Anxiety Disorders

Overview – Anxiety Disorders

Anxiety disorders are a group of psychiatric conditions defined by excessive fear, apprehension, and behavioural disturbance. While normal anxiety is an adaptive response to real or perceived threat, anxiety disorders occur when these responses become disproportionate, persistent, and disruptive. These disorders are frequently comorbid with depression and substance use disorders, and they significantly impact functioning in social, academic, and occupational domains. Proper diagnosis and tailored treatment are critical to prevent chronicity and improve quality of life.

Definition

Anxiety refers to a universal emotional state marked by worry, nervousness, or fear. It becomes pathological when:

  • Disproportionate to the perceived threat
  • Persistent despite resolution of the threat
  • Generalised to unrelated contexts
  • Causes impairment in functioning

Aetiology

Neurobiology

  • Primary brain structure involved: Amygdala (central to fear conditioning)
  • Key neurotransmitters:
    • Serotonin (5-HT)
    • Norepinephrine
    • Dopamine
    • Epinephrine
    • Cholecystokinin

Psychological

  • Distorted perception → exaggerated fear appraisal → maladaptive behaviours
  • Learned patterns (avoidance, safety behaviours) maintain symptoms

Behavioural

  • Fight-or-flight responses cause physiological disruption
  • Escaping feared stimuli reinforces anxiety

Clinical Features

  • Emotional: apprehension, fear, panic
  • Physical: tachycardia, sweating, tremors, dizziness
  • Cognitive: rumination, fear of dying, fear of “going mad”
  • Behavioural: avoidance of triggers, social withdrawal

DSM-5 Diagnostic Criteria

Panic Disorder

A. Recurrent, unexpected panic attacks involving abrupt onset of intense fear/discomfort peaking within minutes, plus ≥4 of:

  • Palpitations, sweating, trembling
  • Dyspnoea or choking sensation
  • Chest pain, nausea, dizziness
  • Derealisation or depersonalisation
  • Paraesthesias, chills, heat
  • Fear of dying or losing control

B. ≥1 month of persistent concern about future attacks or maladaptive behavioural change
C. Not better explained by medical condition or substance
D. Not better explained by another mental disorder

anxiety disorders: DSM-5 Criteria for PANIC DISORDER

Associated Conditions

Agoraphobia

  • Marked fear/anxiety about ≥2 of:
    • Public transport
    • Open/enclosed spaces
    • Crowds
    • Being alone outside home
  • Avoidance behaviour due to perceived inability to escape
  • Duration ≥6 months
  • Impairment in functioning
  • Can be diagnosed independently of panic disorder

Generalized Anxiety Disorder (GAD)

A. Excessive anxiety/worry on most days for ≥6 months
B. Difficulty controlling worry
C. Associated with ≥3 of:

  • Restlessness
  • Fatigue
  • Poor concentration
  • Irritability
  • Muscle tension
  • Sleep disturbance
    D–F. Causes functional impairment and is not attributable to other causes

Differential Diagnosis

  • Medical: arrhythmias, myocardial ischemia, thyrotoxicosis
  • Psychiatric: depression, substance use, obsessive-compulsive disorder, PTSD
  • Neurological: epilepsy, vestibular disorders

Investigations

  • Clinical diagnosis based on history and symptom profile
  • Rule out organic causes: ECG, thyroid function tests, toxicology screen
  • Screening tools: GAD-7, K10

Management

Lifestyle

  • Sleep hygiene
  • Avoid caffeine and alcohol
  • Stress reduction

Pharmacological

  • SSRIs: fluoxetine, sertraline, escitalopram
  • SNRIs: venlafaxine
  • Buspirone (second line for GAD)
  • Benzodiazepines: short-term, scheduled use only
  • Avoid: β-blockers (not effective for core anxiety symptoms)

Psychological

  • Cognitive behavioural therapy (CBT)
  • Graded exposure therapy
  • Relaxation strategies (e.g. visualisation, paced breathing)

Complications

  • Chronic course if untreated
  • Functional impairment (occupational, social)
  • Substance misuse
  • Development of comorbid depression
  • Relapse triggered by psychosocial stressors
  • Up to 30% may be refractory to standard treatments

Summary – Anxiety Disorders

Anxiety disorders are common but treatable psychiatric conditions that often coexist with depression and substance misuse. They include panic disorder, agoraphobia, and generalized anxiety disorder, all of which can severely impair quality of life if left untreated. Management is most effective when it combines pharmacologic treatment, psychological interventions such as cognitive behavioural therapy, and lifestyle adjustments. For a broader context, see our Psychiatry & Mental Health Overview page.

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