Anxiety Disorders and Obsessive-Compulsive Disorder I

Day 23

DSM-5: Anxiety Disorders


Separation Anxiety Disorder
Selective Mutism
Specific Phobia
Social Anxiety Disorder 
Generalized Anxiety Disorder
panic disorder
Agoraphobia

Adaptative and Maladaptive Anxiety

•   Anxiety

– Psychological distress that reflects emotional, behavioral, and cognitive reactions to threatening stimuli

– Two types of anxiety:

–   

–  Behavioral and physiological reaction to an immediate threat

–   

–  Primarily a cognitive response to threat; consideration and preparation for future danger or misfortune

•    Adaptative and Maladaptive Anxiety

–  

–  Expected and normal at certain ages and in certain situations

–  Often occurs when we do something important.

–  Moderate doses help us to think and act more effectively.

•        

•        Developmental: fears beyond a certain age

•        Intensity: intense and out of proportion

•        Chronic: continual worry

•        Impairment: interferes with daily activities

Anxiety Disorders: Onset and Prevalence

•   Childhood Anxiety Disorders: Onset

– Typical Onset: Early to Middle Childhood

–  Separation anxiety disorder

–  Selective mutism

–  Specific phobia

–  Social anxiety disorder 

– Typical Onset: Middle Childhood to Adolescence

–   

– Typical Onset: Adolescence to Adulthood

–  Panic disorder.

–  Agoraphobia

•   Childhood Anxiety Disorders: Prevalence 

– Prevalence

–  Among the most diagnosed mental health conditions in children and adolescents

– Rates

–  

– 5% diagnosed at any given time.

– Higher Rates

– Adolescents compared to children.

– Girls compared to boys.

•   Childhood Anxiety Disorders: Course 

– Course

–   

– Homotypic continuity

– Heterotypic continuity 

–  Anxiety and Depression

– Childhood anxiety can predict depressive disorders in adolescence and young adulthood.

– Anxiety disorders also predict substance use disorders and suicidality.

Anxiety Disorders

•   Classification of Anxiety Disorders

–  

–  Significant distress when separated from a caregiver, clingy behavior in presence of caregiver, anxiety is age- inappropriate.

–  Most common cause of school refusal and academic and social problems

–  Common: somatic problems, nightmares, and panic symptoms

–  High rate of comorbidity

–  Girls at greater risk for SAD

•   Classification of Anxiety Disorders

–  

–  Fail to speak in specific social situations in which there are expectations to speak but will speak in other social situations.

–  At least 1 month in duration and not associated with lack of language knowledge or other disorders.

–  Interference with education, work, social domains

–  Average age of onset = toddlerhood to preschool

–  Average duration without treatment: 8 years 

–  Common comorbidity: other anxiety disorders, oppositional disorders

•    Classification of Anxiety Disorders

–  

–  Marked fear of clearly discernible, circumscribed objects or situations

–  Most phobias are associated with:

–  Animals

–  Natural environment

–  Blood, injections, and injuries

–  Specific situations

–  Other stimuli 

–  Diagnosed when:

–  Anticipatory anxiety or fear significantly interferes with day-to-day functioning.

–  Symptoms cause significant distress.

–  Rates: about 2% to 9%, girls more than boys

–  Average length of phobias: 1 to 2 years if untreated

–  Most phobias do not persist into adulthood but can predict other later problems.

•   Classification of Anxiety Disorders

–  

–  Marked and persistent fear of social or performance situations in which scrutiny or embarrassment might occur.

–  Show immediate anxiety and panic symptoms when the feared situation is encountered.

–  Usually not diagnosed before age 10

–  Most common feared situations:

–  Formal presentations

–  Unstructured social interactions

–  Impairment in social and emotional functioning

–  SAD can predict later: 

–  Depression, social isolation, loneliness

–  Substance use problems.

•   Classification of Anxiety Disorders

–  

–  Excessive and unrealistic worries about a variety of stimuli and situations

–  Apprehensive expectation

–  Excessive worry about the future

–  Criteria: worry about two or more activities or events (minimum)

–  Worry: intense and time-consuming

–  Excessive worry interferes with engagement in daily life. 

–  Observed in childhood, but more common in older children, adolescents, and adults.

–  Average age GAD begins to be diagnosed: 8 to 10 years.

–  Often associated with concurrent depressed mood and dysphoria and later depression

•    Classification of Anxiety Disorders

–  

–  Recurrent, unexpected panic attacks that cause significant distress or impairment.

–  Panic attacks are acute and intense episodes of psychological distress and autonomic arousal.  Signs and symptoms tend to cluster:

–  Cognitive symptoms

–  Emotional symptoms

–  Somatic symptoms

–  +: worry about future attacks, implications of attacks, and negative impact on daily life.

–  Panic disorder onset: 15 to 19 years.

–  SAD in childhood is associated with later panic disorder.

•   Classification of Anxiety Disorders

–  

–  Recurrent anxiety about places or situations from which escape or help is not possible without considerable effort or embarrassment.

–  People with agoraphobia tend to avoid feared situations.

–  Rare in adolescents

–  Average age of onset: 18 to 29 years

–  Disorder typically emerges slowly with additional places or situations added.

–  Disorder can last throughout adulthood.

