Section 06about 14 min · no rush

A gentle note before you read: symptom lists make almost everyone recognise themselves somewhere. That is a normal effect of reading, not a diagnosis. If something here sits on your mind, a conversation with a professional helps more than re-reading.

06

Anxiety disorders

The most common family of mental disorders worldwide. In the CTEVT PSC curriculum this is the first named category ("Anxiety", M2 · Sub-module 2 · Task 3).

Specific Phobia

CTEVT PSC curriculum300.29 · F40.2xx

Marked, excessive fear of a specific object or situation, out of proportion to the real danger.

In plain words: Being far more afraid of one thing (dogs, heights, blood, flying) than the danger deserves, and arranging life to avoid it.

DSM-5 Criteria
  1. Marked fear or anxiety about a specific object or situation (flying, heights, animals, injections, blood…). In children: crying, tantrums, freezing, clinging.
  2. The phobic object or situation almost always provokes immediate fear.
  3. It is actively avoided, or endured with intense fear.
  4. The fear is out of proportion to the actual danger and to the sociocultural context.
  5. Duration 6 months or more.
  6. Clinically significant distress or impairment in functioning.
  7. Not better explained by another disorder (panic, OCD, separation anxiety, PTSD, social anxiety).

Five specifiers by stimulus:

  • Animal
  • Natural environment
  • Blood-injection-injury (the only one with fainting; vasovagal)
  • Situational
  • Other
International

One of the most common mental disorders worldwide (US 12-month prevalence ≈ 7–9%), typically beginning in childhood (median onset ~7–11 years). Fear content is universal, but which fears dominate varies by ecology: snake and animal phobias where those threats are real, flying and injection phobias in industrialised settings.

Nepal

The National Mental Health Survey found a current rate of 0.2% for phobic anxiety disorders (95% CI 0.1 to 0.4), so most people living with a phobia here are never counted, and many are never named as having one. Presentations often arrive as body complaints ("mutu dhukdhuk", dizziness) rather than "fear". Distinguish a phobia from realistic caution: fearing a landslide path in monsoon is adaptive; refusing all travel year-round is not. Fear following a spirit-related interpretation (e.g., fear of a place after "saato gaeko": soul loss/fright) needs the cultural meaning explored before any label. Never invent a Nepali figure for a condition the survey did not measure. See Nepal in numbers for the full survey figures.

A worked example: A 19-year-old named Arun avoids every bus ride because he fears losing control and screaming. His counselor distinguishes this from a phobia of travel itself, notes that the avoidance has spread from buses to leaving home, and explains that the panic curve figure shows what actually happens: the body cannot hold the alarm forever.

Social Anxiety Disorder (Social Phobia)

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Marked fear of social situations where one may be scrutinised: driven by fear of negative evaluation.

In plain words: Dreading being looked at or judged (speaking, eating, meeting people), so that these situations are avoided or endured in fear.

DSM-5 Criteria
  1. Marked fear or anxiety about one or more social situations with possible scrutiny by others: conversation, being observed, performing. In children it must occur with peers, not only adults.
  2. Fear of acting in a way, or showing anxiety symptoms, that will be negatively evaluated: humiliation, embarrassment, rejection, or offending others.
  3. The situations almost always provoke fear or anxiety.
  4. They are avoided or endured with intense fear.
  5. The fear is out of proportion to the actual threat and sociocultural context.
  6. Duration 6 months or more.
  7. Clinically significant distress or impairment.
  8. Not attributable to a substance or medical condition.
  9. Not better explained by another mental disorder.
  10. If a medical condition (e.g., disfigurement, stuttering) is present, the fear is unrelated or excessive.

Specifier: performance only (public speaking/performing).

International

In Japan and Korea, the related cultural concept taijin kyofusho reverses the Western fear: the sufferer fears making others uncomfortable; with one's blushing, gaze, or body odour. DSM-5 lists it as a cultural concept of distress; it shows how the same mechanism (fear of social evaluation) is shaped by a collectivist frame.

Nepal

Think of ijjat (इज्जत): family honour and face. Fear of shaming the family can amplify social fears, and "log le ke bhanchan?" (what will people say?) is a common worry frame. In classrooms, a student who never speaks, avoids the front bench, and misses presentations may be labelled "lajalu" (shy) for years before anyone considers a treatable disorder. Differentiate culturally normal deference (not speaking before elders) from impairing fear.

Separation Anxiety Disorder

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Developmentally inappropriate, excessive fear about separation from attachment figures.

