Very concise summary– Anxiety and related disorders
The highlights of the course
Task 1: Anxiety and hyperventilation + lecture 1
Fear: an emotional response to actual or perceived imminent threat.
Anxiety: an adaptive mechanism in anticipation of future threat.
Panic: a period of intense fear/discomfort; overwhelming emotional arousal.
Worry: repetitive thinking about potential future threats; apprehensive expectations.
Social anxiety disorder (SAD)
The fear or anxiety about social situations, where the individual is exposed to scrutiny by
others. There is a fear of acting in a way or showing anxiety symptoms that will be negatively
evaluated by others. the cognitive aspects include negative thoughts about themselves,
high standards regarding themselves and unrealistic beliefs about other people’s standards.
Prevalence: +/- 7,5% increasing with age.
Comorbidity: avoidant personality disorder (related in terms of symptoms), Body dismorphic
disorder (BDD), psychosis (schizophrenia), bipolar disorders and eating disorders.
Differential diagnosis: avoidant personality disorder (SAD: more severe) agoraphobia
(SAD: about social interactions, AP: places), GAD (SAD: type 1 worry, GAD: type 2 worry).
Generalized anxiety disorder (GAD)
Excessive anxiety or worry about a number of activities or events and finding it difficult to
control these worries. These worries or anxiety is associated with at least three mood-related
or physiological symptoms, e.g. sleep disturbances, fatigue, irritability, muscle tension.
Epidemiology: 0,4-3,6%. Late onset: adolescence or early childhood. Peaks at middle age
and declines across later years in life. Females twice as likely. Course is often chronic.
Comorbidity: MDD, other anxiety disorders, PTSD, OCD, personality disorders (avoidant,
dependent or OCPD) and alcohol or drugs abuse/independence.
Differential diagnosis: MDD (similar repetitive thinking processes, but worry: the future and
can be about others. Depressive rumination: yourself and the past), PD (PD: panic attacks,
GAD: not specific), SAD (SAD: social situations, GAD: general), type 2 worry.
Symptoms of GAD:
Nonadaptive awareness: highly focused on future threat and lack of attention for
other components of their lives.
Nonadaptive physiology: no sympathetic activation; muscle tension.
Nonadaptive behaviour: avoidance of various stimuli and situations.
Nonadaptive cognition: nonadaptive ways of perceiving, interpreting and predicting
events: attentional bias, interpretation bias and thought bias (for negative thoughts).
Nonadaptive emotion: negative emotionality; anxiety and depression.
Anxious people are in a state of over-preparedness, where hyper arousal is often chronic.
low parasympathetic activity: a high and stable heart rate, also without fear-provoking
stimuli, and decreased heartrate reactivity. This seems associated with the worry process.
autonomic inflexibility: reductions in the variability of responses; little heart rate
variability. these may be a coping response when anxiety becomes chronic.
Explanation: In GAD there isn’t a external stressor, but there are (chronically present)
internally generated thoughts about potential future threats. (makes exposure impossible)
Treatment: CGT shows significant increases in variability and parasympathetic activity.
The more anxious the patient, the slower the habituation of the galvanic skins response
(GSR) and the more rapid fluctuations. GSR: changes in sweat gland activity, that are
reflective of the intensity of our emotional state emotional arousal.
,Lack of awareness: people with GAD do not recognize the causal relationship between their
cognitions, emotions, physiology, behaviours and how those influence their lives. This results
in feelings of uncontrollability. This also inhibits the ability to focus on the present moment.
Meta-cognitive framework:
Positive metacognitive beliefs: the benefits of engaging in
worry. (e.g. when I worry, I’ll be prepared/a good mom/ etc)
Type 1 worry: concerns external events and noncognitive
internal events: worries that everyone could have “what if”
scenario’s. Stops when distracted or feeling safe.
Negative meta-beliefs: the disadventage of engaging in
worry. thoughts about uncontrolabillity of thoughts, relating
to the perceived dangerousness. (e.g. worrying is
uncontrollable, worrying will damage my heart, if something
happens, it will be my fault).
