Introduction &

Anxiety disorders
11 September 2018

Miriam Lommen
Clinical Psychology and Experimental Psychopathology
University of Groningen
The Netherlands
 |2

Psychopathology:
symptoms, classifications and diagnosis
Laura Steenhuis,
MSc
Assistant course
coordinator
Pregnancy leave
from 14
september

Dr Charmaine Borg
Dr Miriam Lommen
Course coordinator Julia van Schaik, MSc
Course coordinator (pregnancy leave until 1 Assistant course coordinator
(pregnancy leave) oktober)
 |3

TODAY’S TOPICS:

• Introduction to the course

• Anxiety disorders
-Introduction to course
-Anxiety disorders
 |4

After this course you can...

› ….describe the primary purposes of the DSM-5 and the
pros and cons of using the DSM-5
› …describe the clinical presentation of the psychological
disorders as outlined in the DSM-5
› …recognize and name the classifications and
corresponding symptoms according to the DSM-5
› …explain which (differential) classifications should be
considered based on a case example
› …name what diagnostic criteria still need to be obtained
in order to draw conclusions about the absence or
presence of a classification, given a case description
 |5

This is what you need

ISBN: 978-0890425565 | Edition: 5 (2013)
DESK EDITION
 |6

We recommend to buy the book

Online version of the DSM-5

Available through the University website “Psychiatry
online” (see guide at Nestor)

Please NOTE:
This online version of the DSM-5 includes all (same)
classifications you should study BUT it contains more
background information, which is NOT part of the
examination
 Outline lectures
Week |7

37 Laura Steenhuis – Introduction & Anxiety Disorders

37 Thimo van der Pol & Michel Zevenhoven – Forensic Psychiatry
38 Jojanneke Bruins – Psychotic and related disorders
38 Judith Daniels – Trauma – related disorders/ PTSD and DIS
39 Hermien Elgersma – Feeding- and eating disorders
39 Hermien Elgersma – Personality disorders
40 Rik Geres – Obsessive-compulsive and related disorders
40 Theo Bouman – Somatic symptom and related disorders
41 Marike Lancel – Sleep Disorders
41 Maaike Nauta – Anxiety disorders + Speaker on ADHD
42 Brian Ostafin – Substance-related and addictive disorders
42 Claudi Bockting – Mood disorders
43 Ernst Horwitz – Autism spectrum and developmental disorders
43 Charmaine Borg – Sexual dysfunctions
 |8

Attend the lectures!

› Great fun
› Lots of people “from the field”
› Lectures are EXAM material
› Lectures are NOT recorded
(are you reading this on the handout because you were
not at the lecture: the answer why not can be found in
the FAQ at Nestor…but not everything that is said in the
lecture will be)
 |9

Exam
› 50 multiple choice questions (50 points)
2 open questions (10 points)
(in English; open questions may be answered in Dutch)
Final grade: 80% MC; 20% OC

› (example questions are available on Nestor)

 Exam material
| 10

› Material discussed in lecture

(handouts will be placed on Nestor asap after lecture)
› Article “DSM-5: Rief, W. (2013). DSM-5 Pros and cons.
Verhaltenstherapie, 23, 280-285 (see Nestor)
› DSM-5
 Cover to cover
 Including durations, type, specifiers, number of
symptoms necessary to meet diagnosis etc.
BUT excluding:
 Codes (like F codes and ICD codes)
 Other mental disorders (p. 341-343)
 Medication induced movement disorders and
other adverse effects of medication (p. 345-353)
 Other conditions that may be a focus of clinical
attention (355-375)
 YOUR exam questions
| 11

› Send in a MC question (3 answer options) before the

lecture via Nestor
› After the lecture we select the “best” 3 questions
› These 3 will be posted on Nestor for ONE week

 Out of the 3 (MC questions) * 14 (lectures) = 42 questions,

7 will be used for the exam, 7 for the resit
 | 12

Recommendation
› Divide classifications over the weeks
› Read per classification some case studies (casebook) or
watch some video’s on e.g., youtube
› Look at the practice exam questions that will be
published on Nestor
 | 13

Optional but NO exam material

› Case book DSM-5
(“psychiatry online”- see step-by-step guide on Nestor)
› Extra articles provided by lecturers

Just interesting but also HELPFUL!

 | 14

Any questions?
› See if you can find the answers on Nestor
› FAQ
Post it on Discussion Board!!!

Please avoid emailing the course coordinator:

don’t want to be unfriendly, but….
 | 15

If you would email me and all emails were

printed out it looks like this:
 | 16

Any questions?

