Anxiety Disorders Flashcards
Internalizing Symptoms
Cluster of interrelated problems that include symptom seems in anxiety and mood disorders.
Internalizing Symptoms - Developmental psychopathology framework
- Remember that we evaluate what is abnormal in the context of what is typical for children of that age.
- Fear and sadness are important emotions.
- “Normal” fears come and go over development.
Anxiety Disorders
Associated with significant impairment. Social impairment (excluded, unliked, victimized). Academic impairment. Low service utilization: Anxiety problems often go untreated, most youth with mental health problems do not receive treatment.
3 key points about Anxiety Disorders
1) Some Fear and Anxiety is Normal
–> Is it causing disability, distress, or risk?
2) Some Anxiety is Adaptive
–> Stranger anxiety in young children helps keep them safe.
–> A certain level of anxiety leads to higher level of performance.
3) It may not be as upsetting to adults
–>Anxiety may not be causing as much disruption
–> May be associated with favourable characteristics: less aggression.
Core Features
Focus on threat or danger. Strong fight or flight response. Anxiety is future oriented: “anxious apprehension”. Strong negative emotion or tension, displayed as: physical sensations, cognitive shifts, beahviora patterns.
Diagnoses
Many specific diagnoses: vary on content of threat, vary on balance of symptoms (e.g., worry vs physical): separation anxiety, social anxiety, generalized anxiety, etc. In DSM-5 anxiety disorders now separated from OCD.
Specific Phobia
Specific situations or things. Diagnostic specifiers: Animal, natural environment, blood, situational, other.
Separation anxiety
Characterized by anxiety from separation from loved ones. Has to be out of proportion from what is expected from a kid of this age. Often worry about bad things that might happen to their parents when they’re separated.
Social anxiety
Fear of negative evaluation of others. Fear of social situations in which person will be evaluated. For children, must occur in peer settings (not just with adults).
Selective Mutism
Failure to speak in specific situations and contexts in which speaking is expected, even though they may speak in other settings. Reclassified as an anxiety disorder in DSM-5, but not clear that all children with selective mutism are anxious.
Generalized anxiety disorder
Excessive, uncontrollable anxiety and worry. Worrying can be episodic or almost continuous. Worry excessively about minor everyday occurrences. Somatic symptoms: physical symptoms of this anxiety and worry.
Panic Disorder
Panic attack: period of intense period of fear or discomfort that develops abruptly and is accompanied by at least four symptoms (sweating, shortness of breath, feeling like you are choking, chest pain, nausea). People can have panic attacks and not have panic disorders.
DSM-5 Criteria for Panic Disorder
Recurrent, unexpected panic attacks. At least 1 attack followed by one month+of one of the following:
a) Persistent concern about having additional attacks.
b) Worry about the implications of the attack or its consequences
c) A significant change in behaviour related to the attacks.
Obsessive-Compulsive Disorder: Obsessions
Recurrent, persistent thoughts, impulses, or images that are experienced as intrusive, inappropriate, and that cause marked anxiety or distress. The person attempt to ignore or suppress the thoughts or to neutralize them with another thought or action. The person recognizes that the thoughts are product of their own mind. Common obsessions: Contamination, harm to self or others, symmetry.
OCD: Compulsions
Repetitive behaviours or mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly. The behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded events or situations. However, these behaviours/mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or they are clearly excessive. Common compulsions: Counting, checking the oven is turned off over and over.
Prevalence
Lifetime prevalence of any anxiety disorder during childhood and adolescence is 32%. Specific phobia is highest with 19% (most do not get treatment). Selective mutism is lowest with 0.7%. For every 2 females diagnosed with an anxiety disorder, 1 male is diagnosed.
Socioeconomic Status & Ethnicity
Socioeconomic Status: Lower levels of parental education and living in a single-parent headed household associated with greater likelihood of having an anxiety disorder.
Ethnicity: Anxiety disorders more common among Black youth than among White youth. However, white youth receive same services for anxiety more than Black youth. Race-based rejection sensitivity: based on past experiences of discrimination, people of colour might anticipate discriminated against in future situations, which might provoke some kind of anxiety.
