PSYC 326: Atypical Development (Chapter 11: Anxiety Disorders)

Physical symptoms of anxiety

Mediated by the amygdala and related subcortical structures

• Chemical effects: release of epinephrine and norepinephrine

• Cardiovascular effects: increased heart rate and blood pressure

• Respiratory effects: increased in speed and depth of breathing, feelings of breathlessness/choking/chest pain

• Sweat gland effects: sweating increases

• Other effects: pupils widen, salivation decreases, digestion slows, muscles tense (leading to tension, aches, pains)

Cognitive symptoms of anxiety

Mediated by higher order cortical processing

• Search for threat

• Apprehension, nervousness, difficulty concentrating, panic

• Self-deprecation and feelings of inadequacy

• Specific worries

Behavioural symptoms of anxiety

Mediated by the amygdala and related subcortical structures

• Avoidance/escape behaviours
• Aggression and irritability
• Fidgeting
• Immobilization

Normal fears/anxieties

• Younger children have more anxiety than older children

• Many fears decrease with age, though school-related fears remain stable and social fears increase

• Normal worry can help prepare for the future

Common fears in children

Infancy: loud noises, separation from parent, stranger anxiety
Toddlerhood: separation from parents, the dark, storms, animals
Early childhood: separation from parents, death
School age: specific objects, germs, traumatic events, school-related, social-related
Adolecence: social-related

Separation Anxiety Disorder (SAD)

• Age-inappropriate, excessive, and disabling anxiety related to separation from attachment figures and fear of being alone

• Distressed when separated, worries about losing attachment figures or harm coming to them, avoids separation (e.g. school refusal, fussing, crying, screaming)

• Symptoms must be present for at least 4 weeks in children

• One of two most common childhood anxiety disorders, with the youngest age of onset of those referred

Specific Phobia (SP)

Criteria:

• Marked fear/anxiety about a specific object or situation

• Anxiety is almost always provoked by the object/situation

• The object/situation is avoided or endured with intense anxiety

• Fear is out of proportion to the actual threat

• Symptoms must be present for at least 6 months
  Specify if:

• Blood/injection injury, natural environment, situational, animal, or other

Other:

• One of two most common childhood anxiety disorders

• Children often fail to recognize the fear is irrational

• Natural environment and animal are most heritable

Social Anxiety Disorder

Criteria:

• Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny

• The individual fears they will act in a way or show anxiety symptoms that will be negatively evaluated

• Anxiety is almost always present in the situation

• Situations are avoided or endured with intense anxiety

• Symptoms must be present for at least 6 months

Other

• Anxiety must be present in peer settings, not just when interacting with adults

• Most common secondary diagnosis for other anxiety disorders

• May involve outbursts of anger and aggression

Selective Mutism

• Failure to speak in specific social situations in which there is an expectation to speak, even though they may speak loudly and frequently at home or in other settings

• Symptoms must be present for at least 1 month

Three subgroups:

• Anxious - mildly oppositional

• Anxious - communication delayed

• Exclusively anxious

Panic Disorder

• Recurrent, uncued panic attacks

• Persistent concern about additional attacks or changes in behaviour to prevent additional attacks

• Criterion B. must be present for at least 1 month

Other:

• Panic attacks are common in adolescents and extremely rare in young children

Agoraphobia

• Marked fear of anxiety about at least 2 of 5 situations: enclosed spaces, open spaces, lines or crowds, public transit outside of the home alone

• Fear is due to thoughts that escape will be difficult, or help will be unavailable, if panic-like symptoms occur

• Symptoms must be present for at least 6 months

Three hypothesis for panic attacks

• Hyperventilation hypothesis

• Anxiety sensitivity hypothesis

• Things other than fear (e.g. stress) may produce panic symptoms through production of adrenaline and other chemicals

Generalized Anxiety Disorder (GAD)

• Excessive anxiety and worry about multiple things

• Perception of being unable to control the worry

• At least 1 of 6 physical symptoms: muscle tension, restlessness, irritability, fatigue, difficulty concentrating, sleep disturbance

• Symptoms must be present for at least 6 months
  Other:

