412 Anxiety

Question 1

who is least/most likely to use mental health services

Answer 1

• people with severe and non-severe anxiety do not seek treatment (though girls and older adolescents are slightly more likely)

Question 2

why are people with anxiety less likely to seek treatment

Answer 2

• some fear and anxiety is normal (becoming distressed when separated from parents, short-lived specific fears, must assess if it’s causing distress/disability)
• some anxiety is adaptive (stranger anxiety, test anxiety)
• may not be as upsetting to adults (no causing disruption, may be associated with favourable characteristics like less aggression)

Question 3

core features of anxiety

Answer 3

• focus on threat or danger
• anxiety is future-oriented (anxious apprehension)
• strong negative emotion or tension (physical sensations, cognitive shifts like worry, behavioural patterns like avoidance)

Question 4

different anxiety diagnoses

Answer 4

• vary on content of threat and balance of symptoms (cognitive like worry vs. physical)
• specific phobia
• separation anxiety
• generalized anxiety
• social anxiety
• panic disorder
• agoraphobia
• selective mutism

Question 5

epidemiology of separation anxiety

Answer 5

• often seen in school ages
• high levels of comorbidity (with other anxiety or depressive disorders)
• small percentage of people will persist into adulthood (figure of attachment may change), while others will grow out of it or switch to another anxiety disorder

Question 6

selective mutism

Answer 6

• failure to speak in situations when speaking is expected, even though they may speak in other settings

Question 7

common obsessions and compulsions

Answer 7

• contamination, harm to self or others, symmetry
• counting, checking, washing

Question 8

prevalence of anxiety disorders

Answer 8

• any anxiety disorder in childhood/adolescence = 32%
• specific phobia: 19%
• social anxiety: 9%
• separation: 8%
• GAD: 2%
• PD: 2%
• OCD: 1-2%
• mutism: 0.7%

Question 9

epidemiology of anxiety disorders

Answer 9

• girls 2:1 boys (as age of onset increases, gender disparity increases)
• OCD has a 2:1 male to female ratio that is present throughout development
• contextual cultural experiences can shape anxiety presentation
• lower SES (single parent, lower parental education) = more anxiety
• ethnicity: more common in Black youth, but White youth receive more treatment (race-based sensitivity)
• comorbidity tends to be the norm (with other anxiety disorders and depression)
• usually, anxiety disorders precede depression (internalizing symptoms are highly related)

Question 10

race-based sensitivity

Answer 10

• worry/anxiety/physiological arousal about the idea that someone could discriminate against you in the future
• anticipating people treating you differently because of your race, which contributes to your anxiety

Question 11

comorbidity anxiety and depression

Answer 11

• symptom overlap (GAD and MDD; fatigue, sleep disturbance, irritability, concentration)
• negative affectivity high in both anxiety and depression, but depression is low in positive affectivity and anxiety can still have high positive affectivity

Question 12

clinical correlates of anxiety

Answer 12

• academic difficulties; high IQ but symptoms interfere with functioning (worry impacts concentration, school refusal)
• social difficulties: becoming increasingly rejected with age because of shyness, more likely to experience peer victimization, perceive their friendships to be of lower quality

Question 13

developmental course of anxiety disorders

Answer 13

• fears, worries, rituals can be developmentally appropriate (worries get more complex as you age)
• young children may not realize that their fears/behaviours are excessive/atypical, but may get embarrassed as they age
• earlier stages of development = inability to verbalize distress, so behavioural symptoms are more common
• different anxiety disorders have different ages of onset

Question 14

anxiety disorders age of onset

Answer 14

• separation: 7-8
• OCD: 9-12 (though some kids can present earlier 6-10)
• GAD: 10-14
• social and PD in adolescence

Question 15

homotypic continuity

Answer 15

• stability
• a disorder predicts itself over time
• separation anxiety becomes social anxiety

Question 16

heterotypic continuity

Answer 16

• disorder predicts onset or worsening of a different disorder over time
• social anxiety becomes depression

Question 17

heritability of anxiety

Answer 17

• tendencies toward anxiety are inherited (diathesis)
• children of parents with anxiety disorders are 5x more likely to have anxiety disorders
• twin studies indicate 33% of variability is heritable

Question 18

what could be the inherited biological predisposition for anxiety

Answer 18

• temperament
• behavioural inhibition: fear and distress in response to novel situations, withdrawal
• negative emotionality

Question 19

two-stage model of fear acquisition

Answer 19

• stage 1: develops through classical conditioning (pairing US-CS so that the CS will reliably provoke the CR)
• stage 2: avoidance behaviour maintains fear through operant conditioning (avoidance = relief = negative reinforcement of avoidance & reinforces the idea that the fear is valid)