Comorbidity: Anxiety and Depression
Youth who have on anxiety disorder often meet criteria for others (e.g. selective mutism has high preventive of comorbidity with other anxiety disorders). Many youth with major depression also criteria for an anxiety disorder, and vice versa.
Anxiety and Depression: Symptom overlap
GAD and MDD: fatigue, sleep disturbance, irritability, concentration difficulties.
Anxiety and Depression: Negative and positive affectivity
Negative affectivity: Extent to which a person feels distress. Positive affectivity: Extent to which a person feels positive affect. Negative affectivity is positively related to anxiety and depression. Positive affectivity is negatively correlated with depression, but is independent of anxiety symptoms and diagnoses.
Clinical Correlates: Academic difficulties
Youth with anxiety disorders typically have IQs in the typical range. Symptoms may interfere with academic functioning. Impact of worry on concentration. Impact of worry on concentration. School refusal/difficulty remaining in school (separation and social anxiety). Selective mutism.
Clinical Correlates: Social Difficulties
Shy/withdrawn children become increasingly rejected by the peer group with age. More likely to experience peer victimization.
Developmental Course of Anxiety Disorders
Some fears, worries, and rituals are developmentally appropriate. Different “typical” age of onset for each fear. 2 years of age: Loud noises, animals, the dark, separation from parents. 5 years: Animals, dark separation from parents, bodily injuries, “bad” people.
7-8 years: Dark, supernatural beings, staying alone, bodily injuries. Worries more complex as you age. Young children may not realize that their fears are excessive, as children get older they may become more embarrassed. Young children may not be able to tell you how they are feeling (acting out underlying anxiety).
Different anxiety disorders who different get of onset
Separation anxiety disorder: 7-8 years
OCD: 9-12 years
Generalized anxiety disorder: 10-14. years
Social anxiety disorder: adolescence
Panic disorder: adolescence
Prognosis of Anxiety disorders (Homotypic vs Heterotypic)
Research is ongoing to determine what the long-term outcomes of anxiety disorders are.
Homotypic continuity: Anxiety disorder stays the same over time. Level of separation anxiety at age 7 predicts level at age 17.
Heterotypic continuity: Social anxiety (for example) at a certain age might go way to a certain extent, but get replaced by or predict later depression or generalized anxiety disorders.
Evidence that tendencies towards anxiety are inherited
1) Children with parents with anxiety disorders are ~5x more likely to have an anxiety disorder than are children whose parents do not have an anxiety disorders
2) Twin studies indicate that 33% of variability in anxiety is heritable.
Biological Predisposition to Anxiety
Inherit a general vulnerability (diathesis) to anxiety disorders. Temperament: Behavioural inhibition (fear and distress in response to novel situations, withdrawal), Negative emotionality.
Two-Stage Model of Fear Acquisition: Stage 1
Fear develops through classical conditioning. Unconditioned stimulus: A stimulus that leads naturally to the response. Unconditioned reponse: Response to the unconditioned stimulus. Conditioned stimulus: Neutral stimulus. Conditional response: Response to the CS that results from reliably pairing the CS and the US.
Two-Stage Model of Fear Acquisition: Stage 2
Avoidance behaviour maintained through operation conditioning. We try to avoid stimulus that now elicits fear. The avoidance behaviour and anxiety around that thing gets maintained through the process of operant conditioning. When we start avoiding this stimulus, our avoidant behaviour increases, and increases our thoughts and cognitions that we were afraid of that thing for a good reason.
Maintenance Model of OCD
We have our obsessions (intrusive thoughts), then we have to process that thought so we appraise it (give it importance), so we feel a sense of anxiety and disgust around this thought, and we want to get rid of that so we neutralize that anxiety provoking response by engaging gin compulsions leading to reduction in distress, and lower distress leads us to believe that that thought was important to neutralize in the first place, which primes us for future obsessions and the cycle continues.
Course of OCD
Mean age of onset 9-12 years old. 2 different peak onset periods: early childhood onset (more likely for boys or people with family history), and late adolescence/early adulthood. Lots of continuity overtime: while symptoms might get slightly better across time, people are still having issues or meeting diagnostic criteria overtime.