•    Classification of Anxiety Disorders

– Empirical Approach (Dimensional Classification)

–  Statistical procedures have yielded subcategories related to anxiety disorders.

–  Syndromes:

–   

–  Somatic complaints

–  Withdrawn/depressed.

Anxiety Disorders: Risk Factors

•   Anxiety Disorders: Risk Factors

– Genes and Heredity

–   

–  Genetic role appears to involve a more general vulnerability rather than disorder-specific risk.

–  Note: research suggests an overlap in genetic influences on the development of anxiety and depression

•   Anxiety Disorders: Risk Factors    

– Physiological Factors

–  Implicated brain areas:

–  Right hemisphere

–  Prefrontal cortex

–  Cerebellum

–    

–  Implicated systems

–  Autonomic nervous system

–  Hypothalamic-pituitary-adrenal (HPA) axis

–  Plus – neurotransmitter dysregulation

•     Anxiety Disorders: Risk Factors

–  Child Factors

–  Behavioral inhibition (temperament trait)

–  Negative affectivity (or emotionality)

–  Lack of emotion regulation

–   

–  Insecure attachment

–  Early experience with lack of control

–  Cognitive and attentional biases

–  perceive and attend more closely to threatening stimuli.

–  negative/threatening appraisals of ambiguous situations

–  cognitive distortions associated with self and others. 

–  Learning

–  Direct conditioning, modeling, and/or instruction or information

–  Adverse Life Events (e.g., maltreatment, parental divorce)

–  Chronic stressors (e.g., discrimination, peer problems)

Anxiety Disorders: Risk Factors

•   Anxiety Disorders: Risk Factors

– Parent Factors

–  Parental psychopathology

–  Parental behavior: overprotective/overcontrolling, negative/critical, and intrusive/controlling.

–  Parent fears and worries

–   

–  Acceptance or accommodation of children’s anxiety and avoidant behavior

Anxiety Disorders: Assessment

•    Comprehensive Assessment

–  Developmentally sensitive and address developmental changes.

–   

–  Sensitive to the needs of culturally, ethnically diverse populations

–  Include contextual assessments.

•    Assessment Tools

–  Interviews and self-reports

–  Direct Observations

–  Physiological Recordings

•   Psychological Treatments

– Cognitive- Behavioral

–   

–  Systematic Desensitization

–  Modeling

– Pharmacological Treatments

–  Selective serotonin reuptake inhibitors (SSRIs)

– Black Box Warning

 Anxiety Disorders and Obsessive-Compulsive Disorder III

Day 25

DSM-5: Obsessive-Compulsive and Related Disorders

obsessive-compulsive disorder
Trichotillomania
Excoriation Disorder

DSM-5: Neurodevelopmental Disorders

Tic Disorders (Under Motor Disorder)

Obsessive-Compulsive Disorder (OCD) and Related Disorders 

•    OCD in Children

– Recurrent, unwanted obsessions and/or compulsions that are extremely time consuming, cause marked distress, or significantly impair daily functioning.

–  Obsessions

–  Unwanted, intrusive thoughts, urges, or images

–  Compulsions

–  Repetitive behaviors the individual feels driven to perform.

–  Thought to alleviate the obsession.

–  Important to evaluate children’s obsessions and compulsions within a developmental framework.  

•    OCD in Children

– Childhood vs. Adulthood: Differences

–  May change obsessions and/or compulsions over time.

–  Obsessions and compulsions are often more vague, magical, or superstitious.

–  Many have difficulty describing their obsessions.

–  Even if they can describe the obsessions may be unwilling to do so as they then fear the consequences will come true.

– Most children demonstrate both obsessions and compulsions.

–  Compulsions: can be mental or behavioral

•    OCD in Children

– Prevalence

–  About 1%-2%

–  Childhood: more boys than girls

–  Adolescence: no gender difference

– Childhood OCD: Persistence

–  Clinical Level Continuity: about 41%

–  Subclinical Level Continuity: about 20%

–  Marked Reduction/Remission in Symptoms: about 40%

– Greatest Risk for Continuity

–  Early symptoms onset

–  Longer duration of symptoms

–  Symptoms requiring hospitalization.

– OCD in Childhood: Developmental Risk

–  Relationship, employment, and emotional problems in adulthood

•    Related Disorders

– Tic Disorders

–  Sudden, rapid, nonrhythmic, and stereotyped behavior that is involuntary.

–  Tics:

–  Sudden, unwanted urge, followed by a motor and/or vocal behavior (similar the OCD pattern – obsession, compulsion)

–  Simple (short and one) or complex (longer and multiple)

–  No purpose and involuntary

–  Median age of onset: 5.5 years

–  Highly comorbid with OCD

–  Mild to severe (next slide)

–   Prevalence

–  Chronic tic disorder: 2%-4%

–  Tourette’s disorder: .4%-1.8%

–  Transient tics: 5%-18%

–  Boys more than girls 

•   Related Disorders

– Tic Disorders

–  Provisional Tic Disorder

– Single or multiple motor or vocal tics (or both) lasting less than a year. 

–  Persistent Motor or Vocal Tic Disorder

– Multiple motor or vocal tics (but not both) lasting for more than 1 year.

–  Tourette’s Disorder

– Multiple motor and vocal tics lasting for more than 1 year.

