1. Chapter 6
Anxiety Disorders

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anxious, fearful, withdrawn, timid, depressed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

3. 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

4. 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

5. 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

6. 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

7. 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)

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. Videos Anxiety Disorders in children
OCD
Social Anxiety Disorder (children and adolescents)
Social Anxiety Disorder (adult)
Separation Anxiety Disorder