Lecture 16, 17, 18 + 19 - Anxiety Disorders Flashcards
When does anxiety (fear) become a disorder?
•Fear is a normative developmental event
It’s a disorder when it prevents them from everyday activities and cause impairment
What is included under DSM-V anxiety disorders?
- GAD, social phobia, specific phobia, panic disorder, SAD, Selective mutism, agoraphobia
what is Heller’s dimensional approach?
Two dimensions:
- Anxious arousal: somatic symptoms and acute fear
ex: panic disorder, phobias - Anxious apprehension: worry and fear of catastrophic consequences
ex: GAD, OCD
What is the Penn State Worry Questionnaire for Children
A way to measure anxious apprehension
what is the dimensional approach?
Child Behavior Checklist
Major features of SAD (separation anxiety disorder)
Developmentally inappropriate and excessive anxiety concerning separation from home or from whom they’re attached to - as evidenced by 3 symptoms…
Has to be present for at least 4 weeks in kids and 6 weeks in adults.
Prevalence and characteristics of SAD
4-13% prevalence
Age of onset: 7-8 y.o
•Good prognosis, but it is common to go on to development other disorders, particularly panic disorder
•Often triggered by negative life event (death of a family member, etc)
Major features of GAD (generalized anxiety disorder)
Disorder of worry
•Prevalence 3% to 6%
•Onset typically 10-14 years of age
•In young children, often comorbid with SAD and ADHD
•In older children, often comorbid with depression and specific phobias
•Severe GAD tends to persist over time, and is associated with poor social adjustment, low self-esteem and increased risk for suicide
Major features of Specific Phobias
- Marked fear or anxiety about a specific object or situation (e.g. flying, heights, animals, receiving an injection, and seeing blood)
- Exposure to the phobic stimulus almost always provokes an immediate anxiety response
- The phobic situation is avoided or endured with intense fear or anxiety
- The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context
- The fear, anxiety, or avoidance is persistent, typically lasting 6 months or more
- The fear, anxiety, or avoidance causes clinically significant impairment in social, occupational, or other important areas of functioning
- Extreme, disabling fear of specific objects or situations that pose little or no danger
- Often leads to avoidance or disrupted routines
- Children may not realize the fear is extreme and unreasonable
- 5 general subtypes: animal, natural environment, blood-injection-injury, situational, “other”
- 4-10% of children
- Most childhood phobias have an onset between 7 and 9 years of age
Social Phobia major features
- Marked, persistent fear of being the focus of attention or doing something humiliating.
- Children with social phobias are more likely to be highly emotional, socially fearful and inhibited, sad, and lonely
- Lifetime prevalence is 7-9 % of children and adolescents; more common in girls (2 X)
- Age of onset often early to mid-adolescence
Panic disorder major features
• Panic disorder is defined as having recurrent unexpected panic attacks followed by at least 1 month of either
- persistent worry about having another attack
- persistent worry about the consequences of the attack
• A significant change in behavior (avoidance of situations where panic attack may occur)
• PD with agoraphobia: fear of having an attack in a situation where escape may be difficult or help unavailable (i.e. driving alone, going out in public places alone). —>In DSM-5, this is now called “agoraphobia”
• Prevalence 1-5%, although the occurrence of a panic attack is not uncommon (35%-65% of adolescent report at least one attack)
• Onset almost exclusively in adolescence, onset of 1st panic attack typically 15-19 yrs of age
• Worst prognosis of all anxiety disorders
OCD (obsessive compulsive disorder) Major Features
- Lifetime prevalence around 2-3% of children; twice as likely in boys
- Onset typically 9-12 years of age
- Most common obsessions are concerns with dirt, germs or toxins, and something terrible happening (i.e. accidents, fire, death in the family)
- Most common compulsions are excessive washing, repeating actions (going through a door multiple times), and repeated checking.
- Comorbid disorders include other anxiety disorders, depression, Tourette’s Syndrome, as well as externalizing disorders
- Chronic course
Developmental sequence of Anxiety Disorders
SA -> Specific Phobia -> OCD -> GAD –> Social Phobia —–> Panic disorder
This is time/age based.
