COURSE 5: ANXIETY AND RELATED DISORDERS
TASK 1: ANXIETY AND HYPERVENTILATION
TYPES OF ANXIETY DISORDERS
Anxiety is an innate, adaptive alarm mechanism that readies hum beings for action and protects them
from anticipated threats. Anxiety disorders are disorders that share features of excessive fear and anxiety
and related behavioural disturbances.
There are two types of disorders, Axis I disorders and Axis II disorders. Axis I consist of most major
mental health disorders, especially acute and treatable ones. These are disorders that can often begin at
any point in life and may be episodic. Most anxiety disorders also fall under Axis I, including:
- Generalized Anxiety Disorder (GAD);
- Panic Disorder;
- Social Anxiety Disorder (Social Phobia);
- Specific Phobias;
- OCD (now categorized separately);
- PTSD (now categorized separately);
- Acute stress disorder.
Axis II consists of long-standing, more ingrained conditions. They are personality/developmental
disorders that typically start in adolescence or early adulthood. Anxiety-related diagnoses are less
common in Axis II but could include:
- Avoidant Personality Disorder;
- Dependent Personality Disorder;
- Obsessive-Compulsive Personality Disorder.
Disorder Core Fear/Anxiety Common Symptoms Typical Onset
Generalized Anxiety Everyday life events (e.g., Chronic worry, Adolescence to
Disorder (GAD) health, money, restlessness, fatigue, adulthood
relationships) sleep issues
Panic Disorder Fear of panic attacks and Chest pain, shortness of Late adolescence to
their recurrence breath, fear of dying early adulthood
Social Anxiety Social judgment, Blushing, sweating, Teens
Disorder embarrassment avoiding people or
events
Specific Phobia Specific object or situation Immediate fear Childhood
response, avoidance
Agoraphobia Being trapped or unable to Fear of crowds, open Late teens to early
escape spaces, or public transit adulthood
Separation Anxiety Being away from attachment Clinginess, nightmares, Childhood (can
Disorder figure refusal to go out continue into
adulthood)
Selective Mutism Speaking in specific settings Silence in school or Early childhood
public, normal at home
Other anxiety disorders:
- Substance/Medication-induced Anxiety Disorder: Panic attacks/anxiety mostly during and soon
after intoxication or withdrawal.
- Anxiety Disorder Due to Another Medical Condition: Panic attacks/ anxiety mostly a direct
consequence of another condition.
, - Other Specified Anxiety Disorder: Does not meet the full criteria for any other anxiety disorders
and the clinician communicates a specific reason for this.
- Unspecified Anxiety Disorder: Does not meet the full criteria for any other anxiety disorder and
the clinician does not communicate a specific reason for this.
PANIC DISORDER (PD)
Diagnostic Criteria Panic Disorder (300.1)
A. Recurrent unexpected panic attacks
A panic attack is an abrupt surge of intense fear or discomfort that reaches a peak within minutes, during
which at least 4 of the following symptoms occur:
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, lightheaded, or faint
9. Chills or heat sensations
10. Paresthesias (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: The attacks must be unexpected (not triggered by a specific situation), at least at first. Expected
attacks (e.g., phobia-induced) would fall under a different diagnosis. Culture-specific symptoms (e.g.
tinnitus, neck soreness, headaches or uncontrollable screaming/crying) may also be seen, but not be
counted as one of the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing
control, heart attack, "going crazy")
2. Significant maladaptive behaviour change related to the attacks (e.g., avoidance of situations or
physical exertion)
C. The disturbance is not attributable to:
A substance (e.g., drug abuse, medication)
A medical condition (e.g., hyperthyroidism, heart condition)
D. The disturbance is not better explained by another mental disorder, such as:
Social anxiety disorder
Specific phobia
OCD
PTSD
Separation anxiety disorder
A panic attack alone is not sufficient to warrant a PD diagnosis. An estimated 28% of people will
experience a panic attack in their lifetime, yet less than 5% develop PD. 60% of people with panic attacks
who seek help do not get diagnosed with PD.