•     Clinical Precursors of Tics: An EMTICS Study (Openneer et al., 2022)

–  Method

–  Participants:

–  Data from the European Multicentre Tics in Children Study (16 European Clinical sites)

–  187 children, ages 3 to 10, siblings of children with Tourette syndrome (TS)

–  No tics at baseline, followed for 7 years.

–  Tics: n = 61

–  No Tics: n = 126

–  Longitudinal study and correlational

–  Method of Observation:

–  Children’s Yale-Brown Obsessive-Compulsive Scale: parental report

–  Swanson Nolan and Pelham-IV Rating Scale (ADHD symptoms and ODD severity): parental report.

–  Autism Spectrum Screening Questionnaire: parental report

–  Strengths and Difficulties Questionnaire: parental report

–  KINDL-R Questionnaire (health-related quality of life): parent report

–  Results

–  Tic Onset Group compared to No Tic Onset Group: Baseline Data

–  More likely to be male.

–  At baseline: more severe

–  conduct problems.

–  autism spectrum disorder symptoms

–  compulsions

–  emotional problems

–  Gender Differences

–  Boy specific predictors.

–  Conduct problems and ASD symptoms.

–  Girl specific predictors

–  Severity of compulsions and oppositional and emotional problems

–  Message

–  Tic onset may be proceeded by emotional and behavior problems, some of which may be gender specific.

•    Related Disorders

– Trichotillomania

–  Repeated pulling out of hair, resulting in hair loss.

–  Hair pulling causes distress or interferes with functioning.

–  Two Subtypes

–  Focused: conscious, deliberate pulling, usually in response to unpleasant thoughts or feelings (resembles OCD features)

–  Automatic: habitual plucking, usually outside the person’s awareness; not elicited by distress or negative affect 

–  Onset, Course, and Comorbidity

–  Onset: mean age 11.8 years

–  Course: slow onset to more severe, symptoms peak in young adulthood

–  Common: comorbidity with OCD

•    Related Disorders

– Excoriation Disorder

–  Recurrent skin picking that results in lesions.

–  Habitual picking, or inability to stop, causes distress and impairment in functioning.

–  Often pick at skin on face, head, or neck

–  Medication and/or cosmetic surgery may be necessary to repair the tissue damage.

–  Prevalence and Comorbidity 

–  2%-4.5%

–  Comorbidity: OCD, trichotillomania, depression, anxiety disorders 

•    OCD: Risk Factors

– Genes

–  OCD is heritable (family and twin study evidence).

–  Related disorders tend to also demonstrate heritability.  

– Physiological Factors

–  Neural pathway: cortico-basal-ganglionic circuit

–  Feedback loop involving:

–  Orbitofrontal cortex

–  Detect abnormalities and irregularities in the environment; initiate a behavioral response to correct irregularities.

–  Cingulate gyrus

–  Cognitive rumination and feelings of anxiety, apprehension, or tension

–  A portion of the basal ganglia – caudate

–  Prepares a behavioral response to reduce the negative thoughts and feelings.

•   OCD: Risk Factors

– Physiological Factors

–  Neural pathway: cortico-basal-ganglionic circuit

– People with OCD

– Show overactivity of the cingulate and a lack of inhibition by caudate.

–  Implication: person experiences high levels of distress when they notice abnormalities or irregularities in their surroundings

–  Neural pathway: serotonin,

– High levels of serotonin might exacerbate OCD symptoms.

•    OCD: Risk Factors

– Maintenance of OCD

–  Learning

–  Compulsions are negatively reenforced by the reduction of distress.

–  Cognitive Distortions

–  Inflated responsibility for misfortune

–  Contribute to feelings of guilt and self-doubt.

–  Thought action fusion.

–  Erroneous belief that merely thinking about an event will increase its probability.

–  Adolescent attempts to control negative thoughts to prevent future misfortune. 

OCD and Related Disorders: Assessment

•    Comprehensive Assessment

–  Developmentally sensitive and address developmental changes.

–  Differentiate between typical and atypical obsessions and compulsions.

–  Sensitive to the needs of culturally, ethnically diverse populations

–  Include contextual assessments.  

•    Assessment Tools

–  Interviews and self-reports

–  Direct Observations

–  Physiological Recordings

Obsessive-Compulsive Disorder: Interventions

•    OCD: Interventions

– Cognitive-Behavioral Interventions

–  Education about OCD.

–  Exposure and response prevention

–  Generalization

– Medication

–  SSRIs

•    Tic, Trichotillomania, and Excoriation: Intervention

– Behavioral Interventions

–  Self-monitoring

–  Daily: observes and records the frequency of the actions

–  Habit reversal training

–  Engagement in a behavior, when carried out, makes it impossible to produce the unwanted action.

– Medication

–  Antipsychotic medications

–  Block dopaminergic activity.

–  Alpha-2 Adrenergic Agonists

–  Affect serotonin and norepinephrine, which reduces dopamine activity. 

Trauma-Related Disorders I

Day 27

DSM-5: Trauma- and Stressor-Related Disorders

Reactive Attachment Disorder
Disinhibited Social Engagement Disorder

Attachment Relationships

•   Attachment

– An emotional connection with a specific person that is enduring across space and time.