Social Information Processing & Anxiety Disorders
Encoding: Attention to threat. Those higher in anxiety do show greater attention to potentially threatening stimuli. But lots of situation differences, even among people with anxiety. Depending on threat intensity, personal relevance, and current mood, your attention to treat might vary.
Interpretation Biases in Pediatric Anxiety
2020 review and meta-analysis of interpretation bias and social anxiety. Strong association between social anxiety and negative interpretation bias: Interpreting ambiguous social events and negatively catastrophizing even mildly negative social events. May lead to avoidance, which relieves anxiety in short term but increases anxiety around subsequent social situations.
Family Factors in Paediatric Anxiety
Modelling: Behavioural and environmental factors that parents can engage in. Seeing someone else show fear may cause a child to develop fear.
Information transmission: Being told that something is dangerous can make you fear it.
Parent low expectations: Expect children to have difficulty or not be able to cope.
Parental reinforcement of problematic behaviour.
Overview of Anxiety treatment approaches
Biological treatments: Selective serotonin reuptake inhibitors (SSRIs).
Psychological/behavioural treatments: Cognitive therapy, Behavioural therapy.
Combination treatment: CBT + SSRI
SSRIs
Selective Serotonin Reuptake Inhibitors (Paxil, Prozac, Zoloft, Celexa). Work by stopping the reuptake of serotonin into the presynaptic neuron (more serotonin available in your bloodstream to then be used). Used for OCD, GAD, SAD, social anxiety disorder.
Core Components of Effective Interventions: 1) Reduce cognitive biases
Targeting self biases and negative self-talk. Self-talk: Anxious feelings, thoughts that go with anxious feelings (this is so scary, I can’t to do this). Child learns to identify different thoughts and the behaviour that goes with those thoughts. Coping self-talk: Im brave, I can take care of myself in the dark. Nobody’s perfect, we all make mistakes.
Novel Cognitive Interventions: Dot-probe task
Majority of trials the probe follows a neutral face. There’s a cross that you’re trained to always be oriented towards looking at. Then will show you a stimuli, e.g. two different faces. After we see faces, there will be dots in certain area of the screen, and we are supposed to look away from these dots. Trained to look away from threat. Can reduce potential biases and internalizing a symptoms.
Attention Re-training Study
40 children seeking treatment for anxiety at a hospital based clinic. Primary diagnosis of separation anxiety, generalized anxiety, specific phobia, or social phobia. Participants randomly assigned to either: Attention-bias modification (ABM) (Angry-neutral stimulus pairs, and target was always paired with neutral). Neutral-neutral: Only see neutral-neutral pairs. Placebo: Angry-neutral stimulus pairs, and target was paired with neutral 50% of the time. Trial is double-blind: Families and clinic staff are unaware of assignment. All participants recited four training sessions over four weeks. After treatment, had all participants complete a dot probe task.
Attention Re-Training Study Findings
Only participant in the ABM showed decrease in threat bias at post-test. But other outcomes also decreased for those in ABM group: anxiety symptoms went down, and anxiety-severity symptoms went down. Shows that this cognitive retraining (training someone to look away from threat-related stimuli) can result in meaningful improvements in symptoms and decreases in symptom severity.
Core Components of Effective Interventions: 2) Reduce bodily tension
Diaphragmatic breathing. Progressive muscle relaxation. Guided imagery. Works to relax muscles, calm down. Bring people to a present moment and reduces physiological activation.
Core Components of Effective Interventions: 3) Exposure and habituation
Facing feared stimuli. Controlled exercise. Usually graded (baby steps). Key technique in CBT for anxiety.
Exposure and habituation - Why is exposure important?
Classical and operant conditioning. If you avoid negative reinforcement you are removing fear-inducing stimuli, which gives relief in the moment, but can then lead to reassurance that you were scared in the first place and leads to a long-term cycle. We want to habituate you to a feared stimulus.
Exposure - Extinction Paradigm
US: Danger
UR: Fear
CS: Dog
CR: Fear
CS presented in the absence of the US. Repeated exposure to CS will extinguish the relationship between CS and CR.
