PSYC 211 - Anxiety Disorders (FIVE)

Anxiety

future-oriented mood state

Fear

present-oriented emotional reaction

Panic

a group of physical symptoms of fight/flight response

When may anxiety occur?

May occur in absence of realistic danger

When does fear occur?

Occurs in the face of a current danger and marked by a strong escape tendency

When does panic occur?

Unexpectedly occurs in the absence of obvious danger or threat

Typical developmental fears from birth-6 months

• Loud noises

• Loss of physical support

• Rapid position changes

• Rapidly approaching unfamiliar objects

Typical developmental fears from 7-12 months

• Strangers

• Looming objects

• Sudden confrontation by unexpected objects or unfamiliar people

Typical developmental fears from 1-5 years

• Stranger

• Storms

• Animals

• The dark

• Separation from parents

• Objects

• Machines

• Loud noises

• The toilet

• Monsters

• Ghosts

• Insects

• Bodily harm

Typical developmental fears from 6-12 years

• Supernatural beings

• Bodily injury

• Disease (AIDS, cancer, etc.)

• Burglars

• Staying alone

• Failure

• Criticism

• Punishment

Typical developmental fears from 12-18 years

• Tests and exams in school

• School performance

• Bodily injury

• Appearance

• Peer scrutiny

• Athletic performance

How do physiological symptoms make diagnosis of anxiety difficult for children?

Children with often mislabel physiological problems as symptoms (somatic complaints) and vice versa

4 ways to assess normality of child fears

1. Age of onset

2. Persistence

3. Intensity

4. Prevalence

Age of onset considerations when assessing normality of child fears

Look for an unusual age of onset of a specific fear (i.e. 10 year olds fear of dog is not normal but 2 year olds fear of dog is

Persistence considerations when assessing normality of child fears

Persistence of the fear beyond normal developmental occurrence

Intensity considerations when assessing normality of child fears

Incapacitating fears interfere with daily life (i.e. skipping school to avoid public speech)

Prevalence considerations when assessing normality of child fears

Some problems like agoraphobia are so rare, that when they do occur they are always considered a disorder

Phobias

excessive and unrealistic fears triggered by the presence of a particular situation or object

3 symptoms of phobias

1. Headaches

2. Dizziness

3. Stomach pains

3 types of phobias (with prevalences)

1. Specific (4-10%)

2. Social anxiety disorder (6%)

3. Agoraphobia (rare)

Specific phobias

Specific to an object or situation

Social anxiety disorder

Social or performance situation with strangers

Agoraphobia

Places or situation where it may be difficult to escape or in which help may not be available in the event of a panic attack

2 treatments of phobias (and which is the main treatment typically used for children?)

1. Systematic desensitization (main treatment for children)

2. Flooding

Systematic desensitization

exposure to feared stimulus while providing them with ways of coping other than escape and avoidance

Flooding

prolonged repeated exposure

Response prevention

Prevents child from engaging in escaping or avoidance stimuli

How do children make progress through systematic desensitization and/or flooding?

Modeling and reinforced practice

Selective mutism DSM-5 change

Selective mutism was moved into the Anxiety Disorders Section in DSM-5

4 symptoms of selective mutism

1. Difficulty starting conversations

2. Difficulty responding when people talk to them

3. Child may speak in some situations but not others

4. Child may communicate non-verbally (grunting, pointing, writing)

Selective mutism age of onset

Usually begins before age 5 but may not come to attention until entry in school

4 symptoms/effects of selective mutism (outside of diagnostic symptoms)

1. Social isolation

2. Compulsive traits

3. Temper tantrums

4. Mild oppositional behavior

3 DSM criteria for selective mutism

1. Duration >1 month

2. Impairs functioning

3. Not due to another speech/communication/developmental disorder

Selective mutism prevalence

About 1% (rare)

Main (general) form of treatment of selective mutism - and what other form of treatment may it incorporate?

Exposure/behavioral reinforcement - may incorporate systematic desensitzation

3 steps of talking ladder treatment method

1. Identifies situations where speaking is avoided

2. Guides exposures

3. Exposures will start with low avoidance situations and gradually move up the ladder

When do exposures occur in the talking ladder treatment method?