Post them on www.menti.com CODE 83 22 89

and I will answer them at the end of the lecture

 Learning goals for today’s lecture
| 17

Part 1: Classifying abnormality

• How do we define what is abnormal?

• How do we classify abnormality?

Part 2: Anxiety disorder

• Get to know and recognize different anxiety

disorders
 | 18

How do we DEFINE what is abnormal?

2 minutes
 | 19

How do we DEFINE what is abnormal?

Violating social norms?
| 20
Violating social norms?
| 21
 Violating social norms?
| 22

Questions at www.menti.com CODE 83 22 89

 Violating social norms?
| 23

It is not a matter of asking who is right or wrong here:

The conclusion is that what is perceived as normal or

abnormal depends on social and cultural norms
So it depends on where you are!

Questions at www.menti.com CODE 83 22 89

 Violating social norms?
| 24

A person’s thinking or behaviour may be classified as

abnormal if it violates the social norms of a particular
culture..
But social norms vary by place and over time:

 Homosexuality: considered as a psychological disorder by

the World Health Organization (WHO) until 1980

 Pedophilia in ancient Greek times

 Seeing visions or hearing voices: Psychotic or religious

experience?
Social norms vary with cultural and historical contexts

Questions at www.menti.com CODE 83 22 89

Violating statistical norms?
| 25

IQ
 Personal distress?
| 26

But…

 …does not apply to all psychological disorders

- Antisocial personality disorder, conduct disorder
- Mania or hypomania

 …can apply to ‘normal’ responses

- War, death of a friend or relative

Questions at www.menti.com CODE 83 22 89

 Impairing patterns
of behaviour?
| 27

 To the individual’s life

e.g. individuals with agoraphobia may struggle to leave the house,

find employment etc.

 To their friends and relatives

e.g. individuals who are depressed may isolate themselves from

their friends and family

 To society

e.g. individuals with aggressive tendencies may become violent to

others if provoked

Questions at www.menti.com CODE 83 22 89

 Defining abnormality
| 28

1. Violation of social norms

2. Statistical outlier
3. Personal distress
4. Impairing or disabling pattern of behaviour

All of these capture some aspect of abnormality but are

not sufficient on their own.

Alternatives?

Questions at www.menti.com CODE 83 22 89

 Defining abnormality
| 29

Questions at www.menti.com CODE 83 22 89

 DSM-5 definition
of abnormality
| 30

Mental disorders are defined as a clinically significant

disturbance in cognition, emotion regulation, or
behavior that indicate a dysfunction in mental
functioning that is usually associated with
significant distress or disability in work, relationships,
or other areas of functioning

(American Psychiatric Association, 2013, p.20).

Expectable reactions to common stressors

are not mental disorders.

Questions at www.menti.com CODE 83 22 89

 | 31

How do we CLASSIFY abnormal behaviours?

Questions at www.menti.com CODE 83 22 89

 Classifying abnormality-
categorical approach
| 32

• Presence/absence of a symptom pattern

• Qualitative differences between normal and abnormal

Questions at www.menti.com CODE 83 22 89

| 33
 Criticism of
categorical approach
| 34

Presence or absence of symptom pattern:

 Too reliant on clinical judgement and arbitrary cut-offs

Qualitative differences between normal and abnormal:

 Disorders and symptoms within the ‘normal’ range
are often associated with the same risk factors
 Disorders are usually preceded by subclinical symptoms
 Symptoms may also be associated with psychosocial
impairment
 “Not otherwise specified” diagnoses

Questions at www.menti.com CODE 83 22 89

 Classifying abnormality-
dimensional approach
| 35

• Symptoms vary on a continuum of severity

• Differences are quantitative rather than qualitative
 Can all abnormality be
considered to be continuous?
| 36

Normal variant Disorder

Low mood Depression

Mood swings Bipolar disorder

Neuroticism/ worrying Anxiety

Energetic/impulsivity ADHD

Dieting Anorexia

Social awkwardness Autism Spectrum Disorders

Checking Obsessive Compulsive Disorder

Hallucinations Schizophrenia

Questions at www.menti.com CODE 83 22 89

 Can all abnormality be
considered to be continuous?
| 37

17.5 % (Netherlands)
28 % (US)

van Os et al., 2009

Questions at www.menti.com CODE 83 22 89

 Criticism of
dimensional approach
| 38

There is a need to categorise abnormality:

