Chapter 7 Anxiety disorders

Experiencing Anxiety
One of most common mental health problems in young people Often goes unnoticed Anxiety disorders have a more chronic course Anxiety: characterized by strong negative emotion and tension in anticipation of future danger or threat

Experiencing Anxiety
Many children experience more than one anxiety disorder at a time Moderate amounts of anxiety is adaptive; helps us cope with potentially dangerous situations Anxiety experienced by children with anxiety disorders is excessive and debilitating Neurotic paradox: know there is little to be afraid of but still terrified Anxiety is part of the fight/flight response

Experiencing Anxiety
Three interrelated anxiety response systems:
physical system- fight/flight response, mediated by the sympathetic nervous system cognitive system- attentional shift and hypervigilance, nervousness, difficulty concentrating behavioral system- aggression and/or avoidance

Anxiety vs Fear and Panic

Anxiety: future-oriented mood state, which may occur in absence of realistic danger Fear: present-oriented emotional reaction to current danger, characterized by alarm and strong escape tendencies Panic: sudden and unexpected fight/flight response in absence of obvious danger or threat

Normal Fears, Anxieties, Worries & Rituals

Many fears are developmentally appropriate and most decline with age Anxieties common, but anxious symptoms do not show the same age-related decline as fears Children of all ages worry, but children with anxiety disorders worry more intensely Ritualistic and repetitive activity common in young children and helps them to gain control and mastery of their environment

Separation Anxiety Disorder

Age inappropriate, excessive anxiety about being apart from parents or away from home- persist for 4 weeks, interferes with normal functioning Occurs in 10% of children (equally common in boys and girls)- most common anxiety disorder Of all anxiety disorders, SAD has the earliest onset
Often associated with school refusal

Generalized Anxiety Disorder

Excessive, uncontrollable anxiety and worry about numerous events and activities, occurring more days than not Apprehensive expectations: worry when there is nothing obvious to provoke the worry Worry excessively about minor everyday occurrences thinking consist of what- if statements Often accompanied by physical symptoms (e.g., headaches, stomachaches, muscle tension, trembling)

Generalized Anxiety Disorder

3% to 6% of children (equal rates in boys and girls) Onset in late childhood or early adolescence High co-morbidity with other anxiety disorders and depression Severe symptoms persist over time

Specific Phobia
Extreme, disabling fear of specific objects or situations that pose little or no danger Often leads to avoidance or disrupted routines Anticipatory anxiety is common Children may not realize the fear is extreme and unreasonable

Specific Phobia
5 DSM-IV subtypes: animal, natural environment, blood-injection-injury, situational, other 2-4% of children; more common in girls Few referred for treatment Peak onset between ages 10 and 13

Social Phobia
Marked, persistent fear of being the focus of attention or doing something humiliating Feel anxious about the most mundane activities Children with social phobias are more likely to be highly emotional, socially fearful and inhibited, sad, and lonely Generalised social phobia: fear most social situations

Social Phobia
1-3% of children; slightly more common in girls Age of onset often early to midadolescence- rare in children under 10 20%= depression Selective mutism may be a form of social phobia

Obsessive-Compulsive Disorder
Repeated, intrusive, irrational, and anxiety causing thoughts (obsessions), accompanied by ritualized behaviors (compulsions) to relieve the anxiety Time consuming- at least 1 hour a day Extremely resistant to reason

 Most common obsessions: Contamination Fears of harm Concerns with symmetry Sexual, somatic and religious preoccupation Most children have multiple obsessions and compulsions Often leads to severe disruptions in health, social and family relations, and school functioning

Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder
2-3% of children; twice as likely in boys Age of onset 9-12 years. 2 peaks: Early childhood: likely family history of OCD, dont think obsessions are abnormal Early adolescence High co-morbidity with other anxiety disorders, depression, disruptive behavior problems OCD is chronic for many children

Panic Disorder
Panic attack: a sudden and overwhelming period of intense fear or discomfort accompanied by characteristics of the flight/fight response
Short: reach max in 10 minutes Not physically harmful or dangerous Rare in young children but common in adolescents Physical changes of puberty = critical to occurrence of panic