Question 20

maintenance model of OCD

Answer 20

obsessive intrusive thought = appraised as important = anxiety and disgust = act to neutralize = reduces distress = reinforcement of important appraisals & more likely to have more intrusive thoughts (because you spent so much cognitive time and energy on them)

Question 21

social information processing model of anxiety

Answer 21

• encoding biases: attention to threat and reading ambiguous situations as more threatening
• threat intensity, personal relevance of threat, current mood, contextual factors will moderate attentional biases (not constantly more attentive to threat)
• interpretation biases: interpreting ambiguous events negatively and catastrophizing mildly negative events which can lead to avoidance

Question 22

family factors in youth anxiety

Answer 22

• modeling: parents demonstrating anxious responses to children (parent showing fear = child learns to also display fear)
• information transmission: kids being told that something is dangerous (parents over-emphasizing danger)
• low expectations: parents not believing that their kids have the ability to cope
• parental reinforcement of problematic behaviour

Question 23

study about family factors in youth anxiety

Answer 23

• kids referred for anxiety, ODD, or control group presented with ambiguous situations and give a first answer, then discuss with parents and give a final answer
• parents talked their kids into giving avoidant responses (maybe they had low expectations about their ability to respond in other ways)
• direct transmission of information
• same pattern in kids with ODD: parents socializing and modeling aggressive solutions
• passive GxE (creating environments that foster anxiety) and evocative GxE (reacting to kid’s anxiety and providing avoidant solutions)

Question 24

SSRIs

Answer 24

• stop the reuptake of serotonin into the presynaptic neuron
• some evidence of effectiveness, but not much research in youth
• reduction of symptoms, moderate effect sizes

Question 25

core components of effective treatments for anxiety

Answer 25

• reducing cognitive biases by encouraging positive self-talk about anxious symptoms and thoughts that go with them + coping self talk, identifying and challenging automatic thoughts
• reduce bodily tension though diaphragmatic breathing, progressive muscle relaxation, guided imagery
• exposure and habituation (facing fears in a controlled way)

Question 26

novel cognitive interventions

Answer 26

• re-training attention threat bias
• dot-probe task to train attention away from threat (potentially promising)
• kids assigned to attention-bias modification, neutral-neutral, placebo conditions in a double-blind study
• only people in the ABM condition showed decreases in threat bias, anxiety severity and symptoms

Question 27

exposure therapy

Answer 27

• habituating the CS so that anxiety will decrease naturally (without avoidance)
• CS presented without the US to extinguish the relationship between CS-CR

Question 28

graded exposure

Answer 28

• start small and work up to higher levels of anxiety
• develop a hierarchy of fears ranked from easiest to hardest (subjective anxiety)
• start toward the bottom of the ladder, rate anxiety during each exposure, and keep practicing until habituation to move up the ladder
• first exposure = strong reaction, then anxiety will decrease so that the next reaction will be lower (peak anxiety will be lower and will decrease faster)

Question 29

flooding

Answer 29

• can be very effective
• start with an intense confrontation with the most feared stimulus
• not very tolerated, so clinicians opt for graded (less likelihood of dropout)
• if the person cannot tolerate it, so they avoid or fail, they’re unlikely to benefit

Question 30

CBT for OCD

Answer 30

• normalize OCD and intrusive thoughts (1: psychoeducation)
• create a hierarchy of obsessions (can get very granular)
• exposure response prevention
• teaching to place less importance of intrusive thoughts, limiting compulsions

Question 31

Child/Adolescent Anxiety Multimodal Study (CAMS)

Answer 31

• testing efficacy of SSRIs, CBT, combined in youth with GAD, separation, social anxiety (treated for 12 weeks, clinician blind ratings of severity)
• all treatments were better than placebo group
• combined was better than SSRIs or CBT alone
• CBT was equal to SSRIs
• these patterns were maintained at follow-up
• moderator: anxiety diagnosis (combined was best for all 3, SSRIs were better for social anxiety - maybe taking the edge off, CBT was better for GAD - skills learned might generalize)
• CBT for SOC didn’t include exposure to peers which could influence the results

Question 32

CAMELS (Extended Long-term Study)

Answer 32

• 3-11 years post-Tx
• improvements in functioning (family functioning especially) during CAMS led to long-term improvement in anxiety
• improvements in anxiety during CAMS led to improvements in functioning
• patterns were true across all conditions

Question 33

Pediatric OCD Treatment Study (POTS)

Answer 33

• youth with OCD assigned to SSRIs, placebo, CBT, CBT+SSRI
• severity rated blindly
• combined was better than other conditions
• CBT equivalent to meds
• effect sizes were different based on the site
• Duke: combined was better than meds, which was better than CBT
• Penn: combined and just CBT were equivalent and both better than meds
• clinicians were better at giving CBT at Penn, and there was no added benefit of giving meds