How common are anxiety disorders?
Prevalence of any anxiety disorder in children and adolescents is high (5.7% -17.7%)
Most common:
SAD, specific phobia, GAD
Least common But most severe**:
PD, OCD
Comorbidity of anxiety disorders?
Estimates of comorbidity are approximately 60%, with disorders like GAD at around 90%
Life course outcomes of young people with anxiety disorders
Explain the study.
New Zealand - Longitudinal
Longitudinal study of a full birth cohort (n=1265) born in 1977
• Followed from birth to adulthood
• 24% Attrition
•Asked whether having an anxiety disorder in adolescence (14-16 yrs) was a risk factor for problems in early adulthood (16-21 yrs)
CONCLUSIONS
- risk factor for psychopathology and a host of psychosocial problems
• However, anxiety disorders are associated with all kinds of other risk factors such as family instability and low socioeconomic status
• risk factor for major depression, anxiety disorders, substance use problems, and less education in early adulthood
• This evidence is extremely important if one is to argue a need for early prevention and treatment of childhood anxiety disorders
Etiology of anxiety disorders
• Prevailing view is that anxiety disorder arises from a combination of temperamental factors and early psychosocial influences
What is different in temperament of kids with anxiety disorders?
behavioral inhibition and withdrawal( that is, a tendency to show much fear and distress when faced novel, unfamiliar objects, persons, or situations)
How early can you detect anxiety?
If you look at temperament of babies (1.5 y.o) you can get an idea
What factors are predictors?
Child temperament: “Difficult” temperament at 5 months of age
Lifetime history of maternal depression
What is a developmental sequence of bad temperament and mother’s depression?
Maternal depression/anxiety –> Temperament (also affected by environment such as parents, stress exposure, adversity) –> elevated anxiety in childhood (also affected by env.) –> childhood anxiety disorders (aso env.) –> adult major depression/anxiety OR other problems
What effect does the temperament of “Behavioural inhibition (BI) have?
- Temperamental trait, can be assessed by 20-30 months of age (Jerome Kagan)
• Describes 15%-20% of toddlers
• Show elevated physiological reactivity (cardiac and stress hormone elevations)
• Longitudinal studies show that increased risk for anxiety disorders (particularly social phobia) in adolescence
• Odds ratio for social phobia: 2.0 -4.0
How is BI expressed across lifetime?
INFANCY: high distress to novelty
TODDLERS: Classic BI, slow to approach, avoidance
EARLY CHILDHOOD: Shy and withdrawn
LATER CHILDHOOD + ADOLESCENCE: anxiety disorders, particularly social phobia
Amygdala activation and BI
Novelty activates this area
- people with BI had even greater changes in amygdala when presented a novel stimuli
What is the Behavioral inhibition model of Anxiety disorders
Behavioral inhibition –> Withdraw, avoid, less socially competent OR Attentional biases to threat
Withdraw, avoid, less socially competent –> Peer rejection
Attentional biases to threat –> Increased sensitivity to signs of rejection
ALL this leads to: Negative self-perceptions –>
Increased avoidance/withdrawal and anxiety disorders
What are some tests to assess anxiety?
Stroop effect (colour and words different)
OR emotional stroop task (meaningful words - measures attentional bias)
Dot probe task - have four boxes and two words, focus on word where cue is
Results of tests
Dot probe:
Reaction time is faster when there’s one neutral word and one meaningful negative word and the cue is on the meaningful word (compared to 2 neutral words)
Reaction time is slower when there’s one neutral word and one meaningful negative word and the cue is on the neutral word (compared to 2 neutral words) —-> because focus on meaningful
Also: Controls had same attentional bias - threat words or depressed words depression: avoid to depressed words GAD: attentional bias to threat words PTSD: avoid depressed words
Does BI predict social withdrawl?