 Diagnoses facilitate treatment, intervention, access to

resources

 Diagnoses may provide relief to the family and to the

individual

 Diagnoses may help to raise awareness and reduce stigma

associated with psychiatric conditions

Questions at www.menti.com CODE 83 22 89

 Critical notes on
classifying abnormality
| 39

Normal variant Disorder

Low mood Depression

Mood swings Bipolar disorder

Neuroticism/ worrying Anxiety

Energetic/impulsivity ADHD

Dieting Anorexia

Social awkwardness Autism Spectrum Disorders

Checking Obsessive Compulsive Disorder

Hallucinations Schizophrenia

Different disorders - similar causes or underlying

pathways? Comorbidity is rule rather than exception
 A new approach:
network perspective
| 40

Current view: symptoms caused by underlying factor

Depression

Concentration Loss of pleasure

Tiredness Self-content Sad mood
difficulties in activity

Disorder results from causal interplay between symptoms

(Borsboom & Cramer, 2013; Schmittmann et al., 2013)
 A new approach:
network perspective
| 41

Comorbidity – traditional view

Cramer, Waldorp, van der Maas, & Borsboom, 2010

 A new approach:
network perspective
| 42

Comorbidity under the network approach

Cramer, Waldorp, van der Maas, & Borsboom, 2010

Questions at www.menti.com CODE 83 22 89

 | 43

Why do we focus on DSM-5 (categorical approach)

in this course?
 | 44

DSM widely used in clinical practice! (Language everyone speaks)

 | 45

Questions at
www.menti.com
CODE 83 22 89
| 46
 Fear versus anxiety
| 47

DSM-5 (APA, 2013)

FEAR is an emotional response to

real or perceived imminent threat

ANXIETY is anticipation of
future threat
Adaptive or maladaptive?

Increase chances of survival Excessive & persistent

 | 48

Who is NEVER afraid?

| 49
 | 50

Do I suffer from an anxiety disorder?

According to the guideline for doctors:

• Excessive anxiety or worry?

• “Do you feel anxious”
• “Are your fears realistic?”
• “Does the fear interfere with your daily functioning
at home, at work or in your free time”

Questions at www.menti.com CODE 83 22 89

 | 51

I’m lucky: it’s easy to avoid

complete darkness!

Questions at www.menti.com CODE 83 22 89

 | 52

How many people suffer from anxiety

disorder?

• 1 in 5 will develop an anxiety disorder in their life

• gender ratio about 2:1, in favour of men

• Number 3 in top 10 of diseases with highest burden

Questions at www.menti.com CODE 83 22 89

 DSM-5 | 53

Trauma- and stress-related disorders:

• Posttraumatic stress disorder • Separation anxiety disorder
• Specific phobia
• Selective mutism
Obsessive compulsive and related disorders:
• Social anxiety disorder (SAD)
• Obsessive compulsive disorder (OCD)
Generalized
•Anxiety anxiety disorder (GAD)
disorders:
• Panic Disorder
• Panic attack specifier (no diagnosis on its own!)
• Agoraphobia
• Substance/medication induced anxiety disorder
• Anxiety disorder due to another medical condition
• Other specified anxiety disorder
• Unspecified anxiety disorder

Questions at www.menti.com CODE 83 22 89

 | 54

Characteristics of different anxiety disorders?

OBJECT OF FEAR
Anxiety disorder (DSM-IV):
• Specific phobia
• Social anxiety disorder
• Obsessive compulsive
disorder
• Generalized anxiety
disorder
• Panic disorder
• Posttraumatic stress
disorder
Fear of:
E.g., spiders, heights, flying,
vomiting, small spaces
Being negatively evaluated by others
Harm others, intrusive thoughts/
images
Almost everything…excessive
worrying
Bodily sensations; heart attack,
dying, going crazy
Trauma and memories of the trauma

Questions at www.menti.com CODE 83 22 89

 | 55

Specific phobia
› Persistent irrational fear of an
specific object or situation
› Intense fear response when
confronted with feared
object/situation
› Avoidance, intense fear when
avoidance is not possible
› Fear is out of proportion
› Persistent - 6 months or longer
› Impairment in daily
functioning (school/work;
social)
 | 56

Why does a phobia persist?

Avoidance Relief

Fear

“The spider will attack me”

“The spider will bite me”

Questions at www.menti.com CODE 83 22 89

 Social anxiety disorder
| 57

A. Marked fear or anxiety about one or more social

situations
B. Fear to act in a way or show anxiety symptoms that
will be negatively evaluated by others
C. Almost all social situations provoke fear
D. Avoidance behaviour
E. Fear is out of proportion
F. Persistent: At least 6 months

G. Causes clinically significant distress or impairment

H. Not attributable
Specify to substance
if: Performance only use
I. Not better explained by symptoms of other disorder
J. If another medical condition is present, fear, anxiety or
avoidance is clearly unrelated or excessive.
Questions at www.menti.com CODE 83 22 89
 Social anxiety disorder
| 58

Talk to the person next to you and tell them what you did last night,
trying to make it sound really REALLY interesting and fun!