In the DSM-4, agoraphobia was secondary to PD. In the DSM-5, agoraphobia was a distinct diagnosis.
, Differential diagnoses of PD
- Other anxiety disorders (83% of patients with anxiety disorders have had at least 1 panic attack);
- Substance-induced panic (intoxication/withdrawal);
- Panic due to general condition (acute medical crisis);
- Comorbidity with axis I disorders (e.g. anxiety, mood and substance use disorders).
There are multiple types of panic attacks. Uncued attacks are central to PD, but many patients also
experience situationally bound or predisposed attacks.
3 types of panic attacks:
Type Trigger Predictability Commonly Associated Example
Disorders
1. Unexpected None identifiable No – occurs "out of Panic Disorder Panic attack while
(Uncued) the blue" watching TV or
sleeping
2. Situationally Specific situation High – happens Specific Phobia, Social Panic attack when
Bound (Cued) or object every time Anxiety, PTSD giving a speech or
seeing a spider
3. Situationally Certain situations Medium – not Panic Disorder, Sometimes panics
Predisposed (but not always) every time Agoraphobia, PTSD while driving, but
not consistently
GENERALIZED ANXIETY DISORDER (GAD)
Diagnostic Criteria Generalized Anxiety Disorder (300.02)
A. Excessive anxiety and worry
Occurring more days than not for at least 6 months, about a number of events or activities (such as
work, school performance, health, finances, etc.).
The individual finds it difficult to control the worry.
B. The anxiety and worry are associated with 3 (or more) of the following 6 symptoms:
(Only 1 symptom 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)
C. The anxiety, worry, or physical symptoms cause:
Clinically significant distress or impairment in social, occupational, or other important areas of
functioning.
D. The disturbance is not due to:
The physiological effects of a substance (e.g., drug abuse, medication) or another medical
condition (e.g., hyperthyroidism).
E. The disturbance is not better explained by another mental disorder, such as:
, Panic Disorder
Social Anxiety Disorder
OCD
PTSD
Separation Anxiety Disorder
Eating Disorders
Somatic Symptom Disorder
The key symptom of GAD is worry, defined as apprehensive expectation, repetitive thinking about
potential future threats, imagined catastrophes, uncertainties and risk that are negatively affect-laden and
relatively uncontrollable.
Anxious people are highly aroused and alert, in a state of overpreparedness. With anxiety patients there
usually is a chronic state of hyperarousal. Anxious patients generally have more beta activity and less
alpha activity in their brains. They show less variability in skin conductance and heart rate response to
challenge or stress. This is called autonomic inflexibility. It is suggested that this is related to the fact that
the stimuli feared by these patients are not produced by external environmental stressors, but are
chronically present internally generated thoughts about potential future threats. It is a characteristics of
anxiety disorders in general.
According to the metacognitive framework, individuals with GAD use worrying as a means of coping
with a threat. This is stimulated by positive metacognitive beliefs about worrying. Positive beliefs about
worry are normal and most individuals possess them to some degree. In GAD in particular, 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.
Type 1 and 2 worry
Feature Type 1 Worry Type 2 Worry (Meta-Worry)
Focus Real-life events or physical symptoms Thoughts about the process of worrying
Perceived as Useful, problem-solving Harmful, uncontrollable
Examples “What if I fail my exam?” “What if my worrying causes a
breakdown?”
Emotional result Initial anxiety Amplified anxiety, fear of anxiety
Role in GAD Triggers worry Sustains and intensifies worry
Understanding the difference between Type 1 and Type 2 worry is crucial in metacognitive therapy
(MCT) for GAD, where the goal is to challenge and change meta-beliefs about worry.