BI predicted social withdrawal in those children who showed attentional biases to threat, but BI did not predict social withdrawal in those who showed no attentional bias
Explain attentional bias, interpretation bias, activation of schemas and behavioural response
Example:
Attentional Bias:
•Fast to detect signs of threat in the schoolyard
•Slow to disengage from threat
Interpretational Bias:
•More likely to interpret ambiguous information as threatening
Activation of Schemas:
•World is a dangerous place
•People want to hurt me
•I have little control over what happens to me
Behavioural Response:
•Avoidance -staying away from other kids, makes me safe.
•Non-assertive and lacking social skills–more likely to be refused, teased, etc
Summary of Developmental Trajectories
- Early antecedents of anxiety-Behavioral inhibition
- High sensitivity in the amygdala and behavioral inhibition
- Probably a general risk for anxiety/depression, but some anxiety disorders have specific neurobiological substrates
- Information processing and attentional bias: Possibly associated with the increased sensitivity in the amygdala, and it is an antecedents of later cognitive abnormalities and avoidance
Evidence of a brain dysfunction in OCD
- cortico-striato-thalamocircuit
• Basal ganglia (caudate nucleus, putamen)
• Orbital frontal cortex
• Cingulate
• Thalamus
• Important neural circuit linking the orbital frontal cortex to the thalamus
• The circuit appears abnormally active
• Hypothesized to disrupt inhibition or filtering of information
Are anxiety disorder due to genetic factors?
- A small but substantial genetic component (h2: 25-37%)
- Probably refers to temperament, behavioral inhibition
- Sensitivity in limbic pathways, such as the amygdala (propensity to experience fear)
- OCD has a stronger genetic component, h2: 40-50%)
Three important influences for Anxiety Disorders
Learning mechanisms
Insecure attachment
Parenting
how do learning mechanisms work
- Direct experience: bitten by a snake
- Indirect experience: modelling and vicarious learning (watching father/mother express fear of snakes)
- Transmission of information: hearing frightening stories
How do insecure attachments influence?
Elevated childhood anxiety disorders in insecurely attached children than those securely attached
• early insecure attachments lead children to view the environment as undependable, unavailable, hostile, and threatening
How does parental factors influence
- Perceived overprotection (high control) and criticism/rejection
- Meta-analysis (McLeod et al, 2007) indicates that parenting is important (significant), but only modestly (small effect size)
- Control > rejection
- Evidence that parents reinforce avoidant coping, and model anxious behaviors
- For social phobia, social isolation may play a role
what treatment is used for anxiety disorders
SSRIs BUT, none really APPROVD for use in kids... These are the only APPROVED: Fluoxetine (Prozac)MDD, OCD •Sertraline (Zoloft) OCD •Fluvoxamine (Luvox)OCD •Clomipramine (Anafranil)OCD
Study treatment differences between CBT, meds, combination and control
- Percentage improved:
- Combination therapy: 81%
- CBT: 60%
- Sertraline: 55%
- Placebo: 24%
- Combination therapy significantly better than both treatments alone
- All treatment were better than placebo
- Less adverse events (serious side effects) with CBT than sertraline
Critique of treatment outcome studies
Sometimes there’s invested interest for medications (funded by companies)
CBT
• CBT aims to understand how maladaptive thinking contributes to anxiety, and attempts to provide news of responding to external and internal stimuli that elicit anxiety • CBT includes a number of techniques and strategies (exposure, modeling, identifying anxious thoughts) - Leads to cognitive restructuring - Coping cat: FEAR F: Feeling frightened? E: Expecting bad things? A: Actions and attitudes that can help R: Results and Rewards
Exposure Therapy
- Exposure and response prevention (ERP) is as efficacious in treating OCD as medications
- Each time someone responds with a compulsive behavior (hand washing) when they have an obsessive thought(contagious germs), anxiety decreases and the behavior is reinforced
* Negative reinforcement - ERP is meant to reverse this process through the principles of habituation and extinction
* anxiety will decrease following repetitive exposures to the feared stimulus - a behavior that is no longer reinforced will decrease
- ERP also provides corrective learning experience, in that the feared outcome (becoming ill by touching a dirty glass) never occurs
- Exposure is used for all anxiety disorders, particularly with OCD, the phobias and PTSD
