Learning Objectives
From anxiety to anxiety disorder
1. What is fear, what anxiety? What do they have in common, how do they differ? What are the
functions of fear and anxiety?
Anxiety= state of alarm in response to sense of threat
Fear= state of immediate alarm in response to serious threat
Both have same physiological features and are both adaptive and important emotions. Fear
elicits a fight flight freeze response and activation of the sympathetic nervous system.
2. How is an anxiety disorder defined?
- Unreasonably strong or permanent
- Arises without sufficient reason
- Cannot be controlled or endured
- Causes suffering and constrains life
+ Typical symptom patterns are present
Normal anxiety is adaptive, only when it is excessive and impairs functioning it becomes
pathologic.
There are three diagnostic categories: anxiety disorders, obsessive compulsive and related
disorder and trauma and stressor related disorders
Three diagnostic categories:
Anxiety Disorder: specific phobia, social anxiety disorder, panic disorder, agoraphobia,
generalized anxiety disorder, separation anxiety, selective mutism
Obsessive-Compulsive and related disorders: obsessive-compulsive disorder, body
dysmorphic disorder, hoarding disorder,
trichotillomania, excoriation disorder
Trauma and Stress related disorders: adjustment disorder, acute stress disorder,
posttraumatic stress disorder, reactive attachment
disorder, disinhibited social engagement disorder
There must not be a somatic disease and the anxiety has to be intense or unreasonable.
3. What is a fear reaction - what a panic attack? What is the difference between those two?
A fear reaction is triggered by an external threat stimuli and prepares the individual
to fff response. In a panic attack the panic is triggered by misinterpretation of bodily
sensations. In both reactions the somatic features are similar.
,4. What is the prevalence and time course of an anxiety (related) disorder?
Anxiety disorders are the most prevalent class of mental disorders, with 12-month
and lifetime prevalence rates of 18.1% and 28.8%. Suicide rate is 10x higher than general
population.
5. What do we know regarding biological risk factors of anxiety (related) disorders?
Panic, GAD and depression appear to share genetic liability. Not specific for specific
disorder but general predisposition to anxiety. In anxiety and panic disorder environment
seems to play a bigger role.
Possible risk factors are:
Behavioral inhibition (=persistent tendency to exhibit restraint, withdrawal, and
reticence when faced with novel or unfamiliar situations and people)
Possibly rooted in lower threshold to limbic arousal (higher reactivity of amygdala)
particular predictive for social anxiety disorder
Higher autonomic reactivity
Social fears
Enhanced startle reflex
Respiratory sensitivity, abnormal ventilatory response
6. What do we know regarding psychological risk factors of anxiety (related) disorders?
Childhood anxiety disorder (separation anxiety, overanxious disorder, social or
specific phobia)
Pathology of parents
Two is worse than one, comorbidity increases risk,
overprotective or less warm and accepting parents; children with anxiety also shape
parents behavior
low SES
mixed evidence for life event such as health problems, divorce, abuse and loss
peer relations: being left or rejected (not bullied, teased)
7. What is the role of cognitive biases in the a etiology of anxiety (related) disorders?
Mathews and MacLeod (2005) propose a causal relationship between processing bias
and vulnerability to emotional disorders: cognitive vulnerability via processing biases in early
(anxiety) and late (depression) attention selection.
By increased conceptual processing of negative info (depression) and retrieval, memory is
biased. This is also found in panic disorder and GAD.
Biased emotional associations in the form of coherent negative self-representation.
Biased inhibitory control, good control over attention is a protective factor but thought
suppression has the reversed effect.
, Panic disorder and agoraphobia
1. What are the diagnostic criteria for panic disorder (and a panic attack)?
Panic disorder
Recurrent unexpected panic attacks (unexpected for the observer/therapist). A panic
attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within
minutes, and during which time four (or more) of the following symptoms occur:
Note: The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesia (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from
oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache,
uncontrollable screaming or crying) may be seen. Such symptoms should not count as
one of the four required symptoms.
o Recurrent unexpected panic attacks (discrete episode of intense anxiety, sudden
occurrence of minimum four symptoms in 10 min)
o Persistent worry about having additional attacks, or shift in behavior for at least 1
month.
o Not caused by substance, medical condition etc.
o Not better explained by another disorder.
At least one of the attacks has been followed by 1 month (or more) of one or both of
the following:
- Persistent concern or worry about additional panic attacks or their consequences
(e.g., losing control, having a heart attack, “going crazy”).
- A significant maladaptive change in behavior related to the attacks (e.g., behaviors
designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar
situations).
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, cardiopulmonary
disorders).
The disturbance is not better explained by another mental disorder (e.g., the panic attacks do
not occur only in response to feared social situations, as in social anxiety disorder; in
response to circumscribed phobic objects or situations, as in specific phobia; in response to
obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic
From anxiety to anxiety disorder
1. What is fear, what anxiety? What do they have in common, how do they differ? What are the
functions of fear and anxiety?
