Exam 2

Question 1

Anxiety Disorders - Overview of Etiological Factors

Answer 1

-Attachment figures are often anxious

• Two-Factor Theory
  
  • Classical followed by negative reinforcement
• Cardiac Conditions
• Catastrophic misinterpretation
• Overestimation of somatic sensations
• Genetics

Question 2

Specific Phobia - Description of Disorder

Answer 2

-Excessive fear of a specific object

• Exposure provokes immediate anxiety
  
  • Crying, tantrums, freezing, or clinging
• Children don’t have to recognize it is excessive
• Avoided or endures with intense anxiety
• Interferes with normal routine, social activities, or marked impairment about having the phobia
• Fear persistent, usually lasting 6 mos. or more
• Impairment in functioning
• Not better explained by other disorder
• Prevalence rates in children about 5%
• Prevalence in teens = 16% in teenagers

Question 3

Specific Phobia - Treatment Approaches

Answer 3

• Stimulus Control
  
  • Assess & eliminate antecedents.
• Thought-Stopping
  
  • ‘STOP’ when stimuli occur
• Systematic or In Vivo Desensitization
  
  • Teach progressive muscle relaxation
    
    • 12 seconds of relaxation, 6 seconds of tension
  • Construct Hierarchy
    
    • 10 situations progressively becoming more anxiety provoking
    • Involve kid in construction
    • Imaginary vs. in-vivo
  • Expose to Hierarchy
    
    • Start with least provoking, progress to higher anxiety
    • Allow child to decide when to progress
      
      • Imagine relaxation scene, state relaxing cue words or positive/neutral statements
      • Cognitive skills: talking objectively, confidently, and self-instructed.
    • Instruct child to use fear-rating scale
    • Establish rewards for accomplishing steps in hierarchy
    • Employ other strategies: magic dust, angels, positive events

Question 4

Separation Anxiety Disorder - Description of Disorder

Answer 4

• *Non-developmentally appropriate anxiety defined by 3 or more of the following for at least 4 wks. (6 mos. or more in adults):
• Developmentally inappropriate distress when separated from home or attachment figure (AF)
• Worry about losing, or harm may occur to AF, or event may happen leading to separation of AF
• Reluctance to go to school
• Reluctance/refusal to sleep without AF near
• Repeated nightmares involving theme of separation
• Repeated complaints of physical symptoms when separation occurs or is anticipated
• Worry excessively to be alone, without AF

Question 5

Separation Anxiety Disorder - Other Diagnostic Issues (and Prevalence)

Answer 5

-Periodically see this in infants to pre-schoolers & pets.

• Need to assess school refusal for
  
  • Separation anxiety from caregiver
  • Conduct disorders (usually in adolescents)
• Prevalence:
  
  • 4% in children, 1.5% in adolescents
  • No differences between genders

Question 6

Separation Anxiety Disorder - Treatment Approaches

Answer 6

• Comprehensive Behavior Therapy
  
  • Somatic Training: teach child to differentiate anxious bodily reactions from non anxious responses and deep muscle relaxation
  • Self-Instructional Training: coping self-talk, self-direction, self-evaluation, and self-reward
  • Imaginable and In Vivo Exposure
    
    • Time away from attachment figure.
  • Homework to practice aforementioned skills
    
    • Reward completion of therapy tasks

Question 7

Social Anxiety Disorder (Social Phobia) - Description of Disorder

Answer 7

• Fear or anxiety in social situations in which exposed to possible scrutiny by others
  
  • Kids must evidence this w/ peers, not just adults.

-Fears that s/he will act in way or show anxiety symptoms that will be negatively evaluated.

• Social situation brings about fear or anxiety
  
  • Child may express with crying, tantrums, and freezing
• Social situations almost always provoke fear/anxiety.
• Fear/anxiety out of proportion to actually threat.
• Fear/anxiety/avoidance persistent (usually >6 months)
• Sig. Impairment, not explained by other disorder

Question 8

Social Anxiety Disorder (Social Phobia) - Prevalence

Answer 8

• About 1% in female and male children and adolescents

- Up to 13% lifetime

Question 9

Social Anxiety Disorder (Social Phobia) - Treatment Approaches

Answer 9

• Self-Instructional Training and Imaginable Desensitization
  
  • Construct Hierarchy of social fears
  • Teach self-instructional training
  • Implement imaginable desensitization
• Other interventions include:
  