In plain words: A child (or adult) who cannot bear being apart from the people they are attached to, far beyond what is normal for their age.

DSM-5 Criteria
  1. Excessive fear about separation from attachment figures, shown by at least 3 of 8:
    • Recurrent distress when separation occurs or is anticipated
    • Persistent worry about losing attachment figures (illness, injury, death)
    • Worry that an event (getting lost, kidnapped) will cause separation
    • Reluctance or refusal to go out or to school
    • Fear of being alone without attachment figures
    • Reluctance to sleep away from home or without the figure nearby
    • Repeated nightmares with separation themes
    • Physical symptoms (headache, stomachache, nausea) at separation
  2. Duration: at least 4 weeks in children and adolescents; typically 6 months or more in adults.
  3. Clinically significant distress or impairment.
  4. Not better explained by another disorder (autism, psychosis, agoraphobia, GAD, illness anxiety).
International

DSM-5's key change: it is no longer only a childhood disorder; adult onset is recognised, often around leaving home, migration, or the birth of a child. The most common anxiety disorder in children under 12.

Nepal

Labour migration is the defining Nepali context: millions of households have a parent abroad. A child refusing school with daily stomachaches after a father leaves for the Gulf is a classic presentation, and the family may read it as physical illness or school laziness. Joint-family co-sleeping is normal; measure "developmentally inappropriate" against Nepali norms, not Western sleeping-alone norms. (DACUM anchor: "assess the childhood history; attachments".)

Generalized Anxiety Disorder (GAD)

CTEVT PSC curriculum300.02 · F41.1

Excessive, hard-to-control worry about many things at once: the "worry about everything" disorder.

In plain words: Worrying about many things most days for months, unable to switch it off, with a tense, tired, sleepless body.

DSM-5 Criteria
  1. Excessive anxiety and worry, more days than not for at least 6 months, about a number of events or activities (work, school, family, health).
  2. The person finds the worry difficult to control.
  3. At least 3 of 6 symptoms (1 suffices in children): restlessness/keyed-up · easily fatigued · difficulty concentrating or mind going blank · irritability · muscle tension · sleep disturbance.
  4. Clinically significant distress or impairment.
  5. Not attributable to a substance or medical condition (e.g., hyperthyroidism).
  6. Not better explained by another disorder (panic, social anxiety, OCD, PTSD, illness anxiety, anorexia).
International

Twice as common in women; in primary care worldwide it usually presents as tiredness, aches, and poor sleep rather than "worry". High-income settings show later onset (often 30s) than most anxiety disorders.

Nepal

The classic Nepali GAD presentation is somatic: "jiu dukhcha, nindra lagdaina, man aattincha" (body aches, no sleep, the heart-mind panics). Common worry themes: debt and loans, a son abroad, land disputes, daughters' marriages, crop failure. Screen for thyroid disease and anaemia before concluding GAD: both are common and mimic it. The National Mental Health Survey 2020 found generalized anxiety in 0.8% of adults currently (95% CI 0.6 to 1.1).

Screening tool: GAD-7 (a validated Nepali version exists)

Time frame: the past two weeks.

Answers:

  • 0 not at all
  • 1 several days
  • 2 more than half the days
  • 3 nearly every day

Seven items:

  • Feeling nervous or anxious
  • Unable to stop worrying
  • Worrying about many things
  • Trouble relaxing
  • Restlessness
  • Irritability
  • Fear that something awful may happen

The Nepali adaptation speaks the language of the heart-mind.

Score: 0 to 21; roughly 5 mild, 10 moderate, 15 severe. Ten or more deserves fuller assessment. A screen suggests; it never diagnoses.

Panic Disorder

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Recurrent, unexpected surges of intense fear peaking within minutes: then a month of fearing the next one.

In plain words: Sudden waves of terror with a pounding heart and breathlessness that feel like dying, then a month of fearing the next one.

DSM-5 Criteria
  1. Recurrent unexpected panic attacks: an abrupt surge of intense fear peaking within minutes, with 4 or more of 13 symptoms:
    • Body: palpitations · sweating · trembling · shortness of breath · choking feeling · chest pain · nausea · dizziness · chills or heat · numbness or tingling
    • Altered experience: the world or oneself feels unreal (derealisation, depersonalisation)
    • Feared outcomes: losing control or "going crazy" · dying
  2. At least 1 month after an attack of one or both: persistent worry about further attacks or their consequences; or a significant maladaptive change in behaviour (avoiding exercise, unfamiliar places).
  3. Not attributable to a substance or medical condition (hyperthyroidism, cardiopulmonary disease).
  4. Not better explained by another disorder (the attacks are not cued only by social situations, phobic objects, obsessions, trauma reminders, or separation).

