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Samenvatting GGZ2024 Anxiety and Related Disorders
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GGZ2024 – Anxiety and Related DisordersTask 1 – Anxiety and hyperventilation 2
Task 2 – Fear! 23
Task 3 – How to improve exposure therapy 46
Task 4 – Biological substrate of panic and anxiety 59
Task 5 – Thought suppression and OCD 73
Task 6 – Imagery, Imagery Treatments and PTSD 84
Lecture 1 99
Lecture 2 – Learning theory 107
Lecture 3 – Anxiety and information processing 123
Lecture 4 – Neuropharmacology of anxiety 138
Lecture 5 – Neurobiology 159
Lecture 6 – OCD 170
Lecture 7 – PTSD 175
1
,Task 1 Anxiety and hyperventilation
ANSWERS
1. What are symptoms of Generalized Anxiety Disorder (GAP), Panic Disorder
(PD), Social Anxiety Disorder (SAD)?
Generalized Anxiety Disorder - GAP
A. Excessive anxiety and worry (apprehensive expectation), occurring more days
than not for at least 6 months, about a number of events or activities (such as
work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six
symptoms (with at least some symptoms having been present for more days
than not for the past 6 months);
Note: Only one item is required in children.
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless,
unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause clinically significant distress
or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication) or another medical condition (e.g.,
hyperthyroidism).
F. The disturbance is not better explained by another mental disorder (e.g.,
anxiety or worry about having panic attacks in panic disorder, negative
evaluation in social anxiety disorder [social phobia], contamination or other
obsessions in obsessive-compulsive disorder, separation from attachment
figures in separation anxiety disorder, reminders of traumatic events in
posttraumatic stress disorder, gaining weight in anorexia nervosa, physical
complaints in somatic symptom disorder, perceived appearance flaws in body
dysmorphic disorder, having a serious illness in illness anxiety disorder, or the
content of delusional beliefs in schizophrenia or delusional disorder). (DSM-5)
The cardinal symptom of GAD is worry (repetitive thinking about potential future
threats, imagined catastrophes, uncertainties and risks. The uncontrollability of worry
discriminates between high worries with and without GAD. This normal and
pathological worry may actually exist on a continuum rather than representing 2
distinct categorical constructs.
In contrast to other anxiety syndromes, GAD is not characterized by motoric
avoidance of disorder-specific situations. Many individuals with GAD show signs of
behavioral avoidance of various stimuli and situations. An individual with GAD might
habitually procrastinate due to worries about the quality of her work, or a GAD patient
might habitually avoid having discussions about a relationship with a romantic partner
due to chronic worries about being left for a different partner.
2
, As a result of the almost constant focus on future threat, chronic worriers lack
the attentional resources needed to attend to the other components of their realities
as well as to the present moment.
Chronic worries do not recognize the causal relationship between their
cognitions, emotions, physiology and behavior and how those interconnect elements
influence both the internal and external problems in their life. This lack of awareness
often leads chronic worries to believe that their anxiety escalates quickly and
spontaneously, instead of recognizing that anxiety spirals slowly and results from a
variety of maladaptive ways of thinking and behaving.
GAD does not entail sympathetic activation. The only physiological symptom
shown to be elevated is muscle tension.
The course is often chronic and unremitting, especially when it is comorbid
with other conditions. There is a limited likelihood of recovery if left untreated. Even
among those who remit, the probability of relapse is high.
Individuals with GAD report significant lower quality of life relative to
nonanxious individuals, particularly in areas of self-esteem, goals, values, work,
money, learning, creativity and relationships with friends and family.
There are some impairments of GAD:
- Societal costs
o Direct nonpsychiatric healthcare costs and resource utilization by
individuals with GAD encompass a large portion of these expenses,
accounting for $23.03 billion of the $42.34 billion estimated cost of
anxiety disorders
o Individuals with anxiety disorders (including GAD) have more extended
hospital stays than do individuals in the general population
o Individuals with GAD are also particularly likely to consult several
specialists before the condition is diagnosed. A substantial portion of
primary care providers fail to recognize and/or properly assess for GAD
- Physical impairment
o GAD includes somatic symptoms such as muscle tension and fatigue,
which may produce adverse consequences for physical health
▪ Patients with GAD may often present with and seek treatment for
chest pain despite indication from medical tests that their arterial
function and other indicators of cardiovascular health are normal.
Patients also report that chest pain occurs during periods of
worry.
o GAD symptoms are related to several concomitant health problems,
including cardiovascular irregularities, cardiovascular disease,
respiratory conditions and gastrointestinal conditions
o Chronic gastrointestinal conditions such as peptic ulcer disease and
irritable bowel syndrome (IBS) have also been linked to GAD
- Occupational impairment
o Individuals with GAD are significantly more likely to report a higher
number of days on which they either missed work or felt the need to cut
back on the amount of work they do as a result of their poor emotional
or mental health.
o Diagnosis of GAD is associated with unemployment or nonparticipation
in the labor force
- Interpersonal impairment
o They often worry about their interpersonal relationship
3
, o They report lower-quality relationships with family members, friends
and romantic partners
o They are more likely to report not having close friends
o One proposed reason for this apparent low quality of relationships is
that individuals with GAD excessively seek reassurance from their
loved ones; this can potentially make them seem needy, causing their
loved ones to be less inclined to participate in subsequent interactions,
which then further escalates feelings of inadequacy and isolation for the
individual with GAD
o GAD is strongly associated with marital dissatisfaction (Stevens)
In a cognitive model of GAD, Wells proposed that pathological worry is maintained by
maladaptive metacognitions (negative beliefs about worry concerning
uncontrollability and danger, and negative appraisal of worrying) and linked
behaviors.
Wells advanced a cognitive model of pathological worry and GAD. In this
model, individuals with GAD use worrying as a means of coping with a threat. This is
stimulated by positive metacognitive beliefs about worrying. In GAD, these beliefs are
linked to the maintenance of worrying as a coping strategy. However, it is the
development of negative beliefs about worry, associated negative appraisal of worry
(meta-worry), and linked responses that contribute centrally to distress and the
development of pathological worry that is presented by GAD patients.
In this model, two types of worry are distinguished:
4
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