• Intolerance of uncertainty

• Tendency to relate frightening events in media to themselves

• Continue to worry despite contradicting evidence

Obsessive-Compulsive Disorder (OCD)

• Presence of obsessions, compulsions, or both

• Significant distress/impairment, or obsessions/compulsions last at least 1 hour per day
  Other

• More common in boys for young children, but not adolescents

• Two peaks in onset, one in early childhood and one in adolescence/early adulthood

• Obsessions in young children are more vague and less likely to be perceived as abnormal

Associated Characteristics of Anxiety Disorders

• Cognitive disturbances (hypervigilance/attentional biases, cognitive biases, poor academic achievement)
• Physical symptoms
• Social and emotional deficits (socially withdrawn, contagion of anxiety)
• Depression

Gender, ethnicity, and culture in anxiety disorders

Gender

• Anxiety is twice as common in girls
• Masculinity and anxiety are negatively correlated in both sexes
  Ethnicity
• Anxiety is more common in ethnic minorities in the US
• Ethnicity is not related to treatment outcomes but is related to premature termination due to lack of cultural understanding
  Culture
• Increased levels of fear are found in cultures that favour obedience, compliance, and inhibition

Early theories of Anxiety Disorders

• Psychoanalytic theory (unconscious conflicts and early upbringing, e.g. Little Hans)
• Behavioural and learning theories (e.g. two-factor theory, social learning theory)
• Attachment theories: fearfulness is biologically rooted in the emotional attachment needed for survival

Behavioural inhibition

Temperament involving a low threshold for becoming overexcited, tendency to withdraw in response to novel stimuli infants, tendency to be fearful/anxious as toddlers, and tendency to be shy/withdrawn as young children; predisposing factor for anxiety, especially in combination with overinvolved and controlling parents

Genetics and anxiety disorders

• Inherited tendencies to be inhibited, tense, and fearful
• Genetic influence is highest for OCD and shyness/inhibition
• Genetic influences decrease with age, while shared environmental influences increase
• Variants in the serotonin system are linked to behavioural inhibition

Neurological factors in anxiety disorders

• Neural circuits related to fear and threat (HPA axis, limbic system, PFC)
• Overactive behavioural inhibition system (brainstem, limbic system, cortex)
• Early life stress dysregulates fear/threat brain areas (HPA axis and cortisol)
• GAD is linked to larger volume and overexcitability of areas linked to social-emotional procesing and fear
• GABAergic and serotonin systems

Family factors in anxiety disorders

• Specific factors: overinvolvement, intrusive parenting, granting less autonomy to the child
• Broader relationship: more family dysfunction, low expectations for the child's coping, low SES enhances genetic risk
• Insecure attachment

Four primary aims of treatment for anxiety disorders:

• Distorted information procesing
• Escape/avoidance behaviours
• Sense of lack of control
• Physiological reactions

CBT for anxiety

• Graded exposure with participant modelling and reinforced practice
• Cognitive restructuring (e.g. looking for evidence, replacing thoughts with positive/realistic thinking)

Coping Cat

A CBT program for anxiety focused on learning processes, contingencies, and information processing that uses the following acronym:
Feeling frightened? (recognize physical symptoms)
Expecting bad things (recognize cognitive symptoms)
Attitudes and actions that will help (coping behaviours)
Results and rewards (evaluate performance and self-reward)

Family interventions for anxiety and OCD

• Involve parents in modelling and reinforcement, provide anxiety management strategies for parents

• Psychoeducation about OCD, help parents manage behaviour without accommodation, help cope with feelings

Comorbidities of anxiety disorders

• Most common are other anxiety disorders and depression

• Specific phobias have lower rates of comorbidity

• Social anxiety is also linked to substance use disorders

• Selective mutism is particularly linked to social anxiety and is also linked to communication, elimination, and oppositional disorders

• Panic disorder is particularly linked to GAD and SAD and is also linked to mania/hypomania, ADHD, and ODD

• Agoraphobia is also linked to PTSD and alcohol use disorder

• GAD is linked to conduct disorders in childhood