Positive and negative meta-beliefs
Type Belief Focus Common Beliefs Impact
Positive Meta- Worry is helpful/useful “Worry helps me cope” Encourages more
Beliefs “Worry keeps me safe.” worrying
Negative Meta- Worry is “Worrying will harm me.” Triggers fear of
Beliefs dangerous/uncontrollable “I can’t stop worrying.” worry itself
TASK 1: ANXIETY AND HYPERVENTILATION
TYPES OF ANXIETY DISORDERS
Anxiety is an innate, adaptive alarm mechanism that readies hum beings for action and protects them
from anticipated threats. Anxiety disorders are disorders that share features of excessive fear and anxiety
and related behavioural disturbances.
There are two types of disorders, Axis I disorders and Axis II disorders. Axis I consist of most major
mental health disorders, especially acute and treatable ones. These are disorders that can often begin at
any point in life and may be episodic. Most anxiety disorders also fall under Axis I, including:
- Generalized Anxiety Disorder (GAD);
- Panic Disorder;
- Social Anxiety Disorder (Social Phobia);
- Specific Phobias;
- OCD (now categorized separately);
- PTSD (now categorized separately);
- Acute stress disorder.
Axis II consists of long-standing, more ingrained conditions. They are personality/developmental
disorders that typically start in adolescence or early adulthood. Anxiety-related diagnoses are less
common in Axis II but could include:
- Avoidant Personality Disorder;
- Dependent Personality Disorder;
- Obsessive-Compulsive Personality Disorder.
Disorder Core Fear/Anxiety Common Symptoms Typical Onset
Generalized Anxiety Everyday life events (e.g., Chronic worry, Adolescence to
Disorder (GAD) health, money, restlessness, fatigue, adulthood
relationships) sleep issues
Panic Disorder Fear of panic attacks and Chest pain, shortness of Late adolescence to
their recurrence breath, fear of dying early adulthood
Social Anxiety Social judgment, Blushing, sweating, Teens
Disorder embarrassment avoiding people or
events
Specific Phobia Specific object or situation Immediate fear Childhood
response, avoidance
Agoraphobia Being trapped or unable to Fear of crowds, open Late teens to early
escape spaces, or public transit adulthood
Separation Anxiety Being away from attachment Clinginess, nightmares, Childhood (can
Disorder figure refusal to go out continue into
adulthood)
Selective Mutism Speaking in specific settings Silence in school or Early childhood
public, normal at home
Other anxiety disorders:
- Substance/Medication-induced Anxiety Disorder: Panic attacks/anxiety mostly during and soon
after intoxication or withdrawal.
- Anxiety Disorder Due to Another Medical Condition: Panic attacks/ anxiety mostly a direct
consequence of another condition.
, - Other Specified Anxiety Disorder: Does not meet the full criteria for any other anxiety disorders
and the clinician communicates a specific reason for this.
- Unspecified Anxiety Disorder: Does not meet the full criteria for any other anxiety disorder and
the clinician does not communicate a specific reason for this.
PANIC DISORDER (PD)
Diagnostic Criteria Panic Disorder (300.1)
A. Recurrent unexpected panic attacks
A panic attack is an abrupt surge of intense fear or discomfort that reaches a peak within minutes, during
which at least 4 of the following symptoms occur:
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, lightheaded, or faint
9. Chills or heat sensations
10. Paresthesias (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: The attacks must be unexpected (not triggered by a specific situation), at least at first. Expected
attacks (e.g., phobia-induced) would fall under a different diagnosis. Culture-specific symptoms (e.g.
tinnitus, neck soreness, headaches or uncontrollable screaming/crying) may also be seen, but not be
counted as one of the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing
control, heart attack, "going crazy")
2. Significant maladaptive behaviour change related to the attacks (e.g., avoidance of situations or
physical exertion)
C. The disturbance is not attributable to:
A substance (e.g., drug abuse, medication)
A medical condition (e.g., hyperthyroidism, heart condition)
D. The disturbance is not better explained by another mental disorder, such as:
Social anxiety disorder
Specific phobia
OCD
PTSD
Separation anxiety disorder
A panic attack alone is not sufficient to warrant a PD diagnosis. An estimated 28% of people will
experience a panic attack in their lifetime, yet less than 5% develop PD. 60% of people with panic attacks
who seek help do not get diagnosed with PD.
