Anxiety

Personal, Medical, and Psychological Perspectives

Dr. Sasikala Rajamanoharan
MBBS; FRCP (Past); MSc in Epidemiology; BSc in Psychology;
Postgraduate Diploma in Sexual Health; Postgraduate Advanced
Diploma in Counselling; MBACP
What’s anxiety?
Anxiety is our body’s natural response to stress or perceived danger.
What is anxiety? Automatic response to possible danger

A hunter gatherer tribe; response to a rustle nearby -freeze initially stopping all movement; HR
beats quickly, rapid shallow breathing, firm up your muscle to start running.
The noise is coming from a low flying
bird……..
The brain–body system will reset to its normal state.
Rest and digest Fight and flight
Three Functional layers of brain
(triune brain)– Paul McLean
• Prefrontal cortex
➢ Higher order thinking
• Limbic system- emotional part
Amygdala (director of the primal brain – fear
detector, wired for survival)
➢ Emotion (fear, anxiety, sexual)
Hippocampus
➢ Emotion memory- differentiate past and present
• Brain stem (vagal nerve)
➢ Automatic functions –regulatory stuff keep– temp, BP,
sugar in balance
6
Anxiety is Our Superpower

Anxiety as a Superpower
• Hyper-awareness: Anxious people notice details others miss.
• Empathy: Anxiety often makes us more aware of others’ feelings.
• Drive to Prepare: Anxiety pushes us to plan and anticipate
outcomes.
• “Anxious brains are active brains.”
Famous People with Anxiety

• Emma Stone – Has openly discussed her panic attacks.

• Adele – Gets severe stage fright but still performs worldwide.
• Barack Obama – Used mindfulness to manage pressure and
nerves.
Anxiety doesn't stop greatness—it often fuels it.
What is anxiety?

A modern woman living on her own hears a sudden banging noise from the back garden, leading to spiralling
thoughts and an inability to shut down.
Stress/Trauma
HPA axis

Emotions
10
Anxiety disorder
• A state of heightened arousal characterized by feelings of tension, worried
thoughts, and physical changes like increased heart rate, rapid breathing,
sweating, or fatigue.

• It can be a normal and even helpful response to stress or danger (often called
the "fight-or-flight" response).

• But when it becomes excessive, persistent, or interferes with daily life, it may
be classified as an anxiety disorder.
• Modern brain can’t distinguish real and imagined threat. So we are often
stuck in anxiety mode-
•
Causes of Anxiety disorder
CATEGORY EXAMPLES

- Genetics / family history /generational trauma

- Neurotransmitter imbalance (serotonin, GABA, dopamine)
Biological Causes - Overactive amygdala
- Hormonal changes (thyroid, cortisol)
- Medical conditions (chronic illness, substance use)

- Personality traits (neuroticism, perfectionism, low self-esteem, introversion)

- Cognitive distortions (catastrophising, excessive worrying, negative self-talk, black and
Psychological Causes white thinking)
- Learnt behaviours (avoidance, conditioned fears)
- Past trauma or insecure childhood attachment

