Lecture 9 Flashcards
Anxiety
Anxiety is a mood state characterized by:
Strong negative emotion
Bodily tension
Anxiety disorders involve experiencing chronic, excessive, and debilitating anxieties
Anxiety is a mood state characterized by:
Strong negative emotion
Bodily tension
Anxiety disorders involve experiencing chronic, excessive, and debilitating anxieties
Mood state occurs in anticipation or in fear of negative events or future outcomes
Anxiety is normal
Anxiety disorder prevelant- one child in each classroom- 6-30%
Highly comorbid- experience one anxiety disorder= more likely to experience another anxiety disorder
Amygdala- controls fight. Vs flight
Fear causes paralysis- freeze
Anxiety- what is happening will hurt you- in survival mode
Frontal lobe cant be accessed during this state- cant organize info, higher cognitive thinking
Physical- sweating
Behavioural- freezing
Cognitive- cant focus, cant plan
Moderate anxiety helps us think and act more effectively
Excessive, uncontrollable anxiety can be debilitating
Neurotic paradox
Image= anxiety across continuum helpful vs not
Low levels- not attend or focus on task at hand
Stronger levels= more difficult to perform
Neurotic paradox- feeling anxiety does not feel good and those who feel anxious cant control it- know it is uncomfortable but cant stop the feeling
Fight-Flight-Freeze
Functional Goal: signal danger and mobilize response to escape potential harm
Our bodies automatic response to threat/danger
Goal= maximize survival
Physical System and Symptoms
The brain sends messages to the sympathetic nervous system, which produces the fight/flight response
Inc heart rate, difficulty breathing, stomach upset, sweating Mobilizes body for action- produces chemical and physical ffects
Cognitive System and Symptoms
Fight/flight system activation leads to search for threat, which can lead to thoughts of apprehension, nervousness, difficulty concentrating, and panic
Overthinking, difficulty concentrating, images of harm Actively searching for threat- when not found- causes panick= turn anxiety inward and have distorted though of situation
Behavioral System and Symptoms
Aggression (fight) is coupled with a desire to escape (flight) the threatening situation
Avoidance, clenched jaw, nail biting
Modern societies- not adapted to fight or avoid negative situation- see desire manifest differently
Letting aggression/ avoidance out in other way
Fear vs anxiety
Anxiety is not fear
Fear= immediate response to a fear- need to respond to protect yourself
Anxiety- informs us important event/ danger may happen- prepare a for future/ prepare for negative event
Panic
A group of physical symptoms of the fight/flight response that unexpectedly occur in the absence of obvious danger or threat
Include shaking, disorientation, rapid heartbeat
May feel something is happening to you- triggering anxiety
Usually short- 10-30 min
Normal Fears, Worries, and Anxieties
Moderate fear, worry, and anxiety are adaptive; thinking of and planning for possible negative outcomes can help children prepare for the future
Anxieties are common during childhood and adolescence:
Separation anxiety- linked to healthy attractiveness
Anxiety about harm to a parent
Test anxiety
Excessive need for reassurance
Difficult to recognize those with anxiety disorder- internallly felt
When anxiety becomes excessive = cause for concern
Rituals and Repetitive Behavior
Normal routines help children gain control and mastery of their environment, and make the environment more predictable and “safer”
Ritualistic, repetitive activity is common in young children and often falls into 2 categories:
Repetitive behaviors
Doing thing’s just right
Normative in many ways- provide stable routine= support safety in children
1- desire to watch same movie over nad over, same bed time routine
2- wanting food to not touch
In excess- relates to ocd
Common fears and anxiety
2-3= Fears of thunder and lightning; fire; water; darkness nightmares;
Crying; clinging; withdrawal; freezing; avoidance of salient stimuli; night terrors
Specific phobias (natural environment); panic attacks;
Specific phobias (animal)
4-5= Separation from parents; fear of death or dead people Excessive need for reassurance
Separation anxiety disorder; generalized anxiety disorder; panic attacks
5-11= School anxiety; performance anxiety; extreme shyness with Social anxiety disorder physical appearance; social concerns unfamiliar adults and peers; (social phobia)
feeling of shame
12-18= Personal relations; rejection from peers; Fear of negative evaluation Social anxiety disorder personal appearance; future; natural (social phobia) disasters; safety
Separation Anxiety
Separation anxiety is important for young children’s survival
Separation anxiety is normal from about ages 7 months through the preschool years
Lack of separation anxiety during this time may suggest insecure attachment
Excessive worry regarding separation from home and parent
Experience distress and somatic symptoms when seperated. Experience excessive worry about harm to attachment figures
Beyond this age= not adaptive
Diagnostic Criteria for Separation Anxiety Disorder
Recurrent excessive distress when anticipating or experiencing separation from home or major attachment figures.