– Primary Attachment Classifications

–  Secure Attachment (65%)

–  Anxious/Resistant (10%)

–  Anxious/Avoidant (20%)

–  Disorganized/Disoriented (5%-10%)  

•   Primary Attachment Classifications

–   Influenced by early parenting behavior

–  Secure Attachment

– Sensitive and responsive

–  Anxious/Resistant

– Inconsistent

–  Anxious/Avoidant

– Neglectful or overzealous

–  Disorganized/Disoriented

– Frightening  

Attachment Relationships

•   Attachment Disorders

– Can develop when infants and young children lack developmentally appropriate care from parents or other primary caregivers early in life.

–  Typically observed among children:

–  Raised in orphanages.

–  Raised in group homes.

–  Experience multiple foster care placements.

–  Experience severe abuse and neglect (rarer)

Attachment Disorder: Reactive Attachment Disorder (RAD)

•   Attachment Disorders in DSM-5

– Reactive Attachment Disorder

–  A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers (both):

–  Does not seek comfort when distressed.

–  Does not respond to comfort when distressed.

–  A persistent social and emotional disturbance (at least two):

–  Minimal social and emotional responsiveness to others

–  Limited positive affect

–  Episodes of unexplained irritability, sadness, or fearfulness

•   Attachment Disorders in DSM-5

– Reactive Attachment Disorder

–  The child has experienced a pattern of extremes of insufficient care (at least one)

–  Social neglect or deprivation

–  Repeated changes of primary caregivers, no ability to form an attachment.

–  Rearing in unusual settings that do not allow for attachments to form.

–  Criteria are not met for autism spectrum disorder.

–  The disturbance is evident before age 5.

–  The child has a developmental age of age least 9 months.

•   Risk Factors of Reactive Attachment Disorder

– An Absence of Attachment

– Infant is deprived of care from a primary caregiver during a sensitive period (6 to 12 months) of attachment formation.

– Results in the absence of a clear attachment relationship and attachment behavior (e.g., using the caregiver as a secure base)

– RAD infants appear listless, withdrawn, and sad.

•   Risk Factors of Reactive Attachment Disorder

– Bucharest Early Intervention Project (BEIP)

– Early Deprivation on Children’s Development

– Randomized controlled study.

– Infants were randomly assigned to foster placement (US and UK) or care in the orphanage.

– Assessed outcomes in 3 groups:

–  Children raised in Romanian orphanages.

–  Children initially raised in Romanian orphanages but placed in foster homes before age 24 months.

–  Romanian children living with their biological families.

•   Risk Factors of Reactive Attachment Disorder

– Bucharest Early Intervention Project (BEIP)

– At 24 months:

– Showed a clear attachment pattern.

–  100% of noninstitutionalized children

–  3.2% of institutionalized children

– No attachment pattern or differentiation of people

–   9.5% of institutionalized children

– Slight preference for caregiver, but no positive emotions when interacting.

–  25.3% of institutionalized children

– Sensitive and responsive care

–  Fewer signs of RAD

•   Risk Factors of Reactive Attachment Disorder

– Bucharest Early Intervention Project (BEIP)

– Stability of RAD

–  Stable: continual institutionalized

–  Decreased: foster care children

– Overall Results:

–  Most: develop attachment relationships

–  Better outcomes: leave institutionalized care early.

–  Some: do not develop attachment relationships

Disinhibited Social Engagement Disorder (DSED)

•   Attachment Disorders in DSM-5

– Disinhibited Social Engagement Disorder

–  A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults (two of the following):

–  No hesitancy in approaching or interacting with unfamiliar adults.

–  Overly familiar verbal or physical behavior.

–  Diminished or absent checking back with adult caregiver after venturing away.

–  Willingness to go off with an unfamiliar adult with little or no hesitation. 

•    Attachment Disorders in DSM-5

– Disinhibited Social Engagement Disorder

–  Criteria not limited to impulsivity but include a socially disinhibited behavior.

–  The child has experienced a pattern of extremes of insufficient care (at least one)

–  Social neglect or deprivation

–  Repeated changes of primary caregivers, no ability to form an attachment.

–  Rearing in unusual settings that do not allow for attachments to form.

–   The child has a developmental age of at least 9 months.

•    Risk Factors of Disinhibited Social Engagement Disorder

– A Lack of Social Inhibition

–  Social inhibition

–   Controlling impulses in social situations.

–  The lack of parents or caregivers may mean toddlers do not experience the ability to learn social inhibition.

– Delays or deficits in social inhibition may be demonstrated.

•    Risk Factors of Disinhibited Social Engagement Disorder

– A Lack of Social Inhibition

–  Empirical Studies

– Adoption Study

–  Empirical study  

–  More time spent in institutions or multiple foster homes showed more indiscriminately friendly behavior at age 7.

–  Indiscriminately friendly behavior was associated with deficits in social inhibition, but not children’s attachment.

•    Risk Factors of Disinhibited Social Engagement Disorder

– A Lack of Social Inhibition

–  Empirical Studies

– Children in Foster Care

–  More symptoms of indiscriminately friendly behavior.

–  Children in foster care (compared to controls)

–  More changes in foster care placements

–  Mediational Model:

–  Greater number of foster care placements predicted problems with social inhibition which precited DSED symptoms.

