Thema 5.1 – Angststoornissen
The DSM-5 shows three categories:
1. Anxiety disorders (e.g., separation anxiety disorder, specific
phobia, social phobia, panic disorder, agoraphobia, and generalized
anxiety disorder).
2. Obsessive-Compulsive disorders (e.g., obsessive-compulsive
disorder, body dysmorphic disorder, hoarding disorder,
trichotillomania, and excoriation disorder).
3. Trauma and Stressor-Related disorders (e.g., posttraumatic
stress disorder, acute stress disorder and adjustment disorder).
If we look at the 12-month prevalence of anxiety disorders, more than 18%
of the adult population has an anxiety disorder. 22.8% of these cases are
classified as “severe”. When we look at the different types of anxiety
disorders, we see that the most prevalent disorder is the specific phobia
disorder. Examples of specific phobia’s are fear of flying, spiders or fear of
heights.
As you see in the figure above, there are differences between prevalence
of males and females. In general, females are in a higher risk in
developing anxiety disorders and depression than males.
Fear and anxiety have a function. If your body is threatened by something
external, it is relatively normal that your heart start beating faster, this is
an adaptive and evolutionary reaction to this threatening. Fear is essential
to survival because it helps to avoid dangerous situations.
Fear and anxiety can be adaptive, but to some extent it can also be
problematic. This depends on the intensity, duration, and pervasiveness
(think about the 4Ds: dysfunction, distress, deviance, and dangerousness).
Adaptive/nonclinical: children have one or two fears appropriate to
their age.
Problematic: interference with daily life and development.
Fear and anxiety are adaptive emotions but become pathological when it
interferes with one’s life or development. Anxiety disorders are relatively
prevalent.
There are multiple risk factors for anxiety disorders:
Child factors: genetic predisposition, temperament, and cognition.
There is a relationship with lower levels of intelligence.
Environmental factors: insecure attachment, education and parental
style, and negative life events. If you are born in a family where you
are raised unsafe and you don’t know who you can trust, there is
more risk in developing anxiety disorder.
,When looking at the difference between fear and anxiety we see the
following thing. Fear has a certain start with an immediate response, this
controls your fight/flight reaction. Anxiety is an emotion regarding things
we think may happen, this happens for a longer period. Fear becomes
anxiety when it persists long after the treat has subsided. For example,
some people who have experienced traumatic events continue to be
extremely fearful long after the trauma has ended. And fear can become
an anxiety disorder when a person engages in maladaptive behaviors in
response to a threat, for example, a person with agoraphobia may become
housebound due to hear or venturing out.
There are many different sorts of anxiety disorders. They have some
shared characteristics. They are characterized with excessive fear and
anxiety. This causes related behavioral disturbances. For example, people
can react emotional to fearful stimuli or with anxiety they anticipate to
future treat (e.g., avoidance). The symptoms of anxiety disorders we need
to know that they are not attributable to physiological effects of
medication/substance.
There are also differences in anxiety disorders. Think about the types of
fear or avoided objects/situations. Or the content of associated thoughts or
believes.
There are seven anxiety disorders in the DSM-5:
Separation anxiety disorder
Selective mutism
Specific phobia
Generalized anxiety disorder
Social anxiety disorder
Panic disorder
Agoraphobia
All these anxiety disorders are very well treatable. Obsessive compulsive
disorder (OCD), acute stress disorder and the posttraumatic stress disorder
(PTSD) are no longer considered as anxiety disorders. But anxiety still
plays a very important role in these disorders.
Separation anxiety disorder: a disorder which can be diagnosed in
children because the onset needs to be before the age of 18. Children with
this disorder have an excessive anxiety concerning separation from home
or from attachment figures. They may refuse to go to school because they
fear separation, and they may experience stomachaches, headaches,
nausea, and vomiting if forced to leave their attachment figures.
Selective mutism: another disorder which can only be diagnosed in
children. This 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. This interferes with educational
achievement and social interaction. The duration is at least 1 month. This
failure of speaking is not attributable to a lack of knowledge of, or lack of
comfort with speaking. The disturbance is not better explained by other
,disorders but do often co-exist with social anxiety disorder. Most of the
time the disorder has an early onset, with a later diagnosis.