A panic attack is a symptom, not a diagnosis: it can ride on any disorder ("with panic attacks" specifier). Panic disorder requires unexpected attacks plus the month of aftermath.

International

DSM-5 names culture-specific panic idioms: ataque de nervios (Latin America; shouting, crying, trembling after family stress) and khyâl cap ("wind attacks", Cambodia: panic attributed to wind rising in the body). Same physiology, different explanatory story.

Nepal

Clients usually reach the emergency room or a cardiologist first: chest pain and breathlessness read as a heart attack. "Mutu kamjor bhayo" (my heart has become weak) is a common self-diagnosis. Psychoeducation with the fight-or-flight body map above is often the single most effective first intervention: the symptoms are real, dangerous-feeling, and, once a doctor has ruled out a heart or lung cause, harmless.

time (minutes) fear intensity what panic predicts: "it will never stop, I will die/faint/go mad" peak ≈ 10 min what actually happens: the body cannot hold the alarm; it always comes down
The panic curve. Panic feels endless from inside; physiologically it peaks within about ten minutes and must come down. Riding one attack out, without escaping, is how the brain relearns safety; escaping at the peak is how agoraphobia begins.

Agoraphobia

CTEVT PSC curriculum300.22 · F40.00

Fear of situations where escape might be difficult or help unavailable if panic-like symptoms strike.

In plain words: Avoiding crowds, buses, open or closed places because escape or help might not be possible if panic strikes.

DSM-5 Criteria
  1. Marked fear about 2 or more of 5 situations: public transport · open spaces (markets, bridges) · enclosed places (shops, cinemas) · standing in line or being in a crowd · being outside the home alone.
  2. Feared because escape would be difficult or help unavailable if panic-like or embarrassing symptoms developed.
  3. The situations almost always provoke fear.
  4. They are avoided, require a companion, or are endured with intense fear.
  5. Fear out of proportion to actual danger.
  6. 6 months or more.
  7. Clinically significant distress or impairment.
  8. If a medical condition is present, the fear is clearly excessive.
  9. Not better explained by another disorder. Diagnosed independently of panic disorder: a person can have both.
Nepal · International

Internationally the picture is the person housebound for years. In Nepal, watch for it hidden behind role explanations: a daughter-in-law who "prefers" never to leave the house alone, or an elder who stopped attending the bazaar after one dizzy spell. Crowded microbuses and jatras are common avoided situations.

Also in this chapter: Selective Mutism (312.23/F94.0): a child speaks normally at home but consistently fails to speak in specific social situations (school) for ≥1 month, interfering with education; not explained by lack of language knowledge. Common first referral from schools.

A skill to try · two minutes

Slow breathing, 4 in · 6 out. Breathe in through the nose for a count of 4, out slowly for 6. The longer out-breath tells the fight-or-flight alarm to stand down. Two minutes, shoulders loose, feet on the floor. Free illustrated guide with more skills: WHO, Doing What Matters in Times of Stress. How a counselor works with avoidance over several sessions (ACT) is on Techniques step by step.

A coping skill, not a treatment: it supports care, it does not replace it.

Key points
  1. Anxiety disorders are fear out of proportion to real danger, lasting 6 months or more (1 month for panic).
  2. Each has a focus: an object (phobia), being watched (social), separation, everything (GAD), the body's alarm (panic), escape (agoraphobia).
  3. Psychoeducation and gradual exposure are the core treatments; in Nepal anxiety usually arrives as body complaints first.
Quick check

Three friendly questions to settle what you just read. This is reassurance, not a test: a wrong tap is part of learning, and you can try again.

Minimum duration for specific phobia and social anxiety:

Panic disorder requires unexpected attacks plus:

In adults, GAD needs how many of its six body symptoms?

Learn more

Pick one, not all: these are chosen to be light, not exhaustive.

Video · 5 minWhat causes panic attacks? (TED-Ed): The panic cycle, animated: show it to clients too.
ArticleWHO fact sheet: Anxiety disorders; Two-page global overview; good exam-ready numbers.
Book chapterWhere There Is No Psychiatrist: "Symptoms of stress" sections: How anxiety presents in clinics like yours.

Slow is fine. This curriculum took years to write; nobody expects it in one evening.