•    Risk Factors of Disinhibited Social Engagement Disorder

– Summary of Results

–  DSED does not reflect a disruption in attachment.

–  Indiscriminately friendly behavior may reflect underlying problems with social inhibition.

–  Most children with DSED do not show improvements in their social behavior after being adopted by sensitive and responsive caregivers.

Attachment Disorders: Assessment

•   Attachment Disorders: Assessment

– Assessment Tools

–  History Interview

–  Questionnaires and Structured Tasks

– Attachment Q-sort.

– Adult Attachment Interview

– Doll Play

– Storytelling

– Naturalistic Data Collection

– Home visits or a home-like setting 

Attachment Disorders: Intervention

•   Attachment Disorders: Intervention

– Reactive Attachment Disorder

– Attachment and Biobehavioral Catch-Up (ABC).

– Designed to improve attachment quality between parents and young children.

– Goals of ABC interventions:

–  Cultivate nurturance.

–  Improve synchrony.

–  Reduce intrusive or frightening behavior.

– Research has demonstrated the efficacy of the ABC intervention.

•     Efficacy of Treatment for Reactive Attachment Disorder: A Follow-Up Study (Lawson et al., 2021)

–  Method

–  Participants:

–  71 children and adolescents, all adopted, 31 male, onset average age: 10.61, end of therapy average age: 11.82.

–  Children and adolescents, and their families received intervention at the Attachment Institute of New England

–  attachment- and trauma-focused therapy

–  Longitudinal and correlational

–  Method of Observation:

–  Child Behavior Checklist (pre and post): caregiver report

–  RADQ (attachment disorder assessment): caregiver report

–  Results

–  Pre-Test to Post-Test

–  Internalizing and externalizing problem behavior decreased.

–  No difference in overall child/adolescent competence

–  Decrease in RAD-related symptoms.

–  Message

–  Children diagnosed with RAD may benefit from attachment- and trauma-related intervention.

•   Attachment Disorders: Intervention

– Disinhibited Social Engagement Disorder

– Prevention:

– Adoption of institutionalized children prior to 6 months.

– Provide more stable and consistent care to institutionalized infants.

– Intervention:

– Difficult as even if adopted into nurturing homes socially disinhibited behavior tends to persist.

–  Social disinhibition may decrease slowly over time, but it can continue to interfere with relationships into late childhood and adolescence.

Trauma-Related Disorders II

Day 28

DSM-5: Trauma- and Stressor-Related Disorders

posttraumatic stress disorder

Posttraumatic Stress Disorder

•    Posttraumatic Stress Disorder (PTSD)

– Exposure to a traumatic event of actual or threatened death, serious injury, sexual violation.

–  The traumatic events can be:

–  Intentional

–  Accidental

–  Natural

–  The traumatic event(s) must happen directly to the child or to a close family member or friend.

•    Posttraumatic Stress Disorder (PTSD)

– Four Clusters of Symptoms

–  Intrusion Symptoms

–  Persistently reexperience the event

–  Examples: recurrent dreams, transient images, unwanted thoughts

–  Avoidance Symptoms

–  Attempts to avoid aspects of the traumatic event.

–  Examples: unwilling to discuss the event, do not share feelings  

–  Negative Mood Symptoms

–  Negative alteration in feelings or thoughts 

–  Examples: anxiety, depression, guilt, anger

–  Arousal Symptoms

–  Alteration in level of physiological arousal or reactivity

–  Examples: overactivity of stress response, inability to regulate emotions

•    Posttraumatic Stress Disorder (PTSD)

– Symptoms

–  Last more than one month

–  Less than one month: acute stress disorder

– Symptoms cause distress and impairment to the individual.

•    Dissociative Symptoms: A DSM Specifier 

– May be experienced, but not required for a PTSD diagnosis.

– Two Dissociative Symptoms Relevant to PTSD

–  May be experienced, but not required for a PTSD diagnosis.

–  Persistent or recurrent experiences of feeling detached from one’s own boy or mental processes. 

–  Derealization

–  Persistent or recurrent thoughts or perceptions that one’s surroundings are not real.

– Dissociative symptoms

–  Predict greater impairment and poorer prognosis.

•    Posttraumatic Stress Disorder in Children

– Different criteria for children 6 years or younger

–  Can witness or learn about the traumatic event happening to a parent or caregiver.

–  May manifest intrusion symptoms differently (e.g., traumatic event is the theme of repetitive play) 

–  Only one symptom of avoidance or one symptom of negative mood.

–  Must cause distress, interfere with their behavior at school, or impair relationships with parents, siblings, or caregivers.

PTSD in Children

•   PTSD in Children

– Prevalence of Traumatic Event

–  One traumatic event: 31%

–  Two traumatic events: 23%

–  Three+ traumatic events: 15%

–  Did not differ by gender, race, or ethnicity.

– Prevalence of PTSD

–  PTSD Symptoms:

–  About 3% who experience a traumatic event

–  PTSD Diagnosis:

–  About 16% who experience a traumatic event

–  Girls more than boys

–  Increased risk when trauma is:

–  Multiple

–  Recurring

–  Directly experienced.

–  Intentional and interpersonal 

•    PTSD in Children

– Course of PTSD

–  About 50% experience spontaneous recovery.  

