Anxiety Disorders

Question 1

Internalizing Symptoms

Answer 1

Cluster of interrelated problems, including: Anxiety & Mood disorders
→ Distinct disorders but highly related

Question 2

Kids higher anxiety = Social/Academic impairment, give examples (2)

Answer 2

(1) Social impairment: More social exclusion, less likely to be liked by kids, Excluded, unliked, victimized
(2) Academic impairment: e.g. avoidance “so stressed about midterm that I cannot even open my book”

Question 3

Anxiety disorders & service utilization

Answer 3

LOW service utilization: often go untreated
E.g. survey:
-> Non-severe ADHD: 55% treatment
-> Severe Anxiety: 30% treatment

Question 4

Who’s more likely to receive services for anxiety disorders? (2)

Answer 4

(1) Girls (vs boys)
(2) Older kids (vs younger)

Question 5

Things that are normal

Answer 5

1) SOME Fear and Anxiety is NORMAL: Nearly all 1-year-olds become distressed when separated from their mother + Most children have very short-lived specific fears (~50% of 6-12yo have 7+ fears)
2) SOME Anxiety is ADAPTIVE: Stranger anxiety in young children & kidnapping; Test anxiety okay if middle of distribution
3) It may NOT be as upsetting to adults: “he’s shy”; May be associated with favourable characteristics (less aggression)

Question 6

Fear vs Anxiety

Answer 6

Fear = present-oriented
Anxiety = future-oriented

Question 7

Anxiety = Strong negative emotion or tension, displayed as: (3)

Answer 7

(1) Physical sensations (heart beating fast, trembling…)
(2) Cognitive shifts (seeing negative things that might happen, worry…)
(3) Behavioral patterns (crying, clinging to support figure, avoiding diff types of thing)

Question 8

Diagnoses in Anxiety disorders: how do you specify diagnosis

Answer 8

(1) Vary on CONTENT OF THREAT
(2) Very on balance of symptoms (e.g. cognitive vs physical)

Question 9

Cite the DSM-5 ‘Anxiety disorders’ (7)

Answer 9

!!Not OCD
(1) Separation anxiety disorder
(2) Generalized anxiety disorder (GAD)
(3) Specific phobia
(4) Social anxiety disorder
(5) Panic Disorder
(6) Agoraphobia
(7) Selective mutism

Question 10

In about …% of kids, separation anxiety DOES persist into adulthood

Answer 10

33% (1/3 kids)

Question 11

Onset GAD

Answer 11

Usually early adolescent period (10-14)
=> Bc symptoms are so global (Extends to many things): seems to see persistence over time
-> Can make it difficult to treat

Question 12

Anxiety disorders more common among Black youth than among White youth. What might be a contributor?

Answer 12

Race-based rejection sensitivity

Question 13

Race-based rejection sensitivity def

Answer 13

Based on past experiences (discrimination, race-based bullying…), people of color might anticipate being discriminated against in future situations
-> That might provoke some cognitive/physiological anxiety
-> E.g. ‘worrying about the next time i’ll be bullied’

Question 14

Comorbidity between anxiety disorders and major depression disorder

Answer 14

-> 77% of adolescents who meet criteria for Major Depression also meet criteria for an anxiety disorder
-> 45% of adolescents who meet criteria for an anxiety disorder also meet criteria for major depression
!! Anxiety symptoms/disorders often PRECEDES depressive disorders !!
*Also symptom overlap

Question 15

Negative & Positivity affectivity VS Anxiety & Depression

Answer 15

Negative affectivity → positively related to anxiety & depression
Positive affectivity → ONLY related to depression
**Positive/negative affectivity INDEPENDENT dimensions

Question 16

Anxiety disorders and IQ

Answer 16

Youth with anxiety disorders typically have IQs in the typical range
-> But symptoms may interfere with academic functioning

Question 17

Anxiety Disorders & Social difficulties (4)

Answer 17

Correlates
(1) Shy/withdrawn children become increasingly rejected by the peer group with age
(2) Shy/withdrawn children are AS LIKELY as their peers to have friends
(3) But they actually also perceive these relationships with their friends to be of lower quality than less shy/withdrawn/anxious kids
(4) More likely to experience peer victimization

Question 18

Different “typical” age of onset for each fear (3)

Answer 18

(1) 2 years of age: Loud noises, animals, the dark, separation from parents
(2) 5 years of age: Animals, dark, separation from parents, bodily injuries, “bad” people
(3) 7 to 8 years of age: Dark, supernatural beings, staying alone, bodily injuries
*Worries more complex as youth age
*Defiance, acting out (not DBD, but they don’t have the words to talk about their experience) underlying anxiety