- Increase in awareness /stigma reduction

- Upbringing and parental modelling (overprotective or neglectful parenting)
- Academic / work stress –high stress culture; “always on-call”
Social / Environmental - Family and relationship pressure
Causes - Urbanisation (crowding, noise, pollution), Socioeconomic instability
- Social isolation / rise in Individualism
- Digital overload & social media; Constant negative news cycle → “doomscrolling.”
- Lifestyle factors – alcohol, drugs, poor diet, sleep
Prevalence and change in trends
Anxiety prevalence is rising globally due to lifestyle, societal, and digital
pressures.
UK
• In England, common mental health conditions (CMHCs) include
anxiety disorders such as GAD, phobias, OCD, etc. As of 2023/24,
about 22.6% of working-age adults had a CMHC, up from 15.5%
in 1993 NHS England Digital.
• The Office for National Statistics (ONS) found that, from Oct–
Dec 2024, 22.6% of adults reported high anxiety—higher than
pre-COVID levels (which ranged from 18.9% to 21.3%) The
Scottish Sun.
• Among young people aged 16–24, 25.8% had a common mental
health condition in 2024, up from 18.9% in 2014The Guardian.
India
• According to the National Mental Health Survey (NMHS) 2016,
the current weighted prevalence of anxiety disorders among
Indian adults was 2.57%
• 2022 -A meta-analysis of Indian adolescent studies yielded
a pooled prevalence of around 29% (low risk studies)
to 41% (including higher risk studies)
Key Reasons in India
• Psychological & Lifestyle Factors
• Academic & career pressure: Intense competition, exam stress,
unemployment fears.
• Urban stress: Traffic, pollution, overcrowding.
• Family & societal expectations: Marriage, success, and financial obligations.
• Societal & Structural Factors
• Digital expansion: Smartphone penetration, online harassment, screen
addiction.
• Cultural shift: Move from joint families (support systems) → nuclear setups.
• Mental health awareness: Still emerging; stigma persists, but recognition is
growing.
Different types of anxiety disorders,
• Generalized Anxiety Disorder (GAD) – chronic, excessive worry about various aspects of
day to day life. Lasts ≥ 6 months
• Panic Disorder – sudden, intense episodes of fear (panic attacks).
• Social Anxiety Disorder –Intense fear of social situations and being judged. Common fears:
Public speaking, Meeting new people, Eating in public
• Phobias – irrational fears of specific objects or situations.
Acrophobia-fear of heights
Agoraphobia Fear of being in situations where escape might be difficult.
Arachnophobia- Fear of spiders
Aviophobia- Fear of flying
Claustrophobia - fear of confined or enclosed spaces.
• Obsessive-Compulsive Disorder (OCD) Repetitive thoughts (obsessions) and behaviours
(compulsions).
• Post-Traumatic Stress Disorder (PTSD)
• Separation Anxiety Disorder Excessive fear of being apart from a major attachment figure.
Different approaches to manage
anxiety
Humanistic approach (Carl Rogers, Abraham
Maslow, etc.)
Anxiety is seen less as a medical issue and more as a struggle with personal growth
and authenticity.
Causes of Anxiety (Humanistic Perspective):
• Incongruence: When there is a mismatch between a person’s real self (who they
truly are) and their ideal self (who they think they should be).
• Example: A student who loves art but feels pressured to become a doctor experiences inner
conflict → anxiety.
• Lack of unconditional positive regard: Growing up with conditional love or
acceptance (“I’ll love you if you succeed”) can make people fear rejection and
failure → leading to anxiety.
• Frustration in self-actualization: Anxiety arises when people feel blocked from
reaching their full potential (due to societal, family, or internal pressures).
• Loss of meaning / purpose/ freedom: When people can’t find meaning in life and
existence, they may experience existential anxiety.
Humanist’s perspective
• Instead of saying “My anxiety is a disorder that needs fixing,”
• A humanistic therapist would guide someone toward “My anxiety
is telling me that something in my life feels unsafe or inauthentic—
what can I learn from it?”
How Incongruence Causes Anxiety

• Creates internal conflict

• Leads to self-criticism and perfectionism
• Fear of rejection if the "true self" is revealed
• Constant pressure to meet unrealistic expectations
Case studies – Humanistic
approach
7-year-old Girl with Anxiety ID

Presenting Concerns:
• Anxiety linked to intrusive thoughts (“bad thoughts”).
• Reports fear of:
• “I might get a heart attack while I’m sleeping.”
• Parents describe these episodes as panic attacks.
• Parents worry she may be developing a mental health condition
(e.g., schizophrenia).
Other Worries:
• “What if a delivery man sees me naked?”
• “What if my cousin sees me naked?”
Reflection from the child ID

• “When I was younger, I started watching YouTube because my

classmates did and I thought it was cool.”
• “But YouTube wasn’t always safe — sometimes I came across
scary content.”
• “Now I sometimes wish I could go back and change that
decision.”
• “I always get bad dreams. Not a single day do I have a good
dream.”
Child’s Reflections on Anger & Morality ID

• “Some classmates are bad. Last week, I had a bad thought — I felt
like hitting them.”
• “Getting angry is wrong. Expressing anger is wrong.”
• “I am a true Christian; I should not do such things.”

