Lecture 8 1Anxiety: Fear has a function! Essential to survival. Helps in avoidance of
dangerous situations, makes you more alert.
Fear: emotional response to real/perceived imminent threat. Related to autonomic arousal
(fight/flight). Anxiety: anticipation of future threat. More muscle tension and vigilance. Much
longer lasting. Maybe threat not even present.
-Adaptive -> Problematic -> Pathological. Heeft te maken met Intensity, duration and
pervasiveness. Hoe intenser, langer en pervasive, hoe meer kans om problematisch of zelfs
pathologisch te worden. 4 Ds: Dysfunction, Distress, Deviance, Danger.
-Adaptive/nonclinical: most children have one or two fears appropriate to their age. Also
most adults have fears. Fears in childhood: predictable sequence with initial increase: omdat
ze leren dat er gevaren zijn, maar naarmate kinderen ouder worden, nemen de angsten
weer af, omdat ze meer kennis opdoen.
-Problematic: interference with daily life and healthy development.
Anxiety disorders – shared characteristics:
-Excessive fear and anxiety. Intense and persistent.
-Related to behavioral disturbances: your behavior becomes distorted, e.g. avoid certain
situations/object, overestimate danger, or use maladaptive behaviors in response to fear
and anxiety.
-Not attributable to physiological effects of: medication/substance or medical condition.
Anxiety disorders – differences:
-Types of feared or avoided objects/situations
-Content of associated thoughts or beliefs
Anxiety disorders: -everywhere around the world, most prevalent category of
psychopathology. -Often early onset. -2:1 female to male ratio, geldt over het algemeen
uberhaupt voor internalizing disorders dat dat meer vrouwen zijn en externalizing mannen.
-Wax and wain over time, but are chronic if not treated properly. Dus ook als het even een
tijdje minder is, is kans hoog dat het alsnog terugkomt. -High! comorbidity. -High
individual impairment due to lower education attainment, unstable marriage and lower
occupational status. Very disabling disease.
DSM-5: Anxiety Disorders
Separation Anxiety Disorder (e.g., parents leaving)
Selective Mutism
Specific Phobia
Generalized Anxiety Disorders
Social Anxiety Disorder
Panic Disorder
Agoraphobia
No longer considered anxiety disorders, but are definitely related to anxiety: -OCD -Acute
stress disorder. -PTSD
,Separation Anxiety Disorder: typical childhood disorder. May persist into adulthood, but not
really common.
=Non age-appropriate and excessive (dus urenlang ofzo) anxiety (or anticipation) of going
away from home or leaving attachment figures. Excessive worry that caregivers may be
harmed. Persistent refusal to go anywhere which may cause separation. Frequent
nightmares about separation. Recurrent physical complaints (may be real/fake) when not in
close proximity to attachment figures
Selective Mutism: typical childhood disorder. Rarely in adulthood, then more often you
would diagnose social anxiety disorder. A child shows consistent failure to speak in specific
social situations in which there is an expectation for speaking (e.g., at school), despite
speaking in other situations. The disturbance interferes with educational, occupational and
social achievement and interaction. Duration: at least 1 month (not limited to the first
month of school, die periode telt niet mee). not attributable to a lack of knowledge of, or
comfort with, speaking: dus ze moeten de taal wel kennen. The disturbance is not better
explained by other disorders (e.g. autism spectrum disorder). Behaviors are a method of self-
protection during an episode of intense anxiety and fear: they paralyze, to unconsciously
protect themselves. Can be mistaken for deliberate oppositional behavior, most often not
the case.
Often co-exist with social anxiety disorder; kids also have social anxiety symptoms.
Symptoms: Avoiding eye contact, clinging onto parents, hiding, or completely freezing. But:
Avoidance of initiating or participating in conversations is a symptom of selective mutism,
not of social anxiety disorder. SAD still able to speak, may blush, don’t make eye contact etc
but they are able to speak, in tegenstelling tot selective mutism.
Specific phobia DSM-5: A marked, intense fear/anxiety of a specific object or situation that
substantially interferes with the person’s ability to function. Phobic object almost always
evokes immediate fear/anxiety, so not delayed. Also anticipation of object/situation causes
fear, so not only the object/situation. Phobic object is actively avoided or endured with
intense fear/anxiety. Fear/anxiety is out of proportion (irrational). Persistent: >6months. Not
better explained by another disorder. Degree of fear may vary per occasion, depending on
situation. Most people have more than one specific phobia.