Question 19

Types of Prognosis of Anxiety Disorders (2)

Answer 19

HOMOTYPIC continuity: Predicting something staying the same over time (E.g., separation anxiety @7 → separation anxiety @ 17)
HETEROTYPIC continuity: E.g., social anxiety → depression, generalized anxiety

Question 20

Two-Stage Model of Fear Acquisition

Answer 20

Stage 1: Fear develops through classical conditioning (US->UR; CS->CR)
Stage 2: Avoidance behavior maintained through operant conditioning

Question 21

Two-Stage Model of Fear Acquisition
-> Explain Stage 2: Avoidance behavior maintained through operant conditioning

Answer 21

Avoidant behavior provides relief from anxiety (reinforcer)
-> Avoidant behavior increases + Increase thoughts/cognition that we’re afraid for a good reason

Question 22

Study: 293 undergraduate students
Measured Unwanted intrusive thoughts.
Results?

Answer 22

Unwanted intrusive thoughts are TYPICAL - Difference is not in whether you have unusual obtrusive thoughts, difference is how IMPORTANT you think they are
- Running car of road – 64% of women, 56% of men
- Cutting off finger – 19% of women, 16% of men
- Left the stove on – 79% of women, 66% of men
- Imagining strangers naked – 51% of women, 80% of men

Question 23

Onset of OCD

Answer 23

Bimodal distribution:
(1) Early childhood onset (more likely to be boys, have family hx of OCD)
(2) Late adolescence/early adulthood

Question 24

How is the course of OCD for children? (2)

Answer 24

(1) 50-66% of children with OCD still meet criteria 2-14 years later
(2) <10% experience complete remission
-> Symptoms do get slightly better with time, however
-> Lot of continuity over time

Question 25

Risk factors for poor prognosis of OCD (4)

Answer 25

(1) Earlier onset (2) Poor first response to tx (3) Tic disorder (4) Parental psychopathology

Question 26

Social Information Processing & Anxiety Disorders (2)

Answer 26

(1) Encoding - Attention to threat (2) Negative interpretation bias

Question 27

Study: Do anxious youth show an attentional bias for threat-related information? (2)

Answer 27

(1) Those higher in anxiety show greater attention to potentially threatening stimuli * shown across many different types of tasks (e.g. eye tracking) (2) However, attention to threat varies widely from situation to situation among people high in anxiety as well  * threat intensity, personal relevance of threat information, and current mood moderates people with anxiety’s attention to threat

Question 28

Negative interpretation bias

Answer 28

Interpreting ambiguous social events negatively and catastrophizing even mildly negative social events * may lead to avoidance

Question 29

Family Factors in Pediatric Anxiety (3)

Answer 29

(1) Modelling: Parents demonstrate anxious responses to children. Might teach kids to be fearful around certain situation (2) Information transmission: Being told that something is dangerous can make you fear it (3) Parent low expectations: When kids have anxiety, expect children to have difficulty or not be able to cope with diff types of stressors (4) Parental reinforcement of problematic behavior (e.g. soothing)

Question 30

Study: Three groups of children - Clinically referred for anxiety - Clinically referred for ODD - Community control group Presented with 12 ambiguous situations: “You see a group of students from another class playing a great game. As you walk over and want to join in, you notice they are laughing. What would you do to solve the problem?" -> Children and their parents discussed two of the situations for 5 minutes, afterwards children provided a final answer -> Avoidant vs Aggressive solutions Results?

Answer 30

Parents 'talked anxious children into engaging in avoidant response!' -> Socialization of low expectations! Maybe reflect parents' reflection of 'own' anxiety?

Question 31

Treatment of Anxiety Disorders

Answer 31

(1) Biological treatments: SSRIs (2) Psychosocial/behavioral treatments: Cognitive or Behavioral therapy (3) Combination treatment: CBT + SSRI

Question 32

SSRIs characteristics (3)

Answer 32

(1) Selective Serotonin Reuptake Inhibitors: Work by stopping the reuptake of serotonin into the presynaptic neuron  (2) Famous names: Paxil, Prozac, Zoloft, Celexa (3) Not many studies looking at use of these drugs in youth, but some evidence of effectiveness across different anxiety disorders (OCD, GAD, SAD, social anxiety disorder)

Question 33

Core Components of Effective Interventions (3)

Answer 33

(1) Reduce cognitive biases - Self talk - Identify different thoughts + behavior that goes with those thoughts - Coping self-talk (2) Reduce bodily tension - Diaphragmatic breathing - Progressive muscle relaxation - Guided imagery (3) Exposure and habituation - Facing feared stimuli - Controlled exercise - Usually graded (baby steps) - Key technique in CBT for anxiety

Question 34

Novel cognitive interventions

Answer 34

Retraining threat bias - Recall that anxiety is associated with attentional bias for threat - Can we retrain that?