• “It’s not nice to kill people. My grandfather was in the army, and he
had to kill others to protect his country. I wish people could be
friends instead.”
Safety Concerns ID

• “Do you think I am safe in my house?”

• “What makes you say that?”
• “If I tell Kay that I don’t feel safe, and she tells my parents… then
my parents will ask why I said it.”
• “Then I will be in trouble, and I will get bad thoughts.”
ID’s contract
Introjected Messages from Mum
Conditions of worth
• “Work harder to get better → I’m only valuable if I achieve
something.”
• “Help others; don’t do bad behaviours.” → “I must please others to
be loved.”
• “Love and care for others → “always put others first.”

• “Be resilient.” → “Making mistakes means I’m a failure.”

“In class, I have 20 positive points and no negative points.”

Therapy Process ID

• Relationship building through

• Different types of play:
• Doctor–patient role play
• Jenga
• Puppet shows
• Animals fighting & caring
• Sand tray work
• Expressive tools:
• Emotion charts
• Creative artwork
• Explanation on normal body and emotional response to fear /
threat
Therapy process – exploring Introjected
messages ID
• “ you are having panic attack” - Mother putting scary things into
her
• Accepting that People can have different emotions
• Everyone feels angry sometime. How you react is the issue
• Instead of labelling anxiety as purely "pathological," it needs be
understood in the context of the individual’s life story.
• Understand normal body response to perceived danger
How to Reduce anxiety related to Incongruence

• Self-awareness
• Recognize your true thoughts, feelings, and desires.
• Self-acceptance
• Embrace imperfections; accept that it’s okay not to be perfect. Emotional
resilience
• Authentic living
• Align actions with values and beliefs.
• Therapeutic support
• Person-Centred Therapy helps promote congruence through empathy,
genuineness, and unconditional positive regard.
Child’s Progress ID

• Felt safe, accepted, and not judged during sessions.

• Demonstrated being generous, kind, and non-competitive.
• Showed ability to accept human and animal imperfections.
• Learnt to set personal (not societal) goals
• Learnt to celebrate progress, not perfection
• Learnt curiosity (wanting to watch You tube ) is a normal behaviour
Child’s progress ID
• Frequency of bad thoughts reduced from 10/10 to 0/10
• Neither good nor bad thoughts are going to come true.
• Learnt coping strategies – “Squeeze the pillow”
• “Today I had a good dream; I am a spider man helping people”

Anxiety is reframed as an opportunity for personal growth.

FEEDBACK FROM ID

The picture of a
beautiful Indian art in
the card I gave her on
the last day
ID
What is CBT?

• Cognitive Behavioural Therapy = evidence-based psychological

treatment
• Based on the idea that thoughts, emotions, and behaviours are
interconnected
• Negative thinking patterns → increase anxiety
• Changing these patterns → reduces symptoms
Case Study: KB, 9 year old boy
• Background: Anxiety began after moving to Year 6.
• Student’s thoughts:
• “Everyone in class thinks I’m weird, so nobody likes me.”
• “I have many fears.”
• Family context: Parents are academics.
• Goals:
• Build confidence to make new friends.
• Improve focus in class.
KB: How did he present to me?

• He appeared to be a pleasant-looking boy,

• But made very little eye contact.
• Whenever he spoke about something emotional, he began
sucking his thumb.
KB
Presenting Issues
• Pupil presents with unhappiness since transition to Year 6.
• Reports social isolation following the departure of his best friend.
• Experiences peer rejection (perceived as ‘weird’), particularly
linked to his thumb-sucking behaviour and lack of interest in
football.
• Expresses sadness when excluded from group activities (e.g.,
hockey, classwork).
• Displays immature self-soothing behaviour (thumb-sucking) in
response to emotional distress.
KB
• Background Information
• Age: 9 years.
• Close relationship with mother.
• Mother experienced the loss of her own mother at a similar age
and engaged in thumb-sucking until age 9.
• Father frequently away from home due to work; pupil expresses
that he misses his father.
• Loss of best friend, who transferred to another school.
KB– Creative work
KB Intervention and Progress