Persistent or excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
Persistent and excessive worry about experiencing an
untoward event (e.g., getting lost, being kidnapped,
having an accident, becoming ill) that causes separation from a major attachment figure.
Persistent reluctance or refusal to go out, away from
home, to school, to work, or elsewhere because of fear of separation.
Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.
Repeated nightmares involving the theme of separation.
Repeated complaints of physical symptoms (e.g., headaches, stomachaches, vomiting) when separation from major attachment figures occurs or is anticipated.
The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children
and adolescents and typically 6 months or more in adults.
The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.
The disturbance is not better explained by another mental disorder
Exception- cant be diagnosed during first 4 weeks of new school year- anxiety normal during this time
Separation anxiety Prevalence, Comorbidity, Onset, & Course
Separation anxiety disorder is 1 of the 2 most common childhood anxiety disorders (specific phobia is the other)
Prevalence: Occurs in 4–10% of children worldwide (more prevalent in girls)
Comorbidity: 67% also have another anxiety disorder; 50% have depression
Earliest age of onset of anxiety disorders: 7–8 years (often after a major stress)
Course: progresses from mild to more severe; persists into adulthood for 1 in 3
Earliest age of onset
Mild= harmless request for attention, nightmares to refusing to sleep without parent, refusing to seperate
School Reluctance and Refusal
Refusal to attend classes or difficulty remaining in school for an entire day
Equally common in boys and girls
Occurs most often in ages 5–11
Fear of school may be fear of leaving parents (separation anxiety), but can also occur for other reasons
Often associated with separation anxiety
Fear of school- manifest as fear of separation
Treatment- emphasizes returning to cool and reasons behind refusal
Specific phobia
Have extreme/dabbling fear of specific objec/ situation
Evolutionary theory of fear
Human infants are biologically predisposed to learn certain fears that alert them to possible sources of danger
Typically- naturally occurring things encountered during unman evolution- snakes, heights
Theory of fear= reason why most phobia- present ads fear of natural environment and predators
Diagnostic Criteria for Specific Phobia
Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.
The phobic object or situation almost always provokes immediate fear or anxiety.
The phobic object or situation is actively 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 distress or impairment in social, occupational, or other important areas of functioning.
The disturbance is not better accounted for by another mental disorder
Children vs adult- children less likely to recognize fear is excessive
State subtype of phobia
Animal
Natural environment
Blood
Situational
Other
Prevalence, Comorbidity, Onset, & Course
Specific phobia
Specific phobia is 1 of the 2 most common childhood anxiety disorders (separation anxiety disorder is the other)
Prevalence: 20% of children experience specific phobias (usually more common in girls)
Comorbidity: common, but less common than is seen in other anxiety disorders
Onset: 7-9 years for phobias involving animals, darkness, insects, blood, and injury
Course: Clinical phobias are more likely than normal fears to persist over time
Social Anxiety Disorder (Social Phobia)
Extreme fear of social or performance requirements that expose child to scrutiny and possible criticism
Public speaking, performing, talking to others
Diagnostic Criteria for Social Anxiety Disorder (Social Phobia)
Marked fear or anxiety about 1 or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation), being observed (e.g., eating, drinking), or performing in front of others (e.g., giving a speech).
The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating/embarrassing; will lead to rejection/offend others).
The social situations almost always provoke fear or anxiety.
The social situations are avoided or endured with intense fear or anxiety.
(I) Fear, anxiety, or avoidance not better explained by another mental disorder.