–  Often in the first few months after the trauma

–  Those more likely to experience SR:

–  Good social-emotional functioning before the trauma

–  Support from parents after the trauma.

–  Willingness to talk about the trauma.

– Comorbidity of PTSD

–  Positive correlation between number of traumatic events and comorbidity

–  Common comorbid conditions:

–  Conduct problems.

–  Depression

–  Anxiety

–  Substance use disorders.

•    PTSD in Children

– Adverse Childhood Experiences (ACE) Studies

–  Investigations of long term outcomes of children exposed to trauma.  

–  Results:

– Many experience early traumatic events.

– Positive correlation between number of traumatic events and adult physical and mental health

–  Increased risk for:

–  Obesity

–  Smoking

–  Alcohol and drug problems

–  Depression and suicide attempts

–  Risky sexual behavior

–  Financial and educational struggles

–  Social difficulties

–  Criminal activity

Risk Factors of PTSD 

•   Risk Factors of PTSD

– Learning Theory

–  PTSD develops from:

–  

– Traumatic event is associated with a neutral stimulus.

– The neutral stimulus then elicits the traumatic event experience.

–  

– Negative reinforcement: avoiding stimuli associated with the event reduces pain, arousal, or dysphoria. 

•   Risk Factors of PTSD

–  

–  Theory:

–  Emotions are organized in our memory as cognitive structures or networks.

–  Includes: mental representation of a stimulus, a physiological or emotional response, and the meaning associated with stimulus and response

–  PTSD:

–  Do not learn to associated trauma-related stimuli with new meaning. 

–  Children:

–  Avoid the stimulus.

–  Experience cognitive (e.g., intrusive memories) and emotional (e.g., guilt) symptoms of PTSD.

•   Risk Factors of PTSD

– Physiological Theory: Stress System 

–   

– Regulates the immediate fight-or-flight response.

–  A single traumatic event can sensitize the amygdala so that it responds to benign stimuli associated with the event.

–  Ongoing trauma can cause the cortex to lose its ability to inhibit the flight-or-flight response. 

–  Hypothalamic-Pituitary-Adrenal (HPA) axis

– Regulate the delayed response to stress.

–  Trauma can produce excessive production of cortisol, which can damage the hippocampus over time.

–  A damaged hippocampus may be associated with unwanted memories, flashbacks, nightmares.

•   Risk Factors of PTSD

– Contextual Example:

– Parenting Factors 

–  

–  Trauma produces anxiety symptoms in all family members.

–  Parents and children struggle concurrently.

– Lack of protective shield effect

–  Parents are unable to provide the comfort, support, and security necessary for recovery.

–  Parents may not recognize/minimize trauma effects.

– Toxic family effect

–  Parents’ responses to trauma elicit/maintain anxiety symptoms.

PTSD in Children: Assessment

•   PTSD in Children: Assessment

– Assessment Tools

–  Self-report interviews and questionnaires

–  Observations (e.g., play)

–  Physical exam (if somatic symptoms)

– Considerations

–   

–  Questions about the trauma should be specific.

PTSD in Children: Intervention

•   PTSD in Children: Intervention

–  

–  A general approach to providing sensitive and responsive treatment to individuals exposed to trauma.

–  Trauma-involved care for children and adolescents: Six Principles

–  Safety

–  Support

–  Education

–  Emotion-regulation

–  Trauma-processing

–  Hope

•   PTSD in Children: Intervention

–  

–  Intervention designed to prevent PTSD and other psychological problems in youth exposed to trauma.

–  Administered by professionals at the site of the trauma.

–  Focus on victims’ immediate, tangible physical, social, and immediate needs.

–  Provide information for additional recourses if necessary.

•   PTSD in Children: Intervention

–  

– Multicomponent model

–  Parent treatment

–  Psychoeducation

–  Relaxation and stress management skills

–  Cognitive coping skills

–  Emotional regulation skills

–  Trauma narrative/cognitive processing of the event

–  In vivo desensitization to trauma reminders

–  Joint parent-child sessions

–  Enhancement of safety and future development 

•    Psychotherapy

– Successful formats

–  Individual

–  Group

–  Family 

•    Pharmaceutical

– Many take medications as part of trauma intervention

–  Limited evidence that medications provide significant added benefits.

Depression

Day 29

DSM-5: Depressive Disorders

Disruptive Mood Dysregulation Disorder
Major Depressive Disorder
Persistent Depressive Disorder

Disruptive Mood Dysregulation Disorder (DMDD)

•   Disruptive Mood Dysregulation Disorder

– Severe, recurrent temper outbursts manifested verbally and/or physically that are grossly out of proportion in intensity or duration to the situation or provocation.

–  Outbursts:

–  

– Occur, on average, three or more times per week.

–  Persistent and pervasively irritable mood between outbursts – occurs nearly every day, most of the day.

•   Disruptive Mood Dysregulation Disorder

– Duration of symptoms: 12 months or longer

– Context Requirement: 2 or more/severe in 1 or more

–  

– Age of onset: before age 10

•   Disruptive Mood Dysregulation Disorder

– Prevalence

– Community sample:

– Clinical sample:

– Course

– DMDD symptoms show continuity for many into adolescence.