In the DSM-4, agoraphobia was secondary to PD. In the DSM-5, agoraphobia was a distinct diagnosis.
, Differential diagnoses of PD
- Other anxiety disorders (83% of patients with anxiety disorders have had at least 1 panic attack);
- Substance-induced panic (intoxication/withdrawal);
- Panic due to general condition (acute medical crisis);
- Comorbidity with axis I disorders (e.g. anxiety, mood and substance use disorders).
There are multiple types of panic attacks. Uncued attacks are central to PD, but many patients also
experience situationally bound or predisposed attacks.
3 types of panic attacks:
Type Trigger Predictability Commonly Associated Example
Disorders
1. Unexpected None identifiable No – occurs "out of Panic Disorder Panic attack while
(Uncued) the blue" watching TV or
sleeping
2. Situationally Specific situation High – happens Specific Phobia, Social Panic attack when
Bound (Cued) or object every time Anxiety, PTSD giving a speech or
seeing a spider
3. Situationally Certain situations Medium – not Panic Disorder, Sometimes panics
Predisposed (but not always) every time Agoraphobia, PTSD while driving, but
not consistently
GENERALIZED ANXIETY DISORDER (GAD)
Diagnostic Criteria Generalized Anxiety Disorder (300.02)
A. Excessive anxiety and worry
Occurring more days than not for at least 6 months, about a number of events or activities (such as
work, school performance, health, finances, etc.).
The individual finds it difficult to control the worry.
B. The anxiety and worry are associated with 3 (or more) of the following 6 symptoms:
(Only 1 symptom 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)
C. The anxiety, worry, or physical symptoms cause:
Clinically significant distress or impairment in social, occupational, or other important areas of
functioning.
D. The disturbance is not due to:
The physiological effects of a substance (e.g., drug abuse, medication) or another medical
condition (e.g., hyperthyroidism).
E. The disturbance is not better explained by another mental disorder, such as:
, Panic Disorder
Social Anxiety Disorder
OCD
PTSD
Separation Anxiety Disorder
Eating Disorders
Somatic Symptom Disorder
The key symptom of GAD is worry, defined as apprehensive expectation, repetitive thinking about
potential future threats, imagined catastrophes, uncertainties and risk that are negatively affect-laden and
relatively uncontrollable.
Anxious people are highly aroused and alert, in a state of overpreparedness. With anxiety patients there
usually is a chronic state of hyperarousal. Anxious patients generally have more beta activity and less
alpha activity in their brains. They show less variability in skin conductance and heart rate response to
challenge or stress. This is called autonomic inflexibility. It is suggested that this is related to the fact that
the stimuli feared by these patients are not produced by external environmental stressors, but are
chronically present internally generated thoughts about potential future threats. It is a characteristics of
anxiety disorders in general.
According to the metacognitive framework, individuals with GAD use worrying as a means of coping
with a threat. This is stimulated by positive metacognitive beliefs about worrying. Positive beliefs about
worry are normal and most individuals possess them to some degree. In GAD in particular, 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.
Type 1 and 2 worry
Feature Type 1 Worry Type 2 Worry (Meta-Worry)
Focus Real-life events or physical symptoms Thoughts about the process of worrying
Perceived as Useful, problem-solving Harmful, uncontrollable
Examples “What if I fail my exam?” “What if my worrying causes a
breakdown?”
Emotional result Initial anxiety Amplified anxiety, fear of anxiety
Role in GAD Triggers worry Sustains and intensifies worry
Understanding the difference between Type 1 and Type 2 worry is crucial in metacognitive therapy
(MCT) for GAD, where the goal is to challenge and change meta-beliefs about worry.
Positive and negative meta-beliefs
Type Belief Focus Common Beliefs Impact
Positive Meta- Worry is helpful/useful “Worry helps me cope” Encourages more
Beliefs “Worry keeps me safe.” worrying
Negative Meta- Worry is “Worrying will harm me.” Triggers fear of
Beliefs dangerous/uncontrollable “I can’t stop worrying.” worry itself