• The pupil demonstrated extraordinary talent in art and creative work. Art-based and
creative approaches were utilised to support the development of his social skills
and emotional intelligence. Through these activities, he was encouraged to
express himself, build confidence, and engage more positively with peers.
• Validation was modelled consistently, and the pupil was guided in learning how to
validate the perspectives of others, which enhanced his interpersonal
understanding.
• The pupil identified mathematics as a personal area of weakness, despite
demonstrating clear intellectual ability. His mother, a scientist, values academic
achievement, and the pupil expressed self-doubt in this domain. Targeted support
was provided in learning practical mathematical skills (e.g., calculating perimeter,
reading time). The pupil responded with enthusiasm and expressed amazement at
the simplicity of the explanations provided.
• These experiences contributed to a strengthening of the therapeutic relationship. A
strong bond developed, characterised by trust and openness, which further
supported his engagement and progress within sessions.
KB Recommendations for Counselling
Intervention
• Emotional Regulation Skills
• Thumb-sucking serves as a primary coping mechanism, suggesting limited development of age-
appropriate emotional regulation strategies.
• Introduce alternative self-soothing strategies (e.g., grounding techniques, relaxation breathing, use of
discreet comfort tools).
• Psychoeducation on recognising and managing emotions.
• The mother’s own history of early loss and thumb-sucking may also influence his coping behaviours.
• Social Skills and Peer Confidence
• Explore interests outside of football to foster new friendships.
• Practise social interaction skills through role-play and group work.
• Encourage participation in activities where he has previously succeeded (e.g., hockey), emphasising
strengths.
• Attachment and Loss Processing
• Provide space to explore feelings of missing his father and the loss of his best friend.
• Support the development of secure attachment by working with mother on communication and
reassurance strategies.
• Encourage structured father–son contact during periods of absence (e.g., scheduled calls, shared
activities when possible).
 Erikson’s psychosocial stages
Stage Age Range Psychosocial Conflict Positive Outcome Negative Outcome

If needs are met If needs are not met

Trust vs. Mistrust 0–1 year "Can I trust the world?" consistently → Trust in consistently → Fear,
caregivers and the world suspicion

1–3 years "Can I do things myself?" Encouragement to Overprotection or

Autonomy vs. Shame
explore → Independence criticism → Shame, self-
& Doubt
and confidence doubt

Initiative vs. Guilt 3–6 years "Is it okay to try new Support for initiating Discouragement or
things?" activities → Initiative, punishment → Guilt,
leadership inhibition
6–12 years "Can I succeed at school Encouragement and Repeated failure or
Industry vs.
and tasks?" praise→ Competence, criticism → Inferiority,
Inferiority
productivity failure

12–18 "Who am I?" Strong sense of self; Lack of direction →

Identity vs. Role
years Exploration of self, Confusion, instability
Confusion
values, beliefs → identity
Emotional intelligence (EI) and Anxiety
“Emotional intelligence is the ability to monitor one’s own and other’s feelings
and emotions to discriminate among them and to use this information to guide
one’s thinking and actions.”
Salovey & Mayer
EI is crucial for adolescent (10-19)mental health, social
competence, and adaptation.
Low EI leads to / can amplify Higher Anxiety
Higher EI leads to /can buffer against Lower Anxiety
Emotional intelligence -Key components

• Self-awareness: Practise regular emotional check ins; engage in mindfulness or journaling,

Seek honest feedback, Recognise emotional triggers, Reflect on your emotional patterns

• Self-regulation: Pause and beath before responding, Use grounding techniques, accurately
Label emotions, Reframe negative thoughts

• Motivation : Set personal goals aligned with your values, Celebrate small wins, cultivate
optimism and a growth mindset

• Empathy: Practise active listening, Suspend judgment, Ask open-ended questions, Consider
diverse perspectives