  • Exposure to social situations and social skills training,
  • Relaxation,
  • Self-coping statements, and
  • Rewards

Question 10

Panic Disorder

Answer 10

• Recurrent unexpected panic attacks
  
  • Intense fear or discomfort in which 4 of the following occur abruptly and peak within ten minutes:
    
    • Racing heartbeat,
    • sweating,
    • trembling,
    • shortness of breath,
    • choking,
    • chest pain,
    • tummy ache,
    • dizziness,
    • fear of dying,
    • paresthesia (numbing or tingling),
    • chills, or
    • hot flashes
• At least 1 attack followed by 1 month of at least 1 of the following:
  
  • Persistent concern about having another attack,
  • worry about consequences of attack, or
  • change in behavior due to attacks

Question 11

Agoraphobia

Answer 11

• Fear/anxiety re. 2 or more:
  
  • Public transportation,
  • open spaces,
  • enclosed spaces,
  • standing in line or being in crowd,
  • being home alone
• Avoids/fears aforementioned due to not being able to escape or fear of embarrassing oneself if panic symptoms occur.
• Agoraphobic symptoms provoke anxiety.
• Fear/anxiety out of proportion to actual danger in situation.
• Fear/anxiety/avoidance persists, usually >6 mos.
• Impairment, not due other disorder
• Usually in adolescents, rarely seen in pre-pubertal children.

Question 12

Panic Disorder and Agoraphobia - Prevalence

Answer 12

• 3:1 women to men with agoraphobia
• 2:1 women to men without agoraphobia
• Lifetime prevalence of Panic Disorder is 2-3%, lower rates in most ethnic minorities, excepting Native Americans.
• 2% of adolescents (and adults) have Agoraphobia

Question 13

Panic Disorder and Agoraphobia - Treatment Approaches

Answer 13

• Exposure to interceptive anxiety cues (for those without agoraphobia)
  
  • Expose to anxiety provoking situations
  • Practice objective statements, attack misattributions and faulty thinking patterns
• Graduated exposure In Vivo (for those with agoraphobia)
  
  • Monitoring of all panic attacks (early signals, faulty thinking, alternative thinking, rating)
  • Cognitive restructuring during exposure trials
  • Rewards

Question 14

Post Traumatic Stress Disorder - Description of Disorder

Answer 14

• Exposure to traumatic event
  
  • Experienced/witnessed event involving actual, threatened or real injury to self or others
  • Response to event involved fear, helplessness, horror (or agitation or disorganized behavior in children)
• Experience 3 of following symptoms for at least 1 month:
  
  • 1) Re-experience of trauma
    
    • Recollections, young children might play repetitively along the lines of traumatic themes
    • Dreams of event (might be without recognizable content)
    • Feeling of reliving the experience, hallucinations, or dissociative flashbacks (may reenact)
    • Psychological distress for stimuli resembling the trauma
  • 2) Avoidance of stimuli associated with trauma
    
    • Effort to avoid thoughts, feelings, activities, or conversations associated with trauma
    • Inability to recall important aspects of the trauma
    • Feeling detached from others, restricted range of affect
    • Lack of interest in significant activities and sense of foreshortened future (no future career, marriage, etc.)
  • 3) Two persistent symptoms of increased arousal
    
    • Difficulty falling or staying asleep
    • Irritability, anger outbursts and exaggerated startle response
• Poor concentration and hyper vigilance

Question 15

PTSD - Prevalence

Answer 15

-1-14%

Question 16

PTSD - Treatment Approaches

Answer 16

• Early intervention as soon as possible (i.e., in hospital).
• Empathy for traumatic experiences
• Psycho-education
  
  • Explain how disorder occurs.
    
    • Physiological hyper arousal (neural pathways are created during trauma that sensitize the child to hyper-arousal/emotions)
    • Inform family and child for possible reactions or symptoms to trauma (overreaction, irritability, lack of intimacy)
• Teach child coping strategies
  
  • Relaxation and controlled breathing exercises, thought stopping when flashbacks occur, positive self-statements in anxiety provoking situations

-Open communication about event and related issues.