– Some possible decline in irritability and angry outbursts

– More likely to develop/experience:

– 2x conduct problems.

– 3x ADHD

– 13x depression

– special education

– mental health referral

– bullying and ostracism by peers

•   Disruptive Mood Dysregulation Disorder

–  

– Differential Diagnosis

– ADHD

– First: DMDD – mood disorder, ADHD – behavioral disorder 

– Second: DMDD- severe, recurrent temper outbursts not typical of ADHD

– ODD

– First: DMDD – anger and aggression to people and property, ODD – anger and aggression to people

– Second: DMDD – wide range of people, ODD – specific person

– Third: DMDD more severe and longer outbursts

– Pediatric Bipolar Disorder

– First: Correlation between DMDD and parental depression

– Second: DMDD predicts depression or anxiety, not often bipolar

•   Disruptive Mood Dysregulation Disorder

– Risk Factors of DMDD

–   

– Increased Frustration

– Tendency to respond to minor hassles with frustration and anger.

– Associated Brain Regions 

–  Anterior cingulate cortex

–  Heightened reactivity

–  Associated with feelings of distress and frustration. 

–  Frontal and stratal brain regions

–  Underactivity

–  Associated with emotion regulation and planning an appropriate response when upset or angry.

•   Disruptive Mood Dysregulation Disorder

– Risk Factors of DMDD

–  Model: children have deficits in emotional regulation

–  

–  Tend to focus on emotionally threatening stimuli.

–  

–  Misinterpret benign actions or emotional expressions of others as hostile or threatening.

– Implication

–  Once children become upset due to cognitive biases they have more trouble regulating their emotions

•   Disruptive Mood Dysregulation Disorder

– Assessment

–  Self-report interviews and questionnaires

– Intervention

–  Medication

– Limited evidence for effectiveness but may be more effective for comorbid cases.

–  Comprehensive Family Therapy

–  Components:

–   

–  Parent training

–  Cognitive-behavioral interventions to help children regulate their emotions.

•   Disruptive Mood Dysregulation Disorder

– Intervention

–   

– Help children to interpret others’ emotions in a more accurate and less biased manner.

– Training:

–  Children are presented with a series of faces on a computer screen that fall on a continuum from unambiguously “happy” to unambiguously “angry.”

–  Children label the emotions and receive feedback.

–  Over time, children tend to become less bias in attributing hostility to more ambiguous faces.

Major Depressive Disorder (MDD) and Persistent Depressive Disorder (PDD)

•     Major Depressive Disorder (MDD)

–  Major Depressive Episode

–   

–  At least five out of the nine symptoms

–  Depressed or irritable mood

–  Diminished interest or pleasure in most activities

–  Significant change in appetite or weight

–  Significant change in sleep

–  Psychomotor agitation or retardation

–  Loss of energy or fatigue

–  Feelings of worthlessness or guilt

–  Thought and concentration problems.

–  Recurrent thoughts of death or suicide

–  Significant distress or impairment

–  Specify:

–  Single or recurrent episodes

–  Severity: number of symptoms, distress and impairment experienced  

•     Persistent Depressive Disorder (PDD)

–  

–  For children and adolescents, mood can be irritable for at least 1 year.

–  Two (or more) of the following:

–  Poor appetite or overeating

–  Insomnia or hypersomnia

–  Low energy or fatigue

–  Low self-esteem

–  Poor concentration or difficulty making decisions.

–  Feelings of hopelessness 

–  Significant distress or impairment

•     MDD and PDD

–  Differences

–   

–  PDD – more gradual; MDD – more rapid

–   

–  PDD - longer-term; MDD - shorter-term

–   

–  PDD - some similar symptoms to MDD, but overall, less severe

–  MDD – some similar symptoms to PDD, but overall, more severe

–  Specify:

–  With persistent major depressive episode

–  PDD and MD episode within the same year 

–  With intermittent major depressive episode

–  PDD and MD episode during part of the previous year

–  With pure dysthymic syndrome

–  PDD but no MD episode during the previous year

•     MDD and PDD

–  Prevalence

–  Lifetime MDD before adulthood

–  All: 10.6%

–  Girls: 14.2%

–  Boys: 7.2%

–  Current MDD (within a year)

–  All: 2.7%

–  Girls: 3.7%

–  Boys: 1.8%

–   

–  Current PDD (within a year)

–  All: 1%

–  Girls: 1.2%

–  Boys: 0.7%

–  Rates higher in adolescence than childhood

•    MDD in Girls

– Childhood and Adolescence

–  Pre-puberty: no gender difference

–  Post-puberty: girls more than boys

– Greater impairment of MDD in girls

–  More symptoms, more severe symptoms, self-harm more likely

–  Depressive episodes longer lasting.

–  More predictive of later anxiety and mood problems

– Why the gender differences?

–   

–  Excessive compliance

–  Emotional overcontrol 

•    MDD in Ethnic Minority and Disadvantaged Youth

– Ethnic Minority

–  Mixed research findings: difference is and are not observed

– Disadvantaged Youth

–  Increased risk for MDD

–  Youth from low-SES families

–  Single-parent households

•     Racial and Ethnic Differences in Major Depressive Episode, Severe Role Impairment, and Mental Health Service Utilization in U.S. Adolescents (Fan et al., 2022)

–  Method

–  Participants:

–  Data was from the National Survey on Drug Use and Health from 2010 to 2018

–  137,671 youth ages 12 to 17, 51.1% male

–  White = 76,822, Black = 18,304, Native American = 2,713, Asian American/other Pacific Islanders = 4,946, Hispanic = 27,922

–  Cross-sectional and correlational

–  Method of Observation:

–  Face-to-face interviews and Audio Computer Assisted Self Interview system.