Anxiety= state of alarm in response to sense of threat
Fear= state of immediate alarm in response to serious threat
Both have same physiological features and are both adaptive and important emotions. Fear
elicits a fight flight freeze response and activation of the sympathetic nervous system.
2. How is an anxiety disorder defined?
- Unreasonably strong or permanent
- Arises without sufficient reason
- Cannot be controlled or endured
- Causes suffering and constrains life
+ Typical symptom patterns are present
Normal anxiety is adaptive, only when it is excessive and impairs functioning it becomes
pathologic.
There are three diagnostic categories: anxiety disorders, obsessive compulsive and related
disorder and trauma and stressor related disorders
Three diagnostic categories:
Anxiety Disorder: specific phobia, social anxiety disorder, panic disorder, agoraphobia,
generalized anxiety disorder, separation anxiety, selective mutism
Obsessive-Compulsive and related disorders: obsessive-compulsive disorder, body
dysmorphic disorder, hoarding disorder,
trichotillomania, excoriation disorder
Trauma and Stress related disorders: adjustment disorder, acute stress disorder,
posttraumatic stress disorder, reactive attachment
disorder, disinhibited social engagement disorder
There must not be a somatic disease and the anxiety has to be intense or unreasonable.
3. What is a fear reaction - what a panic attack? What is the difference between those two?
A fear reaction is triggered by an external threat stimuli and prepares the individual
to fff response. In a panic attack the panic is triggered by misinterpretation of bodily
sensations. In both reactions the somatic features are similar.
,4. What is the prevalence and time course of an anxiety (related) disorder?
Anxiety disorders are the most prevalent class of mental disorders, with 12-month
and lifetime prevalence rates of 18.1% and 28.8%. Suicide rate is 10x higher than general
population.
5. What do we know regarding biological risk factors of anxiety (related) disorders?
Panic, GAD and depression appear to share genetic liability. Not specific for specific
disorder but general predisposition to anxiety. In anxiety and panic disorder environment
seems to play a bigger role.
Possible risk factors are:
Behavioral inhibition (=persistent tendency to exhibit restraint, withdrawal, and
reticence when faced with novel or unfamiliar situations and people)
Possibly rooted in lower threshold to limbic arousal (higher reactivity of amygdala)
particular predictive for social anxiety disorder
Higher autonomic reactivity
Social fears
Enhanced startle reflex
Respiratory sensitivity, abnormal ventilatory response
6. What do we know regarding psychological risk factors of anxiety (related) disorders?
Childhood anxiety disorder (separation anxiety, overanxious disorder, social or
specific phobia)
Pathology of parents
Two is worse than one, comorbidity increases risk,
overprotective or less warm and accepting parents; children with anxiety also shape
parents behavior
low SES
mixed evidence for life event such as health problems, divorce, abuse and loss
peer relations: being left or rejected (not bullied, teased)
7. What is the role of cognitive biases in the a etiology of anxiety (related) disorders?
Mathews and MacLeod (2005) propose a causal relationship between processing bias
and vulnerability to emotional disorders: cognitive vulnerability via processing biases in early
(anxiety) and late (depression) attention selection.
By increased conceptual processing of negative info (depression) and retrieval, memory is
biased. This is also found in panic disorder and GAD.
Biased emotional associations in the form of coherent negative self-representation.
Biased inhibitory control, good control over attention is a protective factor but thought
suppression has the reversed effect.
, Panic disorder and agoraphobia
1. What are the diagnostic criteria for panic disorder (and a panic attack)?
Panic disorder
Recurrent unexpected panic attacks (unexpected for the observer/therapist). A panic
attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within
minutes, and during which time four (or more) of the following symptoms occur:
Note: The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesia (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from
oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache,
uncontrollable screaming or crying) may be seen. Such symptoms should not count as
one of the four required symptoms.
o Recurrent unexpected panic attacks (discrete episode of intense anxiety, sudden
occurrence of minimum four symptoms in 10 min)
o Persistent worry about having additional attacks, or shift in behavior for at least 1
month.
o Not caused by substance, medical condition etc.
o Not better explained by another disorder.
At least one of the attacks has been followed by 1 month (or more) of one or both of
the following:
- Persistent concern or worry about additional panic attacks or their consequences
(e.g., losing control, having a heart attack, “going crazy”).
- A significant maladaptive change in behavior related to the attacks (e.g., behaviors
designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar
situations).
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, cardiopulmonary
disorders).
The disturbance is not better explained by another mental disorder (e.g., the panic attacks do
not occur only in response to feared social situations, as in social anxiety disorder; in
response to circumscribed phobic objects or situations, as in specific phobia; in response to
obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic
