → fear of closed spaces
• Zoophobia → fear of animals
• Hematophobia → fear of blood
• Algophobia → fear of pain
• Course: Often persists into adulthood, rarely remits spontaneously.
• Common comorbidities: depression, other anxiety disorders.
• 2. Agoraphobia
• Fear of situations where escape is difficult or help
unavailable (e.g., public transport, crowds, open
spaces).
• Often associated with panic disorder.
• Leads to avoidance of public places and even
confinement at home.
• Case: A young woman avoids theatres and
shopping centers after repeated panic episodes,
eventually becoming housebound.
• Course: Chronic, high risk of comorbid depression
and substance abuse.
Social Anxiety Disorder (Social Phobia)
Definition: Irrational fear of performing activities or
interacting with others due to fear of
embarrassment, humiliation, or negative
evaluation.
ICD-11 criteria:
Marked and excessive fear in one or more social
situations (e.g., conversations, eating in public,
giving a speech).
Symptoms persist for several months or more.
Cause significant distress/impairment in
functioning.
Course

• Onset: childhood or adolescence, often after a

stressful/humiliating experience.
• Chronic if untreated.
• Better prognosis if onset is later, impairment is
mild, and comorbidities are absent.
• Poor prognosis with alcohol misuse, personality
disorders, or other anxiety disorders.
• ✅ Key difference between Panic Disorder and
Phobias:
• Panic Disorder → panic attacks occur spontaneously
without specific triggers.
• Phobias → anxiety occurs only in the presence (or
anticipation) of the phobic object/situation.
 Separation Anxiety
Disorder
• Definition: Excessive, developmentally inappropriate
fear of separation from attachment figures (parents,
caregivers, romantic partner).
• Onset: Typically in childhood, but may persist into
adulthood.
• Symptoms:
• Excessive worry about harm to attachment figure.
• Physical symptoms: sweating, palpitations, stomach
upset.
• Avoidance of school, work, or being alone.
• Refusal to sleep away from attachment figure.
• Recurrent nightmares about separation.
Selective mutism
• Definition: Consistent failure to speak in certain social
situations despite having normal language ability.
• Onset: Usually in childhood.
• Symptoms:
• Speaks normally at home but remains mute in school or
with outsiders.
• Communicates via gestures, nodding, or facial
expressions.
• Associated with anxiety, not speech/language deficits.
• Duration: At least 1 month (beyond first month of
school).
• Leads to academic and social impairment.
 Treatment of anxiety
disorder
• 1. Medications
• Benzodiazepines: alprazolam, clonazepam, lorazepam (short-
term relief).
• Antidepressants (SSRIs, TCAs, MAOIs): sertraline,
imipramine, phenelzine (long-term).
• 2. Behavioral Therapy
• Systematic desensitization: gradual exposure + relaxation.
• Relaxation training: deep breathing, progressive muscle
relaxation, calming music.
• Role-playing and guided imagery.
• Assertiveness training.
• Modeling: observing others facing feared situations.
• Thought-stopping techniques.
• 3. Psychotherapy
• Supportive psychotherapy: reassurance, coping
skills.
• Cognitive-behavioral therapy (CBT): addresses
irrational thoughts, avoidance, and catastrophic
thinking.
Obsessive-Compulsive Disorder (OCD)