• Social skills: Show gratitude and compassion, communicate clearly and respectfully, build
rapport through meaningful connections
KB’ s PHOBIA
Megala hydrothalassa phobia
• Greek thalassa → means sea, ocean.
• People with this phobia may feel anxious about:
• Deep oceans or seas
• Large, endless water surfaces
• The thought of drowning, hidden creatures, or losing control in deep water
• KB had a fear about hidden small monsters (Charybdis was a sea
monster) in the swimming pool. His core beliefs:
• Evidence – we are not aware of all the creatures living in the earth
• DNA evidence
• He saw lochness monster
His creativity was used as exposure therapy- a success story
Borra Caves, Arakku Ha Long Bay
valley
Case 1
• KB’ S FEEDBACK
KB’s Thank you
card
KB’s progress report
KP
17 year old Asian girl with performance anxiety
• Although she studies very hard, she freezes—experiencing a 'going
blank' feeling—during exams.
Case Summary KP

• The pupil is a high-achieving girl who received a pet dog as a

reward for scoring above 95% in the previous exam.
• Recently, she has begun to experience mental blocks during
exams, suggesting anxiety linked to performance pressure and
possible internalised fear of disappointing her parents.
Humanistic Approach

Core Ideas: Unconditional positive regard, empathy, and authenticity.

Parental expectations and introjected messages: The promise of the dog as a
reward may have reinforced a belief that affection and recognition are conditional
upon achievement.

Application in Counselling:
• Creating a safe, accepting space: Provide unconditional positive regard, separate her worth
as a person from exam performance.
• Exploring self-concept: Help her identify how her self-esteem has become tied to academic
success. Facilitate recognition of intrinsic strengths and values beyond grades.
• Promoting self-acceptance: Encourage her to express feelings about pressure, fear of
failure, and parental expectations. Help her move toward a more authentic sense of self, not
reliant on achievement alone.
• Practical strategies: Use relaxation techniques, guided imagery, and mindfulness before
exams to reduce mental blocks.
Common Introjected messages that may lead
to incongruence
• “If I don’t top my exams, I’ll embarrass the family”. If I fail, my
family will be ashamed.
• “My worth depends on academic success.”
Introjected messages / internalised voices
and incongruence
• Her brain sees the exam as a threat – distorted appraisal
• Body goes into "fight or flight":
• Racing heart
• Sweaty palms
• Mind goes blank
• She knows the material, but anxiety shuts down her access to it
Her Response
• Emotional: Fear, dread, self-doubt.
• Physiological: Sweaty palms, racing heart, stomachache.
• Behavioural: Procrastination, avoidance of studying, panic during the
exam.
Therapy Process – therapist as a Virtual Parent

• Relationship – Virtual Parent

• Building a supportive and secure therapeutic alliance.
• Role of the therapist as a “virtual parent” figure, offering guidance, empathy, and consistency.
• Providing a corrective emotional experience where safety and trust are emphasized.
• Incongruence – Neuroscience Explanation
• Explaining the mismatch between self-perception and actual experience (Carl Rogers’
concept of incongruence).
• Neuroscience basis: brain’s threat detection systems (amygdala, limbic system) vs. rational
regulation (prefrontal cortex).
• How incongruence can create stress, anxiety, or maladaptive coping patterns.
• Involvement of Parents / Teachers in the Discussion
• Collaborative approach—engaging caregivers and educators.
• Psychoeducation for parents/teachers to recognise triggers and reinforce positive coping.
• Shared responsibility in supporting emotional regulation and resilience in the
child/individual.
Psychoeducation for parents /teachers
➢Use encouraging, not shaming language
• Instead of “I am proud of you because you got an A”
“I love how hard you worked on that, no matter the grade”
“I got that wrong, but that’s okay. I will try again.”
➢Encourage them to externalise their voice
➢Focus on action; not on labelling
“You didn’t finish your homework” not “ you are irresponsible”
➢Acknowledge the emotion rather than shutting it down
Tips to Use During Exams

• Use “box breathing” (4-4-4-4)

• Remind yourself: “It’s okay to be nervous”
• Start with the easiest questions
• Keep a small anchor object (like a pen or bracelet) to ground
yourself
Psychodynamic Perspective on Anxiety
3rd Approach
• Originates from inner conflicts between:
• Id (instincts, desires)
• Ego (reality, rationality)
• Superego (morals, ideals)
• Anxiety = signal of threat when these forces clash
Defence Mechanisms

• Ego’s way of protecting the self from overwhelming anxiety

• Examples:
• Repression (blocking distressing thoughts)
• Projection (attributing feelings to others)
• Displacement (redirecting feelings to safer target)
• Rationalization (justifying behaviour)
Psychodynamic Approach

