Anxiety and related disorders Case 1
Anxiety and hyperventilation
Problem statement: “What is an anxiety disorder and what is hyperventilation?”
Learning goals:
I. Describe the following disorders
a. Panic disorder, Generalized Anxiety Disorder (GAD), Social Anxiety Disorder (SAD)
II. What are the treatments for anxiety disorders?
III. What is hyperventilation?
a. Underlying mechanisms, symptoms
b. Difference between voluntary hyperventilation and hyperventilation caused by panic
IV. What is the cognitive model of panic? (cognitive model of GAD)
Describe the following disorders
Anxiety disorders include disorders that share features of excessive fear and anxiety and related
behavioral disturbances.
Fear = the emotional response to real or perceived imminent threat.
o Panic disorder fear of fear; fear they will get a panic attack
o SAD fear of social evaluation
o GAD fear of worrying; about (future) catastrophic events
o Agoraphobia fear of losing control
Anxiety = anticipation of future threat and preparation for action.
o This ‘alarm system’ can be malfunctioning: when it is triggered too long, in situations
known to be harmless or for no apparent cause/reason.
Panic attacks = are a particular type of fear response; an intense fight-flight response.
The anxiety disorders differ from one another in the types of objects or situations that induce fear,
anxiety, or avoidance behavior, and the associated cognitive ideation.
Panic disorder1
Panic (an intense fight-flight reaction) can be a result of a malfunctioning ‘alarm system’.
→ Panic attack = a discrete period of intense fear or discomfort that reaches a peak within
minutes and is accompanied by ≥4 somatic and/or cognitive symptoms.
o 3 types;
▪ Unexpected – out of the blue, not associated with specific situation/cue.
• This type of panic attack is required to be diagnosed.
▪ Cued or situationally bound – after exposure to or expectance of a situation.
▪ Situationally predisposed – linked to specific situation but doesn’t always occur.
→ Essential in PD = the presence of recurrent, unexpected panic attacks along with significant
panic-related worry.
o Patients are worried about the next attack and the indication given to others of an
illness, ‘going crazy’, losing control or emotional weakness.
▪ These concerns are often associated with avoidant behaviors, which may
meet the criteria for agoraphobia (AG).
DSM-criteria:
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense
discomfort that reaches a peak within minutes, in which ≥4 of the following symptoms occur:
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
1
Schmidt (2014). Panic Disorder and Agoraphobia.
, 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. 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.
B. At least 1 of the attacks has been followed by ≥1 month of 1 or both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences (e.g.,
losing control, having a heart attack, “going crazy”).
2. A significant maladaptive change in behavior related to the attacks (e.g., avoidant
behaviors, such as avoidance of exercise or unfamiliar situations).
C. The disturbance isn’t attributable to the physiological effects of a substance or medical condition
D. The disturbance is not better explained by another mental disorder.
Prevalence
28.3% of the population experience ≥1 panic attack in a lifetime.
Age of onset: early = 15-24; late = 45-54
o Prevalence <14 = <0.4%
o Prevalence 30-64 = 6%
o Prevalence >64 = 0.7%
12-month prevalence = 2-3%
Life-time prevalence = 4.7-5.1%
o Without AG 3.7-4%
o With AG 1.1%
Males < females 1:2
Variety between ethnic groups
CBT is the ideal type for PD and AG.
o 37% with PD and 17% with PD + AG relapse one year after receiving treatment.
▪ Relapse: males < females
Comorbidity
20-50% with voluntary hyperventilation has panic attacks.
Often earlier onset age than comorbid disorder(s); but when the onset is after the comorbid
disorder this may be a severity marker of the comorbid illness.
Comorbid disorders:
o Anxiety disorders
▪ Agoraphobia
▪ GAD
o Major depression disorder (MDD)
o Bipolar disorder
o Mild alcohol or drug use disorder
o Suicidality PD is an indirect risk factor for suicide
o Manic behavior or psychosis
10-65% = panic disorder + depression or anxiety
In ⅓ of patients with depression + anxiety the depression precedes the onset of panic
disorder.
o In ⅔ depression occurs simultaneously or after the onset of panic disorder.