• Introduction
• Obsessive-Compulsive Disorder (OCD) is a chronic mental
health disorder characterized by the presence of obsessions
(intrusive, unwanted thoughts, images, or urges) and/or
compulsions (repetitive behaviors or mental acts performed to
reduce anxiety or prevent a feared event).
• Prevalence: Lifetime prevalence ≈ 3%.
• Onset: May begin in childhood, but most often starts in
adolescence or early adulthood.
• Gender: Occurs equally in men and women.
• Course: Usually chronic and fluctuating, with periods of
improvement and relapse.
• Key Terms
• Obsessions:
• Intrusive, unwanted, and distressing thoughts, images, or
impulses.
• Cause anxiety or disgust.
• Patient attempts to ignore, suppress, or neutralize them.
• Compulsions:
• Repetitive behaviors (e.g., washing, checking) or mental acts
(e.g., counting, praying).
• Performed to reduce anxiety or prevent a dreaded event.
• Provide temporary relief, but reinforce the cycle.
• ICD-11 Diagnostic Criteria
• Presence of obsessions and/or compulsions.
• Recognized as the person’s own thoughts/behaviors
(not imposed from outside).
• Time-consuming (>1 hour/day) OR cause significant
distress/impairment in personal, family, social, or
occupational functioning.
• Not explained by another mental/medical condition.
• Types of OCD (ICD-11):
• 6B20: OCD
• 6B20.0 – With fair to good insight
• 6B20.1 – With poor or absent insight
• 6B21 – Body Dysmorphic Disorder
• 6B22 – Olfactory Reference Disorder
• 6B23 – Hypochondriasis
• 6B24 – Hoarding Disorder
• 6B25 – Body-focused repetitive behavior disorder
• Etiology
• OCD is multifactorial:
• 1. Genetic Factors
• Higher concordance in monozygotic twins.
• 35% of first-degree relatives of OCD patients are also affected.
• 2. Biochemical Factors
• Dysfunction of serotonin (5-HT) pathways.
• 3. Psychoanalytic Theory (Freud)
• Regression to the anal-sadistic stage.
• Harsh superego and defense mechanisms (isolation, undoing, displacement,
reaction formation).
• 4. Behavioral Theory
• Obsessions → anxiety (conditioned stimulus).
• Compulsions → learned behaviors that reduce anxiety (negatively reinforced).
Clinical Features
(Symptoms
• Obsessive Symptoms
• Obsessional thoughts: unwanted words, ideas,
blasphemous thoughts.
• Obsessional images: violent, disgusting, or sexual
images.
• Obsessional doubts: repeated doubts about
safety/actions (e.g., stove left on, door unlocked).
• Obsessional impulses: urges to perform
embarrassing or violent acts.
• Obsessional ruminations: endless internal debates
• Compulsive Symptoms
• Compulsive rituals: repetitive checking, counting,
washing, praying.
• Obsessional slowness: marked delay in daily activities
due to rituals.
• Avoidance: avoiding situations that trigger obsessions.
• Associated Symptoms
• Secondary depression, hopelessness, helplessness,
disturbed sleep.
Course and prognosis
Course: Long, fluctuating, often chronic.
Good prognosis:
Later onset
Good social/occupational adjustment
Episodic course
Precipitating event present
Poor prognosis:
Childhood onset
Severe, bizarre symptoms
Comorbid depression or personality disorder
Treatment
• 1. Pharmacotherapy
• SSRIs: fluvoxamine, sertraline, fluoxetine.
• Clomipramine (TCA).
• Benzodiazepines (short-term for anxiety).
• 2. Behavior Therapy
• Exposure and Response Prevention (ERP):
• Patient is exposed to anxiety-provoking stimulus
and prevented from performing compulsion (e.g.,
touching dirty object without washing hands).
• Thought Stopping: patient commands themselves
to “Stop!” unwanted thoughts.
• Relaxation Techniques: deep breathing, progressive
muscle relaxation, meditation, imagery, music.
• 3. Other Therapies
• CBT (challenging irrational beliefs).
• Supportive psychotherapy.
• ECT (in refractory cases).
Characteristics of OCD
• 1. Obsessions
• Recurrent and persistent thoughts, ideas, images, impulses, or doubts.
• Intrude into conscious awareness repeatedly.
• Recognized as the individual’s own thoughts, not imposed by others.
• Unwanted, unpleasant, and anxiety-provoking.
• Person attempts to ignore, suppress, or neutralize them.
• Failure to resist → marked distress.
• 2. Compulsions (Rituals)
• Repetitive behaviors (e.g., checking, washing, touching) or mental acts (e.g.,
counting, praying, repeating words).
• Performed in response to an obsession or according to rigid rules.
• Aim to reduce anxiety or prevent some dreaded event.
• If prevented, causes severe anxiety or distress.
• 3. Time-consuming nature
• Obsessions/compulsions usually take more than 1
hour per day.
• Interfere with personal, social, educational, and
occupational functioning.
• 4. Insight
• Patients recognize obsessions and compulsions as
irrational, excessive, and senseless.
• Despite this, they cannot ignore or control them.
• Insight may vary: good, poor, or absent.
• 5. Emotional Impact
• Obsessions and compulsions cause marked anxiety, fear,
guilt, or disgust.
• Often associated with secondary depression,
hopelessness, and helplessness.
• 6. Chronic course
• Usually long-standing and fluctuating (periods of
worsening and improvement).
• Many patients also have comorbidities: major
depression, panic disorder, phobias, eating disorders, or
substance use.