Class 17 (Childhood anxiety disorders pt 2)

Separation anxiety

A normal development stage in securely attached babies/toddlers, in which they become upset when separated from caregivers (usually wanes by around 3-4 y/o)

Separation anxiety disorder

Disorder characterized by significant worry and distress regarding separation from people to whom an individual has a strong, emotional attachment (occurs up into adulthood)

Diagnostic criteria for separation anxiety disorder

Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least 3 of the following:

• Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.

  • e.g. parent going to work, child having an extracurricular activity

• Persistent and 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.

  • this can have a fantastical element to it (e.g. what if the apocalypse happens?)

• 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.

  • e.g. will ask parent to stay with them the whole night

• Repeated nightmares involving the theme of separation.

• Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated (before separation).

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 fxing.

The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.

What is school refusal behavior?

Resistance to going or to remaining in school for a full day. Present in approximately 75% of kids with SAD.

• e.g. insisting on calling the parent, forcing the parent to come pick them up from school

What is SAD commonly associated with (misconception)?

With children — but it occurs throughout the lifespan, and is more common in adults than in children.

What is the prevalence for SAD in children and adults?

• 3-5% prevalence in children

• 7% in adults

When does SAD typically start?

Early in life, before age 7.

• 2/3 of adults with SAD develop it for the first time during childhood

Do people grow out of having SAD?

No, lots of people don’t seem to.

SAD and comorbidity

• SAD overlaps heavily with other disorders

• 2/3 of kids with SAD will also meet criteria for another anxiety disorder at the same time

Why do we make people more anxious in order to make them less anxious (exposure therapy)?

Anxiety symptoms are exacerbated and maintained by avoidant behavior. Exposures are a technique to extinguish the reinforcement associated with avoidance

• Panic example: people are trying to avoid the physical sensations of panic

Are exposures a good method to treat SAD?

Because avoidance is common to all anxiety disorders, exposures are an effective component of treatment for a range of anxiety problems – including SAD.

Diagnostic criteria for panic attack

Abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during that time 4 or more of the following symptoms occur:

• Palpitations, pounding heart, or accelerated heart rate.

• Sweating.

• Trembling or shaking.

• Sensations of shortness of breath or smothering.

• Feelings of choking.

• Chest pain or discomfort.

• Nausea or abdominal distress.

• Feeling dizzy, unsteady, light-headed, or faint.

• Chills or heat sensations.

• Paresthesias (numbness or tingling sensations).

• Derealization (feelings of unreality) or depersonalization (being detached from oneself).

• Fear of losing control or “going crazy.”

• Fear of dying.

In what way do panic attacks have a time component?

They are time-limited. Symptoms typically reach a peak in about 10 minutes and then decline.

Types of triggers of panic attacks

• Situationally bound (typical case)

  • clear triggers like snakes, bugs, flying, social situations, etc.

  • can occur with specific phobia, social phobia, SAD, etc.

• Not situationally bound:

  • out of the blue

  • can even occur in the middle of the night

  • sign that you might have panic disorder

Diagnostic criteria for panic disorder

Characterized by recurrent unexpected panic attacks

At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

• Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).

• A 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)

What do panic attacks feel like? Example from Kevin Love, pro basketball player

• Heart racing

• Trouble catching breath

• Everything was spinning

• Brain was trying to climb out of his head

• Air felt thick and heavy

• Body was trying to tell him he is about to die

What is a comorbid condition that panic attacks may occur with or without?

Agoraphobia

What is agoraphobia?

Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms

What are forms of avoidance we see in panic?

Agoraphobia… but also others:

• Restriction of caffeine and exercise (increases the heart rate)

• Only doing certain activities when safety mechanisms are there (e.g. only driving with meds, only going to certain places with a certain person, etc.)

What is the life trajectory of panic?

Panic disorder is possible but relatively rare in early and middle childhood. The vast majority of cases emerge during or soon after puberty.