Anxiety and hyperventilation
Problem statement: “What is an anxiety disorder and what is hyperventilation?”
Learning goals:
I. Describe the following disorders
a. Panic disorder, Generalized Anxiety Disorder (GAD), Social Anxiety Disorder (SAD)
II. What are the treatments for anxiety disorders?
III. What is hyperventilation?
a. Underlying mechanisms, symptoms
b. Difference between voluntary hyperventilation and hyperventilation caused by panic
IV. What is the cognitive model of panic? (cognitive model of GAD)
Describe the following disorders
Anxiety disorders include disorders that share features of excessive fear and anxiety and related
behavioral disturbances.
Fear = the emotional response to real or perceived imminent threat.
o Panic disorder fear of fear; fear they will get a panic attack
o SAD fear of social evaluation
o GAD fear of worrying; about (future) catastrophic events
o Agoraphobia fear of losing control
Anxiety = anticipation of future threat and preparation for action.
o This ‘alarm system’ can be malfunctioning: when it is triggered too long, in situations
known to be harmless or for no apparent cause/reason.
Panic attacks = are a particular type of fear response; an intense fight-flight response.
The anxiety disorders differ from one another in the types of objects or situations that induce fear,
anxiety, or avoidance behavior, and the associated cognitive ideation.
Panic disorder1
Panic (an intense fight-flight reaction) can be a result of a malfunctioning ‘alarm system’.
→ Panic attack = a discrete period of intense fear or discomfort that reaches a peak within
minutes and is accompanied by ≥4 somatic and/or cognitive symptoms.
o 3 types;
▪ Unexpected – out of the blue, not associated with specific situation/cue.
• This type of panic attack is required to be diagnosed.
▪ Cued or situationally bound – after exposure to or expectance of a situation.
▪ Situationally predisposed – linked to specific situation but doesn’t always occur.
→ Essential in PD = the presence of recurrent, unexpected panic attacks along with significant
panic-related worry.
o Patients are worried about the next attack and the indication given to others of an
illness, ‘going crazy’, losing control or emotional weakness.
▪ These concerns are often associated with avoidant behaviors, which may
meet the criteria for agoraphobia (AG).
DSM-criteria:
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense
discomfort that reaches a peak within minutes, in which ≥4 of the following symptoms occur:
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
1
Schmidt (2014). Panic Disorder and Agoraphobia.
, 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. 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.
B. At least 1 of the attacks has been followed by ≥1 month of 1 or both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences (e.g.,
losing control, having a heart attack, “going crazy”).
2. A significant maladaptive change in behavior related to the attacks (e.g., avoidant
behaviors, such as avoidance of exercise or unfamiliar situations).
C. The disturbance isn’t attributable to the physiological effects of a substance or medical condition
D. The disturbance is not better explained by another mental disorder.
Prevalence
28.3% of the population experience ≥1 panic attack in a lifetime.
Age of onset: early = 15-24; late = 45-54
o Prevalence <14 = <0.4%
o Prevalence 30-64 = 6%
o Prevalence >64 = 0.7%
12-month prevalence = 2-3%
Life-time prevalence = 4.7-5.1%
o Without AG 3.7-4%
o With AG 1.1%
Males < females 1:2
Variety between ethnic groups
CBT is the ideal type for PD and AG.
o 37% with PD and 17% with PD + AG relapse one year after receiving treatment.
▪ Relapse: males < females
Comorbidity
20-50% with voluntary hyperventilation has panic attacks.
Often earlier onset age than comorbid disorder(s); but when the onset is after the comorbid
disorder this may be a severity marker of the comorbid illness.
Comorbid disorders:
o Anxiety disorders
▪ Agoraphobia
▪ GAD
o Major depression disorder (MDD)
o Bipolar disorder
o Mild alcohol or drug use disorder
o Suicidality PD is an indirect risk factor for suicide
o Manic behavior or psychosis
10-65% = panic disorder + depression or anxiety
In ⅓ of patients with depression + anxiety the depression precedes the onset of panic
disorder.
o In ⅔ depression occurs simultaneously or after the onset of panic disorder.