Question 35

Study: - Do a dot-probe task - Majority of trials the probe follows a neutral face - Trained to look away from threat Results?

Answer 35

Evidence from randomized trials with adults that this re-training reduces attention bias and internalizing symptoms

Question 36

Study: - 40 children seeking treatment for anxiety at a hospital-based clinic - Primary diagnosis of separation anxiety, generalized anxiety, specific phobia, or social phobia - 75% met criteria for two anxiety disorders Participants randomly assigned to: (1) Attention-bias modification (ABM): Angry-neutral stimulus pairs, and target was always paired with neutral (2) Neutral-neutral: Only see neutral-neutral pairs (3) Placebo: Angry-neutral stimulus pairs, and target was paired with neutral 50% of the time -> Trial is double-blind -> All participants received four training sessions over four weeks (one session a week) After treatment, had all participants complete a dot probe task Results? (2)

Answer 36

(1) Only participants in the ABM showed decrease in threat bias at post-test (2) Other outcomes also decreased: Less anxiety symptoms + lower severity!

Question 37

Developing a Graded Exposure Hierarchy: Method (3)

Answer 37

(1) List anxiety triggers (2) Rate each trigger: “Subjective Units of Distress” from 0-10; May use a Mood Thermometer (faces) with young children (3) Rank order triggers: Organize from easiest to hardest tasks; Build a good ladder

Question 38

Conducting Exposure: Steps

Answer 38

(1) Plan: Towards the bottom of the hierarchy (2) Keep track: - Rate anxiety during exposure - Keep track of anxiety across exposures (3) Practice - Practice each exposure until habituation - Move up the hierarchy

Question 39

Effects of Exposure on Anxiety

Answer 39

You cannot be fully activated for a long period of time! Over and over the exposures, the emotion reaction will be lower and lower

Question 40

Treatment Goals for OCD (2)

Answer 40

(1) Normalize OCD and Intrusive Thoughts (2) Exposure and response prevention

Question 41

Medication efficiency for Anxiety disorders

Answer 41

Medication does NOT cure anxiety: Suppresses symptoms -> Learning may be context specific!!

Question 42

Major RCTs Testing Efficacy of Treatments for Pediatric Anxiety (2)

Answer 42

(1) Child/Adolescent Anxiety Multimodal Study (CAMS) (2) Pediatric OCD Trial (POTS)

Question 43

Child/Adolescent Anxiety Multimodal Study (CAMS) What did they do?

Answer 43

Major RCT for youth anxiety Test efficacy of 1- SSRI 2- CBT 3- Combined 6 sites, 488 youth with GAD, separation anxiety, social anxiety disorder - Randomly assigned to receive: 1- SSRI 2- Pill Placebo 3- CBT 4- SSRI + CBT Treated for 12 weeks Clinician ratings of anxiety symptoms: Clinicians do NOT know what treatment group the child was in

Question 44

Child/Adolescent Anxiety Multimodal Study (CAMS): Results? (7)

Answer 44

(1) Combined, CBT, SSRI > Placebo (2) Combined > CBT, SSRI (3) CBT = SSRI (4) Moderator: Anxiety diagnoses (5) Combined is associated with best outcomes across all three diagnoses (6) Social anxiety disorder: SSRI > CBT (7) GAD: CBT > SSRI *This general pattern of differences maintained at 3- and 6-month follow-ups

Question 45

CAMELS (Extended Long-term Study of CAMS): Results? (3)

Answer 45

(1) Improvements in functioning (overall, family dysfunction, caregiver strain) during CAMS led to long term improvements in anxiety severity (2) Improvements in psychopathology during CAMS (anx severity and parent psychopathology) associated with long-term increases in overall functioning (3) Improvements/tx response related to long-term outcomes (nonspecific to condition)

Question 46

POTS Study: Description

Answer 46

Pediatric OCD Treatment Study (POTS) - 112 youth with OCD Randomly assigned to one of four groups 1- SSRI 2- Pill placebo 3- CBT 4- CBT + SSRI Measured OCD symptoms: Rated by an observer unaware of treatment condition

Question 47

POTS Study: Results? (4)

Answer 47

(1) Combined treatment > CBT, meds, placebo (2) CBT = Meds (3) CBT, Meds > Placebo (4) BUT …. Site was a MODERATOR of treatment response -> In Duke, combined group > CBT (and med) -> In Penn, combined group = CBT → Suggests that, if you have rly high CBT quality, might not be an added benefit from medication! (esp if adherence to medication isn't great)