Why does the vast majority of panic disorder cases emerge during or soon after puberty?

We don’t know, but one idea is the catastrophic misinterpretation of bodily sensations

• Fear of physical sensations associated with panic are believed to be the biggest reason some people develop panic disorder and these physical sensations seem to be more common once people have reached a certain developmental level

Fear of Fear Model

→ Bodily sensations → Uh-oh reaction → Increased anxiety → More symptoms →

• Bodily sensations = heart pounding, rapid breathing, sweating, muscle tension, dizzy/lightheaded, etc.

• Uh-oh reaction = “I am having a heart attack/stroke! What if other people notice or if I fall down or go crazy or die or lose control?”

• Increased anxiety = worry about possibility of future panic, excessive focus on small changes in bodily state

• More symptoms = thoughts about the meaning of physical sensations keeps the body at high level of physiological arousal

How to treat panic disorder

Effective treatments for panic disorder blend exposures with cognitive restructuring surrounding panic

• “If I panic, I won’t be able to handle it”

• “I’m dying”

Psychoeducation

• Learning what a heart attack really feels like (not like a panic attack)

• Learning what the evolutionary origins of panic symptoms are

When treating panic, what should the focus of exposures be?

Stage 1: Interoceptive exposures

• Exposures which are designed to mimic the physical sensations of panic in a controlled, intentional way

• A Fear and Avoidance Hierarchy is constructed from these symptoms, rated according to intensity of symptom and similarity to panic

• These include breathing through a straw, head rolling, running in place, breath holding, body tensing, spinning in a swivel chair, hyperventilating, etc.

• **Interoceptive == the perception of physical states

Stage 2: In vivo exposures

• Therapist and client construct and follow Fear and Avoidance Hierarchy for situations which typically bring on panic outside of therapy sessions

Remission

No more symptoms (e.g. no more panic attacks, reduction in worry about having panic attacks)

Does exposures work for treating panic?

There is 70-80% remission for moderate levels of panic, 50-70% for higher levels of panic

Results generally maintained over 2 years, though about 27% will have another panic attack and seek additional treatment during that time

• Unlike other disorders, for which therapy or meds are roughly equally efficacious, there is a clear advantage for CBT with panic

Panic medication

Anxiety medication (benzodiazepines) tends to be good at relieving panic

• Effects are short lived though

• Considered addictive

• 80% of patients relapse after stopping medication

What do benzodiazepines do?

Increase the inhibitory neurotransmitter GABA

• reduces neuronal excitability and promotes a calming effect by blocking certain brain signals

What is one of the rarest childhood anxiety disorders?

Selective mutism

Selective mutism

A child lacks speech in some social situations but not in others, despite the ability to use and comprehend language

What is the prevalence of selective mutism?

About 0.7%, possibly less

Diagnostic criteria for selective mutism

• Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g. at school) despite speaking in other situations

• The disturbance interferes with educational or occupational achievement or with social comms

• The duration of the disturbance is at least 1 month (not including the first month of school)

• The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation

• The disturbance is not better explained by a communication disorder (e.g. childhood onset fluency disorder aka stuttering) and does not occur exclusively during the source of autism spectrum disorder, schizophrenia, or another psychotic disorder

Why might parents be surprised to find that their child has selective mutism?

One of the big indicators that a child has SM is not talking in certain situations, but usually the child speaks a lot at home

What age range is linked to selective mutism?

SM is considered a childhood disorder (lots of allusions to school setting in the diagnostic criteria) but there’s no explicit age range

How do selective mutism vs social phobia contrast?

They are viewed as different but related disorders; about half of children with selective mutism will also meet criteria for social phobia (for reasons other than reluctance to speak)

Who becomes selectively mute?

Selective mutism is more common in…

• kids with family histories of anxiety disorders

• kids with another comorbid anxiety disorder

• some studies suggest it’s more common in children from immigrant communities, especially those who speak a different language at home (not consistently replicated)

It’s rare, so we don’t know that much about it