• Flooding or graduated imaginable exposure
  
  • Utilize relaxation exercises & process content reviewed during exposure trials
  • Stress management focusing on dysfunctional thoughts and false attributions

Question 17

Obsessive Compulsive Disorder - Description of Disorder

Answer 17

• Involves either or usually both of the following:
  
  • Compulsions
    
    • Repetitive behaviors (i.e.: washing, ordering, checking) or mental acts (i.e., praying, counting, repeating words), child feels compelled to do in response to obsession or rule.
    • Done to prevent anxiety or bad event (not connected in realistic way)
  • Obsessions
    
    • Recurrent unwanted thoughts, impulses, images, usually causing anxiety
    • Attempts to ignore or suppress thoughts, impulses, images or neutralize them w/ some other thought or behavior
    -*Impairment in functioning OR time consuming (1 hr. per day), & not explained by other disorder.

Question 18

Obsessive Compulsive Disorder - Prevalence

Answer 18

• 1% in adolescents, males > females in childhood (opposite in adults)
• Rare in children particularly below age 7
• Compulsions
  
  • Reported more often than obsessions
  • Most frequent: hand washing, grooming, repeated rituals, checking
• Obsessions
  
  • Most frequent: dirt, germs, orderliness, thought that something bad will happen

Question 19

Obsessive Compulsive Disorder - Treatment Approaches

Answer 19

• Exposure to obsessive situation and response prevention of compulsive behavior
• Teach family to ignore the compulsions
• Serotonin reuptake inhibitors
  
  • Clomipramine
  • Prozac
  • Zoloft

Question 20

Generalized Anxiety Disorder - Description of Disorder

Answer 20

• Excessive anxiety or worry about a # of events
• Difficult to control the worry
• 1 of the following for 6 months, more days than not (3 for adults):
  
  • Restlessness, keyed up/on edge
  • Easily fatigued
  • Poor concentration, mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance

-Impairment in functioning, not due to other disorder

• 1 of the most common anxiety disorders in adolescents
  
  • 9% lifetime

Question 21

Generalized Anxiety Disorder - Treatment Approaches

Answer 21

• Cognitive Behavior Therapy
  
  • Relaxation exercises (PMR/cue-controlled relaxation): assign homework to relax, provide rewards
  • Daily diary of situations that induce anxiety/worry
  • Example: (CHECK CHART ON SLIDE 24)
• Cognitive Restructuring
  
  • Review thought patterns associated with worry/anxiety
  • Discuss how each thought pattern is detrimental
  • Review alternative thinking patterns
    
    • Positive and negative self-statements
    • Thought stopping
  • Develop a plan to cope with anxiety situation and anxious thoughts
  • Establish a reinforcement

-Social skills training targeting assertion for underlying worries

Question 22

Chronic Motor or Vocal Tic Disorder (Tic Disorder)

Answer 22

• Single or multiple motor or vocal tics (sudden, rapid, recurrent, nonrythmic, sterotyped motor movements or vocalizations) but not both for 1 yr.
• Never a time of more than 3 months without a tic during 1 yr. Of the tic disorder.
• Causes distress or impairment
• Onset prior to 18
• Not due to substance or medical condition
• No tourette’s disorder

Question 23

Transient Tic Disorder (Tic Disorder)

Answer 23

-Occurs for at least 4 weeks but less than 12 months

• Symptoms the same as chronic motor or vocal tic disorder
  
  • Onset before 18 years
• Prevalence
  
  • 2x more likely in males, about 1 in 2,000 have Tourette’s
• Treatment
  
  • Habit reversal

Question 24

Tourette’s Syndrome (Tic Disorder)

Answer 24

• Neurological disorder characterized by repetitive, stereotyped, involuntary movements and vocalizations called tics.
• Must have had multiple motor and at least 1 vocal tic.
• Onset between ages 7-10 yrs.
• Males affected 3-4x more than females
• Approx. 200,000 Americans have TS (can be genetic/hereditary)
• Tics are often worse with excitement or anxiety and better during calm, focused activities
• Related to OCD and ADHD
• Types:
  
  • Simple tourettes
  • Complex tourettes

Question 25

Simple Tourette’s (Tic Disorder)

Answer 25

• Motor tics are sudden, brief, repetitive movements that involve a limited number of muscle groups.
  
  • Simple tics include eye blinking, facial grimacing, shoulder shrugging, head or shoulder jerking.
  • Simple vocalizations might include repetitive throat-clearing, sniffing, or grunting sounds.