For children- most occur in peer setting not just with adults
Fear is out of proportion of social situation
Last for 6 months or more
Specify if
Performance only: If the fear is restricted to speaking or performing in public
Prevalence, Comorbidity, Onset, and Course
Social anxiety
Prevalence: lifetime prevalence of 6–12% of children (2x as common in girls)
Comorbidity:
2 in 3 children with social phobia also have another anxiety disorder
2 in 5 also have major depression
Onset: early to mid-adolescence (rare under age 10)
Course: average duration: 20–25 years
Selective mutism
Consistent failure to speak when expected to- occurs even though child may speak in limited situations
Highly comorbid with social anxiety disorder
Diagnostic Criteria for Selective Mutism
Failure to speak in in certain social situations where there is an expectation to speak (e.g., at school) despite speaking in other situations
Interferes with the child’s education or social communication
Has been present for at least 1 month
Not attributable to a lack of knowledge or lack of comfort with the language in use
The issue is not better explained by communication disorder
Prevalence, Comorbidity, Onset, & Course
Prevalence: estimated to occur in 0.7% of children
Comorbidity: other anxiety disorders (social phobia and specific phobia). Selective mutism may be an extreme type of social phobia.- oppositional- more common in mutism, trauma may be a factor
Onset: ~3–4 years (early childhood)
Course: variable course; some “outgrow”
Prevalence, Comorbidity, Onset, & Course
Selective mutism
Prevalence: estimated to occur in 0.7% of children
Comorbidity: other anxiety disorders (social phobia and specific phobia). Selective mutism may be an extreme type of social phobia.- oppositional- more common in mutism, trauma may be a factor
Onset: ~3–4 years (early childhood)
Course: variable course; some “outgrow”
Panic disorder
Frequent panic attacks and feelings of terror- strike repeatedly and unexpectedly
1 month of fear after
Diagnostic Criteria for Panic Disorder
(A) Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time 4 (or more) of the following symptoms occur:
Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sensations or shortness of break or smothering.
Feelings of choking.
Chest pain or discomfort.
Nausea or abdominal distress.
Feeling dizzy, unsteady, light-headed, or faint.
Chills or heat sensations.
numbness or tingling sensations.
Derealization (feelings of unreality) or depersonalization (being detached from oneself).
Fear of losing control or going crazy.
Fear of dying.
At least 1 of the attacks has been followed by 1 month (or more) of 1 or both
of the following:
Persistent concern about additional panic attacks or their consequences (e.g., losing control, having a heart attack)
Significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
The disturbance is not attributable to the physiological effects of a substance (e.g., medication) or another medical condition.
The disturbance is not better accounted for by another mental disorder.
Panic disorder Prevalence, Comorbidity, Onset, & Course
Prevalence: panic attacks: 16%; panic disorder: 2.5% (more common in girls)
Comorbidity: most have another anxiety disorder or depression (mania, hypomania, ADHD, and ODD, and substance abuse also co-occur)
Onset: adolescence (first panic attack ~15–19 years); 95% post-pubertal
Course: tends to be stable over time, rates of complete remission are low
Rare in children- puberty may play role in panick attack
Agoraphobia
Used to be under panic disorder
May develop as complication from panick disorders- associated attack with situation and event
Fear and avoiding situations that cause panick and trap- because cant get help
Marked fear or anxiety in certain places or situations (i.e., being in a crowd, being outside the home alone, using public transportation, being in enclosed spaces)
The individual fears or avoids these situations due to thoughts that escape might be difficult, or help may not be available if they experience panic-like or other incapacitating symptoms
Now thought to be distinct from panic disorder
Diagnostic Criteria for Agoraphobia
Marked fear or anxiety about 2 (or more) of the following 5 situations:
Using public transportation (e.g., cars, buses, trains, ships, planes)
Being in open spaces (e.g., parking lots, grocery stores, bridges)
Being in an enclosed place (e.g., shops, theaters)
Standing in line or being in a crowd
Being alone outside the home
The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms
The situations almost always provoke fear or anxiety
The situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety
The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.
The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
The fear, anxiety, or avoidance causes clinically significant distress or impairment in social or occupational, or other important areas of functioning.
If another medical condition is present, the fear, anxiety, or avoidance is clearly excessive.
The fear, anxiety, or avoidance is not better explained by another mental disorder.