The most prevalent anxiety disorder: 7.4% cross-national life-time prevalence, animal phobia
most prevalent. Young age of onset (8 y/o). 60% has at least 1 comorbid disorder.
Often suffered for many years. Not always overt anxiety in daily life, but can spike up in the
presence/anticipation of fear.
Most patients recognize excessiveness of their fear reaction. But do not recognize
overestimation of actual danger. Do feel that it is a truly dangerous situation.
Generalized Anxiety Disorder – DSM-5. Worrying disorder. Excessive anxiety and worry,
occurring more days than not for at least 6 months about a number of events or activities.
Dus niet alleen over geld, maar more things. Happens consistently. Out of control and no
idea how to stop. Difficulty controlling the worry.
Associated with 3 or more other symptoms: chronic fatigue, edginess, restlessness,
irritability, difficulty concentrating, difficulty sleeping, muscle tension.
Clinically significant distress or impairment. Not attributable to medication, substance or
other medical or mental disorder. Important: Distinguishing GAD from normal worry: easier
, to stop, less pervasive, less frequent, smaller range of topics, vaak niet van die fysieke
symptomen.
Prevalence: ~3%. Age of onset: 25-30 y/o. But often, anxiety reported all their lives. So they
were also very anxious as child. 66% has comorbid disorder
Social Anxiety Disorder - DSM-5: social phobia. Marked fear/anxiety about one or more
social situations in which the individual is exposed to possible scrutiny (critically observed)
by others: - Social interactions - Being observed e.g. while eating -Performing in front of
others.
Individual fears he/she will act in a way or show anxiety symptoms that will be negatively
evaluated. humiliating or embarrassing. leading to rejection (dat zijzelf worden
buitengesloten) or offending others (dat zijzelf anderen offenden).
Social situations (and behaviors) are avoided or endured with intense fear/anxiety (and
while still avoiding e.g. eye contact, or shaking hands etc.).
Bij kinderen: geldt om deze diagnose te krijgen dat ze ook deze sociale angsten moeten
vertonen bij peers, niet alleen bij adults.
Social situations almost always provoke fear or anxiety, in tegenstelling tot selective mutism
wat heel erg over een specifieke sociale situatie gaat, en dit is any social situation.
Fear/anxiety is out of proportion. Persistent: > 6 months. Clinically significant distress or
impairment. Not attributable to substance, medication, or other disorder/condition
Prevalence: 2-5%. Age of onset: adolescence (10-15 y/o). Panic attacks may occur in social
situations. Niet per se een teken van panic disorder, komt ook voor in andere anxiety
disorders.
Panic Disorder – DSM-5: Recurrent and unexpected panic attacks. Dit in tegenstelling tot
SAD, waar je weet dat het komt na een sociale situatie. Attacks are followed by one month
period or more of either: Persistent worry about having additional attacks or their
consequences. Or: Significant change in behavior because of the attacks.
Not attributable to substance, medicine or other disorder.
Panic attack = Abrupt surge of intense fear or discomfort that reaches a peak within 10
minutes and during which time 4 or more of the following symptoms occur:
Prevalence: 2-3%. Age of onset: early adulthood (20-24 y/o). A panic attack ≠ panic disorder.
There is a great variety in severity and frequency of attacks, also within one patient. There
can be possible episodic outbreaks with years of remission in between.
Agoraphobia – DSM-5: eerst was het in DSM altijd Panic Disorder with/without agoraphobia.
Nu gediagnosticeerd los ervan.
=Fear of situations in which you can’t escape, or where escape might be difficult, or help
unavailable. Marked fear or anxiety for more than 6 months about two or more of the
following 5 situations: almost always provoke anxiety. Anxiety is out of proportion and
avoided or endured with intense anxiety. Interferes with daily functioning.
Prevalence: 2%. Mean onset is 17 years. 30% of persons with agoraphobia have panic attacks
or panic disorder. People with agoraphobia may fear social situations too.
Difference agoraphobia and SAD: people with agoraphobia fear that escape may be difficult,
and not because people will judge them.