Core Ideas: Psychodynamic counselling explores unconscious

conflicts, childhood experiences, and internalised parental
expectations that shape present behaviour.
• Application in Counselling:
• Exploring internal conflicts: Anxiety may stem from unconscious fear of
losing parental approval or love if she underperforms.
• Goal: To bring unconscious fears into awareness, helping her understand
and reframe the source of her exam anxiety (long-term personality
change). Management involves insight, strengthening the ego, and
healthier defences
Case history JP
• 78 year old Indian woman born in England to parents from Kenya
• Low mood, Chronic feelings of worthlessness and self-blame
• Anxiety, recurring panic attacks/ intrusive memories, frequent
nightmares.
• Took early retirement as suffered with social anxiety
JP - In the therapy session
• Looked so nervous and anxious
• Head down
• When started talking about her childhood stories, she was in tears

After 5 sessions,
• Brighter
• Improvement in eye contact
JP- Early life

• Abused by men thrice, between the age of 8-11.

• Indian immigrant men who were brought to their house by her father who
simply try to help his country men by organising food, accommodation
and assisting in obtaining visa and job etc.
• Third time, at the age of 11, she was abused by a local English man who
was a family friend. She was sent with him to help him to bring some milk
from his farm, although she was reluctant. He abused her while they were
in the farm.
• She never shared these incidents to her authoritarian parents. She
felt guilty and ashamed. Thought it was all her fault.
JP- Case history – the impact of trauma
• Low self esteem
• Anxiety
• Low mood
• Intrusive thoughts
• Anger towards her parents
• Feeling numb at times
Therapy process
Therapeutic alliance

Worked Through her trauma: repeatedly exploring trauma-

related feelings until they lose their overwhelming power

Dream Analysis: nightmares seen as symbolic expression of

repressed trauma.
FEEDBACK
- JP
Conclusion
• Anxiety is a natural response of the body to real or perceived
threats. However, when certain factors intensify and maintain this
response, it can develop into an anxiety disorder.
• Early intervention is essential.
• A combination of approaches—including humanistic therapy,
psychodynamic exploration, cognitive behavioural techniques,
work on developing emotional intelligence, and the
incorporation of relaxation strategies—can provide effective
support and help prevent the escalation into more serious mental
health difficulties.
References
• Cejudo, J., Rodrigo-Ruiz, D., López-Delgado, M.L. and Losada, L., 2018.
Emotional intelligence and its relationship with levels of social anxiety
and stress in adolescents. International journal of environmental
research and public health, 15(6), p.1073.
• CBT for Psychotherapists- Avigdor Boncheck
• CBT Basics and Beyond Judith S beck
• Change your thinking with CBT
• Emotional Intelligence – Daniel Goleman
• Manjunatha, N., Jayasankar, P., Suhas, S., Rao, G.N., Gopalkrishna, G.,
Varghese, M. and Benegal, V., 2022. Prevalence and its correlates of
anxiety disorders from India’s National Mental Health Survey
2016. Indian Journal of Psychiatry, 64(2), pp.138-142.
References
• Pal, D., Sahu, D.P., Maji, S. and Taywade, M., 2022. Prevalence of
anxiety disorder in adolescents in India: a systematic review and
meta-analysis. Cureus, 14(8).
• Publication, Adult Psychiatric Morbidity Survey: Survey of
Mental Health and Wellbeing, England, 2023/4
• Suzuki, W., 2021. Anxiety is Your Superpower (GOOD ANXIETY):
Using anxiety to think better, feel better and do better. Hachette
UK.
References
• Shi, M., Lu, X. and Du, T., 2022. Associations of trait emotional
intelligence and stress with anxiety in Chinese medical
students. Plos one, 17(9), p.e0273950.
• Trigueros, R., Padilla, A.M., Aguilar-Parra, J.M., Rocamora, P.,
Morales-Gázquez, M.J. and López-Liria, R., 2020. The influence of
emotional intelligence on resilience, test anxiety, academic stress
and the Mediterranean diet. A study with university
students. International journal of environmental research and
public health, 17(6), p.2071.