Exposures will occur in session and out of sessions

Relapse prevention for selective mutism

parents should watch for avoidance behaviors and be aware of not “filling in” for the child

5 methods of relapse prevention for selective mutism

1. Do not finish the child’s sentences

2. Allow enough time for the child to respond

3. Validate child’s efforts

4. Reward child for increasingly difficult speaking behaviors

5. Introduce difficult situations gradually (teacher, principal, etc.)

Separation anxiety disorder (DSM definition)

Developmentally inappropriate and excessive anxiety concerning separation from home or attachment figure as evidenced by 3 or more of the following symptoms

7 DSM symptoms of separation anxiety disorder

1. Distress when separation is anticipated

2. Excessive worry about harm/death/loss of attachment figure

3. Reluctance or refusal to go to school/work

4. Fearful or reluctant to be alone

5. Refusal to sleep away from home

6. Repeated nightmares about separation

7. Somatic complaints around separation

Separation anxiety disorder prevalence

4-10% in children, less common in adolescence and adulthood

What must separation anxiety disorder be differentiated from?

Must be differentiated from school phobia/refusal

4 child factors that may contribute to the development of separation anxiety disorder

1. Child vulnerability (temperament, behavioral inhibition)

2. Early experience (attachment, conditioning)

3. Coping skill access and use

4. Child cognitions (self-concept, distortions, threat schema activity, insecurity, verbal mediation, coping knowledge)

3 parental factors that may contribute to the development of separation anxiety disorder

1. Parental vulnerability (pathology, genetic factors)

2. Parental cognitions

3. Parental behaviors (interactions, verbal information, rewards, modeling, protectiveness)

What is one factor (not necessarily classified as child or parental) that may contribute to the development of separation anxiety disorder?

Ongoing experiences (avoidance, negative experiences)

3 treatments of separation anxiety disorder

1. Exposure

2. Systematic desensitization

3. Reducing parental reward

Panic attack

discrete period of intense fear or discomfort that appears abruptly and unexpectedly and peak within 10 minutes

7 symptoms of panic attacks

1. Pounding heart

2. Shaking/trembling

3. Shortness of breath

4. Sweating

5. Abdominal distress

6. Lightheadedness

7. Fear of losing control

Panic disorder prevalence in teens

2.3% of teens, more common in girls

Common comorbidity/fear of people with panic disorder

Many people with panic disorder have some symptoms of agoraphobia or fear of being in places where escape may be difficult

Panic disorder DSM-5 change

But, DSM 5 unlinked panic disorder and agoraphobia and suggested that panic disorder might be a specifier for a wide range of other disorders

Panic disorder DSM criteria

DSM criteria: must have one or more attacks followed by a period of at least one month during which the person has concerns about…

1. Having another attack

2. Implications of the attack

3. Changing behavior related to the attack

Cognitively-based panic disorder

physical changes in the body are misinterpreted as being catastrophic

Treatment for cognitively-based panic disorder

Cognitive restructuring

Behavioral panic disorder

panic results in learned tension in situations where one is not in complete control

Treatment for behavioral panic disorder

Systematic desensitization of interoceptive cues

Anxious thoughts regarding interoception in panic disorder

Dizziness and lightheadedness → I will pass out/faint/fall down

Alternative perspective regarding interoception in panic disorder

Dizziness is a common symptom of anxiety - it is caused by the fight or flight response

Systematic desensitization of interoceptive cues method

Spin in an office chair or while standing up for one minute and drop safety behaviors such as sitting or lying down

What treatment is most empirically supported for anxiety disorders?

Cognitive and behavioral treatments (cognitive portion is addressed in later childhood)

Alternative CBT-like method for children with anxiety disorders

Children can be given a detective sheet, where they identify the fear, what happened surrounding the fear, worry ratings, and a more realistic thought

Generalized anxiety disorder

excessive anxiety and worry that occurs on most days for a period of 6 months about events and activities such as work or school

5 symptoms of general anxiety disorder

1. Fatigue

2. Difficulty concentrating

3. Irritability

4. Muscle tension

5. Sleep disturbance

General anxiety disorder prevalence

4% in the general population

Is generalized anxiety disorder more common in boys or girls?

More common in girls

Median age of onset of generalized anxiety disorder

10

Treatment of generalized anxiety disorder and justification

• Medication (SSRIs) may be more commonly relied on for this condition

• The anxiety does not have a clear source, so some of the behavioral strategies that work with other anxiety disorders may not be as applicable

Is comorbidity low or high with anxiety disorders?

High

About 25% of kids with separation anxiety have _______

phobias

About 30% of kids with separation anxiety have ________

generalized anxiety disorder

____% of anxious kids are also depressed

10

______% of depressed kids are also anxious

50-75

Influence of high comorbidity rates on anxiety resesarch

Makes etiology and treatment research more complex