–  Dependent measures

–  Past year major depressive episode (MDE)

–  MDE-related severe role impairment MDE-SRI

–  Mental health service utilization

–  Independent measures

–  Family structure

–  Past-year substance use

–  Engagement in youth activities or problem-solving groups (e.g., faith-based services)

–  Socio-demographic characteristics

–  Results

–  Prevalence Rates

–  MDE and MDE-SRI increased from 2010 to 2018 for U.S. youth.

–  Mental health intervention remained low from 2010 to 2018 for U.S. youth.

–  Racial and Ethnic Differences

–  Black youth = less likely to report a MDE and MDE-SRI compared to White youth

–  Multiracial youth = more likely to report a MDE and MDE-SRI compared to White youth

–  Racial and ethnic minority youth were less likely to receive mental health intervention compared to White youth. 

–  Prediction of MDE and Intervention

–  Youth-activity engagement = lower MDE incidence

–  Problem-solving group engagement = greater mental health intervention

–  Message

–   

•    Course and Comorbidity

– Course

–   

–  Symptoms in children (untreated): average 8-12 months

–  Symptoms in adolescents (untreated): average 3-9 months

–  Common: relapse

–  Kindling hypothesis: early depressive episodes sensitive to stressful life events and PDD, which over time stressors can trigger MDD more easily. 

– Comorbidity: Common conditions

–  ADHD

–  Substance use problems.

–  Disruptive behavior problems

–  Anxiety

•    Risk Factors of MDD and PDD

– Biological Factors

–  Genes and Neurotransmitters

– Heritability

–  Genes can explain 30% to 50% of the variance in children’s depressive symptoms.

– Neurotransmitters

–  Monoamine hypothesis:

–  Temperament

– Difficult temperament

•    Risk Factors of MDD and PDD

– Stressful Life Events

–  Stressful Life Events

–  20% to 50% report on major life stressor before an onset of a depressive episode

–  Gene-Environment Interactions

–  Diathesis-stress hypothesis

–  Stress and Coping

–  

–  If actions are not rewarded, actions decrease; adaptive behaviors might be decreased.

–  Cope with negatively by withdrawing or avoiding pleasant activities.

•    Risk Factors of MDD and PDD

– Cognitions

–  Negative Attributions

–  

–  Exposure to uncontrollable stressors lead to feelings of pain and despair.

–  

–  Attribute negative events to internal, stable, and global which can lead to feelings of helplessness, hopelessness, and depression.

•    Risk Factors of MDD and PDD

– Cognitions

–  Beck’s Cognitive Theory of Depression

– Three levels of maladaptive thinking that predisposes to depression.

–   

–  Immediately “pop” into mind when negative events occur.

–  Cognitive bias

–  Attend only to the negative aspects of an event.

–   

–  Make events more problematic than they really are.

– Negative schema (self, world, future) is developed by people. 

•    Risk Factors of MDD and PDD

– Relationships

–  Parental Depression

–   

–  Greater risk: mothers

–  Influence:

–  Genes

–  Atypical prenatal development of the children’s neurological and endocrine systems

–  Modeling of maladaptive behavior

–  Peer Problems

–  Poor quality friendships and peer rejection

•    Risk Factors of MDD and PDD

– Relationships

–  Biased in Social Information Processing

– Children with MDD: Two Biases

– Interpret ambiguous social situations negatively.

– React to problems by avoiding them or withdrawing from the situation.

MDD and PDD

•    MDD and PDD Intervention

– Assessment

–  Self-report interviews and questionnaires

– Cognitive-Behavioral Therapy

–  Cognitive-Behavioral Therapy: improve mood by targeting thoughts and actions.

–  Psychoeducation

–  Ensure a shared understanding of depression and treatment.

–  Goal setting and mood monitoring  

–  Identify realistic goals for treatment.

–  Behavioral Activation

–  Increase activity engagement to increase opportunities for positive reinforcement and pleasure.

–  Social Information Processing Training

–  Develop social problem-solving skills.

•    MDD and PDD Intervention

– Interpersonal Therapy

–  Interpersonal Therapy:

– Interpersonal Inventory

–  Address the number and quality of significant relationships.

–  Changes in the relationships

–  How the relationships impact mood

– Interpersonal Problem Areas

–  Identify one or two problem areas that focus on:

–  Grief and loss

–  Interpersonal role disputes

–  Role transitions

–  Interpersonal deficits

– Communication Analysis

–  Review the conversation and find more effective ways to interact and improve the relationship quality.

•    MDD and PDD Intervention

– Pharmacological Intervention

–  Goals of pharmacological treatment

– Ameliorate the distress and dysfunction in children.

– Prevent or limit relapse.

–  Common Medications

– Selective serotonin reuptake inhibitors (SSRIs)

– Black Box Warning 

– Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

– Black Box Warning