Agoraphobia Prevalence and Comorbidity
Prevalence: 2.5% of children ages 13–17
Comorbidity: anxiety disorders (panic disorder, specific phobias, social phobia), major depressive disorder, PTSD, and alcohol use
Generalized Anxiety Disorder (GAD)
Focus is widespread- variety of life events and activities – worry about grads, safety, relationships
Was referred to as free floating anxiety- but have many focuses of anxiety
Diagnostic Criteria for Generalized Anxiety Disorder
Excessive anxiety and worry (apprehensive expectation) occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
The individual finds it difficult to control the worry.
The anxiety and worry are associated with 3 (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required for children.
Restlessness or feeling keyed up or on edge.
Being easily fatigued.
Difficulty concentrating or mind going blank.
Irritability.
Muscle tension.
Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep).
The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The disturbance is not due to the general physiological effects of a substance (e.g., medication) or another medical condition.
The disturbance is not better explained by another mental disorder.
Prevalence, Comorbidity, Onset, & Course
Generalized anxiety disorders
Prevalence: lifetime prevalence is 2% for ages 13–18 (equally common in boys and girls)
Comorbidity: high rates of other anxiety disorders and depression
Onset: early adolescence
Course: Symptoms persist over time; 50% of severe cases are diagnosed again 2 years later; rates of full remission are low
OCD
Used to be an anxiety disorder
Characterized by recurrent, time-consuming (> 1 hour per day), and disturbing obsessions and compulsions:
Obsessions: persistent and intrusive thoughts, urges, or images that are experienced as intrusive and unwanted
Compulsions: repetitive, purposeful, and intentional behaviors or mental acts performed to relieve anxiety (in an effort to neutralize obsessions)
OCD cycle
Anxiety causes behaviour- which are done to relieve anxiety- not permanent= continuous pattern
Diagnostic Criteria for OCD
Presence of obsessions, compulsions, or both. Obsessions defined by (1) and (2):
Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
Compulsions defined by (1) and (2):
Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., medication) or another medical condition.
The disturbance is not better explained by another mental disorder.
Specify if:
With good or fair insight: Individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.
Specify if:
Tic-related: The individual has a current or past history of a tic disorder.
Prevalence, Comorbidity, Onset, & Course
OCD
Prevalence: Lifetime prevalence 1–2.5%
Comorbidity: most common are other anxiety disorders (ADHD, ODD, motor and vocal tics, depressive disorders, substance-use, learning and eating disorders also co-occur)
Onset: 9–12 years; 2 peaks (early childhood and late adolescence)
Course: Chronic disorder; 2 in 3 continue to have OCD 2–14 yrs after initial diagnosis
Cognitive disturbance
Disturbances in how information is perceived and processed
Deficits in memory & attention
Anxious vigilance or hyper vigilance
Catstrophizing and rumination
Evaluate non threatening events as threatening
Focus on potentially threatening stimuli
Helps to attune to potential threat- but over respond to threat
Interpreting threat to confirm danger bias
Continually think about negative event
Focus on negative- see them selves as controlless
Physical symptoms
Somatic complaints, such as stomachaches or headaches
Common in GAD, PD, and SAD (relatively less so in specific phobias)
90% of individuals with anxiety disorders have sleep-related problems
Physical manifestation of anxiety- caused by activated fights vs flight
High level of anxiety- reduce risky behaviour
Pay a toll in health related problems
Social and emotional deficits
Expect danger
Deficits in understanding emotion
Defificts in theory of mind
High levels of social anxiety, socially withdrawn, lonely, cant maintain relationships
Difficulties differentiating between thoughts and feelings
Cant recognize how others are feeling/ thinking
Anxiety to depression
In most cases, anxiety precedes and predicts depression
Anxiety and depression may form a single indistinguishable dimension in younger children, but are increasingly distinct in older children
Negative affectivity: persistent negative mood (e.g., sadness, anger, guilt)
Similar in depression and anxiety
Positive affectivity: persistent positive mood (e.g., joy, enthusiasm, energy)
Negatively correlated with depression, but independent of anxiety
In younger children- anxiety and depression very similar- becomes more distinct with age
Anxiety and depression associated with high negative affectivity
Anxiety= till show positive affectivity
Ethnicity and culture
The experience of anxiety is pervasive across cultures
Ethnicity and culture may affect the expression, developmental course, and interpretation of anxiety symptoms but research is limited