Question 26

Complex Tourette’s (Tic Disorder)

Answer 26

• Tics are distinct, coordinated patterns of movements involving several muscle groups
  
  • Include facial grimacing combined with a head twist and a shoulder shrug

-Other complex motor tics may actually appear purposeful, including sniffing or touching objects, hopping, jumping, bending, or twisting

Question 27

Tourette’s Syndrome - Treatment and Research (Tic Disorder)

Answer 27

• Abnormalities in basal ganglia, frontal lobes, and cortex
  
  • Specifically, circuits that connect these regions, & neurotransmitters (dopamine, serotonin, and norepinephrine) don’t function well.
• Treatments include:
  
  • Clonidine
  • Habit Reversal

Question 28

Tourette’s Syndrome - Website Information (Tic Disorder)

Answer 28

• Dr. Georges Gilles de la Tourette
• A neurological disorder characterized by repetitive, stereotyped, involuntary movements and vocalizations called tics
• Typically noticed first in childhood
  
  • Average onset between ages 3 and 9 years
• Occurs in all ethnic groups
• Males are affected about 3-4 times more often than females
• An inherited disorder
• Estimated that 200,000 Americans have the most severe forms of TS
  
  • As many as 1 in 100 exhibit milder and less complex symptoms, such as chronic motor or vocal tics

-Most people with the condition experience their worst tic symptoms in early teens, with improvement in late teens and continuing into adulthood

• Symptoms:
  
  • Tics are simple or complex
    
    • Simple motor tics - sudden, brief, repetitive movements that involve a limited number of muscle groups
      
      • Eye blinking and other eye movements
      • Facial grimacing
      • Shoulder shrugging
      • Head/shoulder jerking
    • Simple vocalizations might include
      
      • Repetitive throat-clearing
      • Sniffing
      • Grunting sounds
    • Complex motor tics - distinct, coordinated patterns of movements involving several muscle groups
      
      • Facial grimacing combined with a head twist and shoulder shrug
      • Other complex motor tics may actually appear purposeful (sniffing or touching objects, hopping, jumping, bending, or twisting)
    • Simple vocal tics
      
      • Throat-clearing
      • Sniffing/snorting
      • Grunting
      • Barking
    • Complex Vocal Tics - include words or phrases
    • Most dramatic and disabling tics include motor movements that result in self-harm (punching oneself in face) or vocal tics including coprolalia (uttering socially inappropriate words such as swearing ) or echolalia (repeating words or phrases of others)
  • Tics often worse with excitement or anxiety and better during calm, focused activities
  • Certain physical experiences can trigger or worsen tics (ex: tight collars may trigger neck tics, or hearing person sniff or throat-clear may trigger similar sounds)
  • Tics don’t go away during sleep, but are often significantly diminished
• Causes:
  
  • Current research points to abnormalities in certain brain regions (basal ganglia, frontal lobes, and cortex), circuits that interconnect these regions, and neurotransmitters (dopamine, serotonin, and norepinephrine) responsible for communication among nerve cells
• Disorders associated with TS:
  
  • Additional neurobehavioral problems that often cause more impairment than the tics themselves
    
    • ADHD
    • Problems with reading, writing, arithmetic
    • OCD symptoms, such as intrusive thoughts/worries and repetitive behaviors
  • Depression or anxiety disorders (and other difficulties with living that may or may not be directly related to TS)
  • Although most individuals with TS experience decline in motor and vocal tics in late adolescence and early adulthood, the associated neurobehavioral conditions may persist
• Treatment:
  
  • Since tic symptoms often don’t cause impairment, majority of people with TS require no medication for tic suppression
    
    • There are effective medications for those whose symptoms interfere with functioning (neuroleptics)
  • Behavioral treatments, such as awareness training and competing response training, can also be used to reduce tics
    
    • Cognitive Behavioral Intervention for TICS (CBIT) - showed that training to voluntarily move in response to a premonitory urge can reduce tic symptoms
    • Other behavioral therapies, such as biofeedback or supportive therapy, have not been show to reduce tics
  • Supportive therapy can help person with TS better cope with the disorder and deal with secondary social and emotional problems that sometimes occur

