Chapter 6 Anxiety Disorders

Anxiety Disorders Internalizing Disorders: anxious, fearful, withdrawn, timid, depressed seem to be unhappy and lack self-confidence

Anxiety Fear Immediate reaction to current threat Anxiety Alarm reaction to future oriented concerns Excessive Worry Anxiety : a future oriented emotion, characterized by perceptions of uncontrollability and unpredictability over potentially aversive events

Anxiety Tripartite model : 3 types of reactions to perceived threat Behavioral responses (e.g., running away) Physiological responses (e.g., heart rate change) Subjective/cognitive responses (e.g., thoughts of being scared) In anxiety Cognitive response  Worry Thoughts about possible negative outcomes that are difficult to control

Normal Fears Kids have lots of them Parents may underreport fears Girls exhibit more fears than boys Girls exhibit more intensity than boys (Caution: gender role expectations) Fears decline with age Worry becomes more prevalent and complex with age Fears coincide with different stages of development Few cultural differences Figure 6-1 shows declining fears with age King et al 1989

Anxiety Disorders Prevalence 12-20% in school-age children and adolescents In young children various symptoms of anxiety and depression co-occur. Girls are more likely to have anxiety disorders

Anxiety Disorders Specific Phobias Social Anxiety Disorder (SAD) Separation Anxiety School Refusal Generalized Anxiety Disorder (GAD) Panic Attack / Panic Disorder (PD) Posttraumatic Stress Disorder (PTSD) Acute Stress Disorder Obsessive-Compulsive Disorder (OCD)

Specific Phobias Excessive Cannot be reasoned away Beyond voluntary control Lead to avoidance Interfere with functioning Most commonly diagnosed anxiety disorder in children Usually more prevalent in girls Usually diagnosed with other disorders Usually persistent to adulthood

Social Anxiety Disorder Persistent fear of acting in an embarrassing or humiliating way in social or performance situations Okay with familiar adults / Problems with unfamiliar peers and adults Exposure to feared situation provokes anxiety (in children can be displayed as crying, tantrums, freezing…) Fear is excessive and unreasonable May develop somatic complaints to avoid social situations Miss school Report lower self-worth, sadness, loneliness Speaking Writing Maintaining conversations Reading Eating Public performances

Social Anxiety Disorder 1-2% of community youth Onset typically middle- to late-teens May go unrecognized Comorbid with other disorders, particularly another anxiety disorder May have a history of separation anxiety Social fears may evolve with development See accent on selective mutism

Separation Anxiety Excessive anxiety about separation from a major attachment figure and/or home Demonstrates distress when faced with separation Worries about losing or harm befalling attachment figures Persistent and excessive worry that an unlikely event will lead to separation from the attachment figure (e.g., being kidnapped). May refuse to go to school Refuses to be alone Nightmares about separation Physical symptoms when separation occurs or anticipated Table 6-5 DSM criteria for SAD Some anxiety is acceptable but not excessive

Separation Anxiety Presence of the symptoms for at least 4 weeks May follow a stress or trauma 3-12% in community samples Usually comorbid with other diagnoses (GAD most common) Prevalence decreases with age

School Refusal Often associated with SAD Need to do functional analysis (the function the behaviors serves) to understand motivation 1-2% of general population No gender differences Important to get child back to school

Generalized Anxiety Disorder Overanxious disorder Excessive anxiety and worry that the child cannot control The worry and fear are not focused on a particular object or situation Usually perfectionist and set high standards for themselves Significant distress or impairment in functioning Worries not due to a specific event or stress Constantly seek approval and reassurance Exhibit nervous habits (e.g., nail biting) and sleep disturbances Table 6-6 criteria for GAD

Generalized Anxiety Disorder 2-14% of youth Most common anxiety disorder among adolescents More common in girls Median age of onset is 10 Comorbid with depression, phobias and separation anxiety Appears to be chronic

Panic Attack & Panic Disorder Panic Attack- A discrete period of intense fear or terror with sudden onset Need 4 or more of the following: Pounding heart Sweating Trembling Shortness of breath Choking Chest pain Nausea Dizzy or faint Feelings of unreality or detachment Fear of losing control or going crazy Fear of dying Numbness Chills or hot flashes Table 6-7 DSM criteria for Panic Attack

Panic Attacks & Panic Disorder Cued - caused by a trigger Uncued - spontaneous occurrence Panic disorder- unexpected panic attacks that the person is concerned will reoccur without warning With agoraphobia or without Agoraphobia - attempts to avoid circumstances where an uncontrollable embarrassing attack may occur People are often homebound Table 6-7 DSM criteria for Panic Attack

Panic Attacks & Panic Disorder Panic attacks more common than panic disorder Panic disorder rare in childhood Panic disorder is more common in females Few seek treatment Stress seems to make it worse Appears to run in families Comorbid diagnoses are common Table 6-7 DSM criteria for Panic Attack

Post-Traumatic Stress Disorder (PTSD) Person exposed to traumatic event Includes threats of death or serious injury to self or others Person feels fear, helplessness or horror Person experiences triad of symptoms Reexperiencing Avoidance of trauma-related stimuli and numbing Symptoms of increased arousal Symptoms last for at least 1 month following the trauma Table 6-9 PTSD criteria

Post-Traumatic Stress Disorder (PTSD) Children avoid reminders of trauma Likely experience intrusive memories or flashbacks, may be evident in repetitive play Increased fears May be clingy or dependent Depressed mood Table 6-8 PTSD criteria Figure 6-1 DeBellis, 2001 Table 6-10 has rates of symptoms for abuse and non abuse stressors

Post-Traumatic Stress Disorder (PTSD) One-third of children exposed to trauma will develop PTSD Higher incidence in girls Early trauma can cause changes to the brain (HPA axis) Can have a chronic course Outcome impacted by: Nature of trauma Degree of exposure Subjective experience of threat Prior level of functioning (e.g., anxiety level) Reactions of parents Coping style of the child

Acute Stress Disorder Reaction (symptoms) to trauma lasts between 2 days and 1 month Must have dissociation General numbing Detachment Depersonalization Dissociative amnesia Table 6-8 PTSD criteria

Obsessive Compulsive Disorder Obsessions - unwanted repetitive intrusive thoughts Compulsions repetitive, stereotype behaviors that child feels compelled to perform and that are meant to reduce anxiety or prevent a dreaded event Germs and washing most common OCD- either O or C or both (so don’t need to have both) Highly time-consuming, interferes with normal routines Child may not realize there is a problem In children, compulsions reported more often Parents may not see the problem 1% prevalence rates Boys more than girls in childhood, evens out by teens Mean age of onset 10 years of age Comorbid with other disorders (anxiety, depression, Tourette’s) Persistent Table 6-11 has criteria for OCD Table 6-12 has common obsessions and compulsions

Videos Anxiety Disorders in children http://www.youtube.com/watch?v=4VbxjsO9IYI&feature=related http://www.youtube.com/watch?v=loRC9T8qUGk&feature=related OCD http://www.youtube.com/watch?v=OcXn3m3M-U0 Social Anxiety Disorder (children and adolescents) http://www.youtube.com/watch?v=BCABXBMu_E4 Social Anxiety Disorder (adult) http://www.youtube.com/watch?v=i-jHGYWAFTQ&feature=related Separation Anxiety Disorder http://www.youtube.com/watch?v=FzMExXi8hYo