Type 2 worry: worry about the worry and it’s dangerous
consequences for mental or physical wellbeing. (e.g. I will
damage my biody/go crazy) predictor of pathological worry.
Type two worry contributes to two feedback cycles to maintain
the worry process:
1.The behaviours based on meta-worry (e.g.
avoidance/ reassurance seeking) leads to missing
out on opportunities to learn that worry is harmless,
controllable and learn more adaptive coping
strategies.
2. thought control strategies (e.g. supression)
increases the number of thoughts and reinforce the
belief of uncontrollability.
Patients with GAD report high negative
metacognitions (uncontrabillity, danger), where they
worry about an elevated, non-specific combination of
both health and social content. type 2 worry.
High health worry and intermediate levels
of negative metacognitions characterize a
panic disorder.
High social worry and low negative
metacognitions characterize social
phobia.
Moderate levels of negative metacognitions
and high levels of social worry characterize depression.
type 1 worry.
Panic disorder (PD): Panic attacks + panic-related worry.
PD is characterized by recurrent, unexpected panic attacks and the fear of additional panic
attacks or their consequences. Possibly leading to a maladaptive change in behaviour.
Three types of panic attacks:
, Unexpected, spontaneous or uncued attacks: occur unexpectedly.
Situationally bound or cued attacks: in exposure/ anticipation of a particular situation.
Situationally predisposed attacks: linked to a situation, but do not always occur.
Uncued attacks are central and required for PD-diagnosis, but in PD is often a mixture of
different types present leads to concerns about the implications or consequences of panic.
Epidemiology: 2-3%, peak during adulthood (30-64 year olds). Women twice as likely.
Comorbidity: agoraphobia, other anxiety diorders, mood disorders, psychoses/ manic
behaviour, substance use disorders and personality disorders.
Differential diagnoses: other anxiety disorders (PD: specific fear of panic attacks and it
consequences), substance induced panic or medical conditions.
Agoraphobia: fear or anxiety about two (or more) specified public situations, in which
someone feels like escape would be difficult or help might not be available if needed.
General: All these anxiety disorders need to be persistent, out of proportion, (almost always
provoke fear, avoided or endured with intense fear or anxiety), cause significant distress or
impairment and can’t be attributable to another medical condition, disorder of substances.
Physical stress responses
Prepare the body to face or flee from immediate threat, normally when danger passes this
reaction subsides. But with long lasting stressors or slow recovery other reactions will follow.
general adaptation syndrome (GAS): 3 stages of physical reaction:
1. The alarm reaction: the fight or flight reaction.
the sympathetic branch of the autonomic nervous system (ANS) is activated by the
hypothalamus: sympatho-adreno-medullary (SAM); which stimulates the medulla of
the adrenal gland; secretes catecholamines (especially noradrenaline and adrenaline)
to provide the energy needed to cope with stressors.
HPA-as is activated, the hypothlamus stimulates the pituitary gland, which
secretes hormones (ACTH) to the adrenal glands that secrete corticosteroids.
the goal of these processes is to generate emegency energy.
2. Resistance stage of gas: the body settles to resist the stressor on a long term basis,
slower but draining delivery of adaptive energy.
3. Exhaustion: signs of physical wear and tear. Possibly leading to diseases of
adaptation: illnesses that are caused or worsened by stress.
Psychological stress response:
Emotional changes: the longer the stress, the more tense, irratable, sad or anxious
you get possibly leading to stress-related problems or disorders.
Cognitive changes: not being able to concentrate, think clearly or remember
accurately Narrowing attention, impaired judgement and decision making. It can also
lead to functional fixedness: only using objects for one purpose.
cognitive changes can be due to ruminative thinking and/or catastrophizing.
Behavioural responses: changes in how people look, act and think.
Stress is mediated by how
Hyperventilation & hyperventilation syndrom:
The function of breathing is to provide oxigen, which is then transported to the body for
metabolic needs. The brain uses a lot of this oxygen.
Stages of hyperventilation:
1. Increased breathing (overbreathing) removes CO2 from the lungs, faster than it can
be manifactured by the body. decrease of CO2. (hypocapnia).
2. Leading to repiratory alkalosis: high pH level in de blood.