Question 29

Childhood-Onset Fluency Disorder (Stutter) - Description of Disorder

Answer 29

• Abnormal fluency/time patterning of speech not developmentally appropriate.
• Frequent repetitions or prolongations of speech sounds
• Broken words (pause w/in a word)

Silent blocking (unfilled blocking in speech)

• Word substitutions to avoid difficult words
• Monosyllabic whole word substitutions (He He He is…)
• Causes anxiety about speaking or limits effective communication or life experience
• Onset in early development period

Question 30

Childhood-Onset Fluency Disorder (Stutter) - Other Diagnostic Issues

Answer 30

• Usually begins between age 2-7 yrs.
• Most young children go through stage of stuttering.
• Most kids are unaware of stuttering AT FIRST
  
  • Awareness increases as age; 57% in 2-year olds, 90% by 7 years.

-Children young as 3 yrs. evaluated speech disordered puppets negatively; 47% chose fluent puppet over stuttering puppet at age 3 yrs., 69% at age 4 yrs., 88% at 5 yrs.

Question 31

Childhood-Onset Fluency Disorder (Stutter) - Is Stuttering Something Parents Should Worry About?

Answer 31

• Most stuttering (about 60%) remits on its own by 16 yrs.

- 80% remit at some point in their lives

Question 32

Childhood-Onset Fluency Disorder (Stutter) - Prevalence

Answer 32

• Prevalence: 1%

- 3:1 males to female ratio

Question 33

Childhood-Onset Fluency Disorder (Stutter) - Treatment

Answer 33

• Regulative breathing
• Recognize when stuttering is most likely (reading, speech, nervous, etc).
• Take ¾ breath prior to breathing.
• Practice exhaling while speaking/reading

Question 34

Rumination Disorder - Description of Disorder

Answer 34

• Repeated regurgitation and rechewing of food for at least 1 month after eating.
  
  • Food may be swallowed or expelled following rechewing
• Not due to a medical condition.
• Does not occur exclusively during the course of anorexia or bulimia nervosa

Question 35

Rumination Disorder - Health Risks

Answer 35

• Rumination may result in
  
  • malnutrition
  • decreased resistance to disease
  • dehydration
  • esophagitis (inflammation of the esophagus)
  • tooth decay

Question 36

Rumination Disorder - Prevalence

Answer 36

• More common in males than females, rare, usually occurs during infancy.
• More common with mental retardation.
• As the disorder is often outgrown, and causes embarrassment in older individuals, true numbers of prevalence are unknown

Question 37

Rumination Disorder - Treatment Approaches

Answer 37

• DRO: Positive strokes and praise when rumination is not present and withdrawal of attention when rumination is observed.
  
  • E.g. Play a Barney video while child is eating normally, and turn off while rumination is present.
• Aversive conditioning: Effective with infants, “No” followed by application of lemon juice to the tongue.
• Make child assist in cleaning up floor, etc. when food is spit out. This can be used to help teach the child why rumination is not acceptable.

Question 38

Rumination Disorder - Treatment Approaches for Rumination When Children Evidence Intellectual Disorder

Answer 38

• As infants ruminate to seek stimulation, it is often outgrown after infancy.
• Rumination in those w/ intellectual disorder or autistic spectrum disorders is less likely to remit, and may individuals may continue to seek stimulation into adulthood. Other treatments may be required to stop tooth decay and other health risks. As such approaches can be used that provide appropriate and harmless stimulation.
• Starch Satiation and Mini-Meals (Not sure?)
  
  • Patients are given unlimited access to starchy foods, typically immediately after meals.
  • Several studies have demonstrated this to be an effective treatment w/ long-lasting effects.
  • Mini-meals

Question 39

Rumination Disorder - Starch Satiation and Mini-Meals

Answer 39

• Patients are given unlimited access to starchy foods, typically immediately after meals.
• Several studies have demonstrated this to be an effective treatment w/ long-lasting effects
• Mini-meals

Question 40

Rumination Disorder - Concluding Comments

Answer 40

• Although true figures regarding rumination are unknown, it is more common in males, and most common in infants and the mentally retarded.
• Rumination will often remit in regular infants.
• Rumination can have severely negative physical health risks.
• Treatments can be conceptualized into two groups, aversive approaches, which cause annoyance/displeasure to discourage the behavior, and stimulation based approaches which seek to replace rumination with less harmful and more acceptable stimulation