Behavior Lens Principle: child psychopathology reflects a mix of actual child behavior and the lens through which it is viewed by others in a child’s culture
Differences in stigma= causes differences in prevelance and diagnosis
Gender
By age 6, twice as many girls as boys have experienced symptoms of anxiety
Many disorders- higher prevalence in females
Theories
Psychoanalytic- anxiety and phobia caused by unconcious conflicts- caused in ealry childhood- regressed and placed on self
Behavioural and learning- anxiety is learned through conditioning and maintained through operant conditions
Attachement- fearfulness biologically routed in attachement
Need support to build trust in environment
Insecure attachment see environment as hostile and threatening and to not trust caregiver
Child temperament
Behavioral inhibition (BI): low threshold for becoming overexcited and withdrawing in response to novel situations or stimuli:
BI temperament places an individual at greater risk for anxiety disorders
~7x higher risk for developing social phobia
Genetic Risk and Family Factors
Family and twin studies suggest:
About 30–40% of the variance in childhood anxiety symptoms is genetic
Moderate level of heritability and leaves most individual differences in vulnerability to anxiety to environmental influences
Parenting practices
Excessive parental control: overinvolved, intrusive, limiting independence
Parental attitudes: low expectations for child’s coping skills, expect child to get upset
Accommodation- accomadting to child-perpetuate behavior and anxiety
Neurobiological Factors
Potential danger signals are monitored and sensed by the more primitive brain stem, which then relays the signals to the higher cortical centers through the limbic system
Behavioral inhibition system is believed to be overactive in children with anxiety disorders
Difficulty distinguishing between threat and safety cues
Threat-related appraisal biases
Behavioural inhibition- decrease behaviour impulse to avoid negative consequence
Heightened awareness of negative consequences
Treatment
Relatively ethical and effective
Expose child to anxiety
Often aim to modify 4 primary problems:
Distorted information processing
Physiological reactions to perceived threat
Sense of a lack of control
Excessive escape and avoidance behaviors- teaching alternatives
Most common
Behavior Therapy
Cognitive-Behavioral Therapy
Family Interventions
Medications
1- exposure therapy
Most effective=CBT- usually combined with exposure therapy
Behaviour therapy
Main technique is exposure to the feared stimulus while providing ways of coping other than escape and avoidance
About 75% of children with anxiety disorders are helped by this treatment
Graded exposure:
Construct anxiety hierarchy
Present anxiety-provoking stimuli sequentially
Systematic desensitization:
Teach the child to relax
Construct an anxiety hierarchy
Present anxiety-provoking stimuli sequentially while the child is relaxed
Differby element of relaxation
Gradual= no relaxation- gradually exposed to fear, come up with feared situation and rate it 0-10
Child exposed to situations least to most distressing
2- includes relaxation
- Flooding (i.e., massed exposure)
Typically used in combination with response prevention of preventing the child from engaging in escape or avoidance
Experience immediate exposure
Remains in anxiety- provide ratings as going- diminish anxiety over time
Participant modeling and reinforced practice:
Therapist models the desired behavior (e.g., approaching the feared object)
Therapist encourages and guides the child in practicing this behavior
Therapist reinforces the child’s efforts
Reducing physical symptoms of anxiety:
Muscle relaxation
Breathing exercises
Real-life or in-vivo
Virtual reality
Role playing
Imagining or observing others in contact with the feared object or situation (modelling)
All exposure procedures are effective but real-life works best
Cbt
The most effective procedure for treating most anxiety disorders
Almost always used along with exposure-based treatments
Teaches children how thoughts can contribute to anxiety and how to modify maladaptive thoughts to decrease symptoms
Child taught how thought contributes to anxity
Teach fear plan- recognizes feelings of anxiety
Help child recognize anxious cognitions
Next part= exposure to anxiety
Coping cat
71% of children no longer diagnoses with primary diagnosis at the end of treatment
For many children, these gains have been maintained for 7–19 years
after treatment
Family intervention
Child-focused treatments may have positive spillover effects into the family
Addressing children’s anxiety disorders in a family context can also support more lasting effects
Family treatment for OCD:
Provides education about the disorder
Helps families cope with their feelings
Using cbt and family=extremely beneficial
Medication
Medications can help reduce symptoms (seem to be most effective when combined with CBT)
Medications are particularly effective for OCD
The most common and effective medications are selective serotonin reuptake inhibitors (SSRIs)