Specific phobia: is an adult disorder but can also happen in children. It is
an excessive or unreasonable fear for object or situation. When they are
exposed to this object or situation this provokes immediate anxiety
response or panic attack. The person recognizes that this fear is excessive
or unreasonable, he/she knows that the fear is not normal and that he/she
shouldn’t be afraid because the fear is disproportionate to the actual
danger. Avoidance or endurance under intense distress, so for example
people avoid spiders wherever they can, or they endure spiders but are
very afraid. It is difficult to recall the specific reason for the onset of the
phobia. These symptoms have to last for at least six months, cause clinical
distress or impairment, and cannot be better attributed to another mental
or physical disorder. There are five categories of specific phobias: animal
type, natural environment type, situational type, blood-injection type, and
other.
Generalized anxiety disorder (GAD): a disorder with excessive worry
about multiple things, these people are anxious all the time in almost all
situations. Worrying is experienced as uncontrollable, they keep thinking
about new things, it is like thinking about a cycle in which you keep
thinking/worrying. The focus of their worries may shift frequently, and they
tend to worry about many things instead of focusing on only one issue of
concern. Because of anxiety and worry about situations, these individuals
frequently spend inordinate amounts of time and energy preparing for
feared situations or avoiding those situations, are immobilized by
procrastination and indecision, and seek reassurance from others. This
results in physical and cognitive reactions, e.g., irritability, tension and/or
sleeping problems. The prevalence of GAD is 3%. The age of onset is most
of the time 25-30 years old, but often they report anxiety all their lives.
66% of the people with generalized anxiety disorder has a comorbid
disorder such as depression. These people are also at a higher risk of
suicide. People with GAD report experiencing more intense negative
emotions, even compared to people with major depression, and are highly
reactive to negative events. In neuroimaging studies, people with GAD
showed heightened reactivity to emotional stimuli in the amygdala.
Individuals with GAD have concerns about losing control or being unable to
tolerate uncertainty.
Social anxiety disorder: like the specific phobia, but then for social
situations. It is marked as fear/anxiety about one of more social situations
in which the individual is exposed to possible scrutiny by others, think
about social interactions, being observed or performing in front of others.
The individual fears that he/she will act in a way or show anxiety
symptoms that will be negatively evaluated. Social situations and
behaviors are avoided or endured with intense fear/anxiety. The
prevalence of social anxiety disorder is 2 to 5%. The age of onset is
adolescence, so 10-15 years old. This can occur together with panic
attacks. There are some cognitive perspectives on social anxiety disorder,
, these people have excessively high standards for their social performance,
for example they believe they should be liked by everyone. They also
focus on negative aspects of social interactions and evaluate their own
behavior harshly. People with social anxiety disorder often describe their
parents as having been overprotective and controlling but also critical and
negative.
Panic attacks can occur among all anxiety disorders. Panic attacks are an
abrupt surge of intense fear or discomfort that reaches a peak within 10
minutes and during which you have 4 or more of the following symptoms:
Pounding or accelerated heartrate
Sweating
Trembling or shaking
Shortness of breath
Feelings of choking
Nausea
Feeling dizzy, unsteady, light-headed, or faint.
Chills or heat sensations
Numbness or tingling sensations
Derealization or depersonalization
Fear of losing control or going crazy
Fear of dying
Panic disorder: recurrent unexpected panic attacks and worrying about
new panic attacks. They start avoiding things that can make the chance of
a panic disorder larger. This panic is not related to medicines or substance,
specific phobias, obsessive-compulsive disorder, PTSD, or separation
anxiety disorder. The prevalence is 2 to 3%. Usually, the age of onset is
during early adulthood, so 20-24 years old. Remember, panic attacks and
panic disorders aren’t the same, because panic attacks are very common
and do not directly lead to a panic disorder. There is a great variety in
severity and frequency in panic attacks. It is possible that there are
episodic outbreaks with years of remission in between. Research suggest
that the heritability of panic disorder is 43-48%. Cognitive theorists argue
that people prone to panic attacks tend to (1) pay very close attention to
their bodily sensations, (2) misinterpret these sensations in a negative
way, and (3) engage in snowballing catastrophic thinking, exaggerating
symptoms and their consequences.
Agoraphobia: also related to panic disorder. It is a generalized fear of
situations in which the person might not be able to escape or get help if
needed. It is the persistent fear in at least two of the following situations
(crowd, public spaces, public transportation, standing in line, etc.). People
with agoraphobia also often fear that they will embarrass themselves if
others notice their symptoms or their efforts to escape during an attack.
Exposure to these situations provokes immediate anxiety response or
panic attack. The persons also recognizes that fear is excessive or
unreasonable and avoids or endures these situations under intense
distress. The prevalence of agoraphobia is 2%, the mean onset is 17 years.