Panic Disorder
Panic disorder: recurrent unexpected panic attacks, as well as persistent concern about the possible implications and consequences of having another attack
Behaviour changes due to attacks

High anticipatory anxiety and situation avoidance may lead to agoraphobia

Agoraphobia usually after 18

Panic Disorder
Panic attacks common, panic disorder much less common Adolescent females more panic attacks Age of onset 15-19 years Worst prognosis of all anxiety disorders

Posttraumatic and Acute Stress Disorders

PTSD: characterized by persistent anxiety following an extremely traumatic experience
Experiences include: major accidents, natural disasters, sexual abuse, war and violence

Posttraumatic and Acute Stress Disorders

Three core features of PTSD: 1) persistent re-experiencing of the event, eg. persistent nightmares and reenactment during play 2) avoidance of associated stimuli and numbing of general responsiveness, and 3) symptoms of extreme arousal Acute stress disorder: development of dissociative symptoms within one month after a traumatic experience, lasting at least two days but not longer than a month (short-lived)

Posttraumatic and Acute Stress Disorders

Common in children exposed to traumatic events Children have different traumatic thresholds Can be a chronic disorder for some children

Associated Characteristics
Cognitive deficits in areas such as memory, attention, speech, or language Interference with academic performance Hypervigilance to and avoidance of threatening stimuli Misattribution of threat Somatic complaints- some experience nocturnal panic

Associated Characteristics
Social withdrawal, loneliness, low selfesteem, difficulty initiating and maintaining friendships Strong relationship between depression and anxiety; both similar in terms of negative affectivity, however, those with anxiety have greater positive affectivity

Gender, Ethnicity, and Culture

Higher incidence in girls likely due to genetic vulnerabilities and gender role orientations Childrens ethnicity and culture may affect the expression and developmental course of fear and anxiety Cultures that favor inhibition and compliance may have increased levels of fears in children Child psychopathology reflects a mix of actual child behavior and the lens through which others view it in a childs culture (Behavior + Lens Principle)

Theories and Causes

Early Theories
classical psychoanalytic theory: anxiety and phobias seen as defenses against unconscious conflicts rooted in the childs early upbringing behavioral and learning theories: fears and anxieties learned though classical conditioning and maintained through operant conditioning (two factor theory) attachment theory: early insecure attachments lead children to view the environment as undependable, unavailable, hostile, and threatening

Theories and Causes

Temperament
children born with a low threshold for novel and unexpected stimuli are at greater risk for anxiety disorders; this type of temperament called behavioral inhibition (BI) development of anxiety disorders in a child temperamentally predisposed is dependent on parental response- those whose parents set firm limits and teach children to cope with stress have better outcomes

Theories and Causes

Genetic and Family Risk
family and twin studies suggest a biological vulnerability a general disposition to become anxious is what is inherited; the CRH (corticotropinreleasing hormone) gene may be associated with anxiety levels the form of anxiety that takes place is a function of environmental influences

Theories and Causes

Neurobiological Factors
overactive behavioral inhibition system implicated; BIS may be shaped by early life stressors brain abnormalities such as more pronounced right > left asymmetries and an over excitable amygdala have been implicated in children who are anxious and/or behaviorally inhibited norepinephrine, GABA, neuropeptides, and serotonin implicated

Theories and Causes

Family Influences
excessive parental control, overprotection, rejection, and modeling of anxious behaviors Parents are over involved and intrusive Parents more critical lower parental expectations for childrens coping abilities low SES + parental anxiety disorder= poor outcome for child insecure early attachments (particularly ambivalent attachment)

Treatment
Behavior therapy- exposure to feared stimulus, while providing ways of coping other than escape and avoidance Cognitive-behavioral therapy- teaches modification of maladaptive thoughts to decrease symptoms (most effective for most anxiety disorders) Medications can reduce symptoms, especially for OCD Family interventions may result in more dramatic and long-lasting effects