Questions at www.menti.com CODE 83 22 89

 Social anxiety disorder
| 59

They will think I am stupid

I will look anxious

Social rejection

I won’t be able to come across well

They think I am weak or inadequate
They will think I am uninteresting

Questions at www.menti.com CODE 83 22 89

 Social anxiety disorder
| 60

Overestimate visibility of anxious symptoms

Underestimate own skills

Bias towards social threatening information

Negatively interpreting ambiguous social information

Questions at www.menti.com CODE 83 22 89

 Panic disorder
| 61

Instead of just displaying the list of symptoms…..

get a feel for it!
 Panic disorder
| 62

Get yours straws out!!!

 Panic disorder
| 63

 Panic attacks are recurrent and unexpected

 Panic attacks reach peak within minutes
 Panic attacks are accompanied by at least 4 of following
physical symptoms:
- Palpitations, pounding heart - Feeling dizzy, light-headed
- Sweating - Chills or heat sensations
- Trembling or shaking - Numbness or tingling sensations
- Shortness of breath sensations - Feelings of unreality
- Feelings of choking - Fear of losing control or
- Chest pain or discomfort “going crazy”
- Nausea or abdominal distress - Fear of dying
 At least 1 month of worrying about new attacks or consequences
 Changes in behaviour
Questions at www.menti.com CODE 83 22 89
 Panic disorder
| 64

Internal / external
trigger

Threat appraisal

Anxiety

Misinterpretation Physical symptoms

Avoidance and safety behaviour

Questions at www.menti.com CODE 83 22 89
 Generalized anxiety disorder
| 65

 Excessive anxiety and worry occurring more days then not,

at least 6 months, about number of events
 Finds it difficult to control worry
 Anxiety / worry associated with at least 3 of following
symptoms:

- Restlessness / feeling keyed up or on edge

- Being easily fatigued
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbance
 Differential diagnosis
| 66
Anxiety symptoms/attack
GAD PD
Anxiety attacks interpreted as Symptoms interpreted as indicative
indication that worrying is of fainting, losing one’s mind, heart
threatening/harmful attack, loss of control or dying
Worrying

GAD SAD
Focus of worrying varies Focus of worrying is always negative
assessment and/or embarrassing
behaviour
GAD Other anxiety disorders
Worrying about minor, everyday Worrying about one or some major issues
life events
Worrying largely about an invariant
Worrying about transient, shifting stimulus, mostly concerning the specific
issues disorder
 | 67

Case example

I am feeling so anxious, becoming more and more often.

For example I was in the train last week, and there were
so many people, I felt this tension coming up and I just
wanted to get off at the next stop. Which I did even though
it meant I had to walk for 45 minutes to get back home!

Questions at www.menti.com CODE 83 22 89

 | 68

What were you afraid of what would have happened

if you would have stayed in the train?

Everyone would have seen me blushing, the person opposite

of me already looked weirdly at me. I would have made a fool
out of myself.
My heart would have started racing even worse, I would start
sweating and feel so hot, I might have gotten a heart attack.
I thought about this article which said how likely it is you
pick up illnesses in busy places like public transport,
when I got off I was worried I might be late and others might
start worrying about my absence.
Questions at www.menti.com CODE 83 22 89
 Agoraphobia
| 69

Anxiety about being in (or anticipating) situations from

which escape might be difficult or in which help may not
be available in the event of having a panic attack.

› Intense fear in response to & avoids ≥2 situations:

• using public transportation
• being in open spaces (parking lots, market places, bridges)
• being in enclosed spaces (shops, theatres, cinemas)
• standing in line or being in a crowd
• being outside of the home alone

Questions at www.menti.com CODE 83 22 89

 Anxiety disorders
| 70

Generally speaking, fear/anxiety …

• …must be out of proportion to the actual danger or threat

in the situation (according to clinical judgment),
after taking cultural contextual factors into account

•…have a typical duration of 6 months or longer

Questions at www.menti.com CODE 83 22 89

 | 71

Questions you have posed on

www.menti.com CODE 83 22 89
 | 72

https://www.youtube.com/watch?v=hEWn
zBSwJyE

https://www.youtube.com/watch?v=oup-m8Hxx4Y