Developing a Graded Exposure Hierarchy
People don’t want to jump into their fear all at once. Need to develop a fear or avoidance hierarchy. List all of the different situations or things that might trigger their anxiety, and then rate the in “Subjective Units of Distress” from 0-1. May use a Mood Thermometer (faces) with young children. Rank order triggers: organize from easiest to hardest tasks. Build a good ladder that has full range of experiences.
Conducting Exposure
Want to start closer to the bottom of the hierarchy, where there is anxiety but low enough so that you can engage and habituate. Rate anxiety during exposure. Keep track of anxiety across exposures. Repeat with multiple exposures, across time you start to not have as big of a reaction to that trigger.
CBT for OCD
Where can we break into this system? Often times we start by stopping that actual ritual/behaviour. What happens when we stop the ritual and star to habituate to the automatic obsessive thought? Treatment Goals: 1) Normalize OCD and intrusive thoughts. 2) Exposure and response prevention - same as anxiety, let people sit with uncomfortable thoughts, and over time habituate them.
Treatments for Paediatric Anxiety Disorders
SSRIs, CBT: For youth, cognitive-bahavioral approaches usually recommended first. Medication does not cure anxiety, it just stresses the symptoms. Learning may be context specific: potential concern that doing exposures when already taking SSRIs might result in the work you did not generalizing to when the person is no longer taking medication.
Major RCTs Testing Efficacy of Treatments: Child/Adolescent Anxiety Multimodal Study (CAMS)
Aimed to test efficacy of SSRIs medications. Test efficacy of: SSRI, CBT, and Combined. 488 youth with GAD, separation anxiety, social anxiety disorder. Randomly assigned into 4 groups to either receive SSRI, Pill Placebo, CBT, SSRI + CBT. Treated for 12 weeks. Clinician ratings of anxiety symptoms - clinicians do not know what treatment group the child was in.
Major RCTs Testing Efficacy of Treatments: Child/Adolescent Anxiety Multimodal Study (CAMS) - Findings
Unsurprisingly, the combined SSRI + CBT, and SSRI and CBT only treatments all did better than placebo. The combined treatment did better than both the CBT only and SSRI only conditions in terms of anxiety symptoms. CBT only and SSRI only conditions led to similar reductions in symptoms. Anxiety diagnosis was a moderator of that relationship: the impact of the intervention differed based on the actual diagnoses that the kids had. Kids who were combined had the best outcomes regardless of diagnoses, but the anxiety of kids with SAD went down more if they were in the SSRI only condition vs CBT. For GAD the opposite pattern showed: those in CBT did better than SSRI. However, combined SSRI + CBT still lead to grates reaction across a disorder, and CBT and SSRIs are generally similar in overall sense.
CAMELS (Extended Long-term Study) - follow up 3-11 years post-tx
Improvements in functioning (overall, family dysfunction, caregiver strain) during CAMS led to long term improvements in anxiety severity. Improvements in psychopathology during CAMS (and severity and parent psychopathology) associated with long-term increases in overall functioning. When family function increases as a function of an intervention, we see lots of additional benefits in terms of other outcomes as well.
Major RCTs Testing Efficacy of Treatments for Paediatric Anxiety: POTS
Paediatric OCD Treatment Study (POTS). 112 youth with OCD. Randomly assigned to one of four groups: SSRI, Pill placebo, CBT, CBT + SSRI. Measured OCD symptoms: Rated by an observer unaware of treatment condition.
Major RCTs Testing Efficacy of Treatments for Paediatric Anxiety: POTS - Findings
Some similar findings: Combined did the best, CBT and SSRIs did similar. But there were some interesting findings because the study was done at two different sites. If we look at the site-level data, we find that site was a moderator. The difference between CBT vs Placebo was a lot bigger at University of Pennsylvania compared to Duke. This suggests that if you have really high quality CBT there might not be an added benefit for medication.
Summary of CAMS trial and POTs trial
Found that CBT and SSRI are both better than placebo for reducing symptoms of anxiety/OCD. In both trials, combined treatment (CBT + SSRI) was more effective than either treatment alone for reducing symptoms of anxiety/OCD. Important nuances in both trials: CAMS: type of anxiety disorder moderated efficacy of treatment. POTS: effect of CBT and SSRI varied across treatment sites.
