1. Chapter 6 Anxiety Disorders Bilge Yağmurlu PSYC 330
Developmental Psychopathology

2. Anxiety Tripartite model Fear Anxiety Behavioral responses
Physiological responses
Subjective/cognitive responses
Fear
Immediate reaction to current threat
Anxiety
Alarm reaction to future oriented concerns
Worry

3. Normal Fears Kids have lots of them Parents may underreport fears
Girls exhibit more fears than boys
Girls exhibit more intensity than boys
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

4. Anxiety 12-20% of school age children Higher prevalence in girls
Some ethnic differences
Empirically coincides with depression see Table 6-1

5. Specific Phobia Animal Natural/environment Blood-injection-injury
Situational
Other (e.g., costumed figures)
Child shows fear in response to object
Avoids situations
Fear causes impairment
Most common anxiety disorder diagnosis in children
Comorbid with other disorders
Persistent
Table 6-2 has specific phobia criteria

6. Social Anxiety Disorder
Persistent fear of acting in an embarrassing or humiliating way in social or performance situations
Speaking
Reading
Writing
Eating
Maintaining conversations
Public performances
Speaking to authority figures
Okay with familiar adults
Problems with unfamiliar peers and adults
May develop somatic complaints to avoid social situations
Miss school
Report lower self-worth
Table 6-3 has the DSM criteria for social phobia

7. Social Anxiety Disorder
1-2% of community youth
Onset typically middle- to late-teens
May go unrecognized
Comorbid with other disorders, particularly anxiety
May have a history of separation anxiety
Social fears may evolve with development
Fears must be intense and cause impairment
May be related to Selective Mutism
See accent on selective mutism

8. Separation Anxiety
Excessive anxiety about separation from a major attachment figure
Demonstrates distress when faced with separation
Worries about losing or harm befalling attachment figures
May refuse to go to school
Refuses to be alone
Nightmares about separation
Physical symptoms with separation
May follow a stress or trauma
3-12% in clinic samples
Comorbid with other diagnoses, GAD most common
Prevalence decreases with age
Table 6-5 DSM criteria for SAD

9. School Refusal Often associated with SAD Other causes possible
Need to do functional analysis to understand motivation
1-2% of general population
No gender differences
Important to get child back to school

10. Generalized Anxiety Disorder
Overanxious disorder
Excessive anxiety and worry that the child cannot control
Worries not due to a specific event or stress
2-14% of youth
More common in girls
Median age of onset is 10
Comorbid with depression, phobias and separation anxiety, social phobia
Appears to be chronic

11. Panic Attacks & Panic Disorder
Attack - 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

12. Panic Attacks & Panic Disorder
Cued - caused by a trigger
Uncued - spontaneous occurrence
Panic disorder
Repeated unexpected attacks
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

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

14. 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
Table 6-9 PTSD criteria

15. 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
Depression
Survivor guilt
Related to maltreatment Figure 6-1
Table 6-8 PTSD criteria
Figure 6-1 DeBellis, 2001
Table 6-10 has rates of symptoms for abuse and non abuse stressors

16. Figure 6-1

17. 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
Reactions of parents
Coping style of the child

18. Acute Stress Disorder
Reaction to trauma that lasts between 2 days and 1 month
Must have dissociation

19. Obsessive Compulsive Disorder
Obsessions - unwanted repetitive intrusive thoughts
Compulsions repetitive, stereotype behaviors
Don’t need to have both
Highly time-consuming, interferes with normal routines
Child may not realize there is a problem
Germs and washing most common
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

20. Anxiety Disorders Specific Phobia Social Anxiety Disorder
Separation Anxiety
School Refusal
Generalized Anxiety Disorder
Panic Attacks & Panic Disorder
Post-Traumatic Stress Disorder (PTSD)
Acute Stress Disorder
Obsessive Compulsive Disorder

21. Etiology of Anxiety Genetics Runs in families Twin study data
Brain circuits and neurotransmitters
Serotonin
Gamma aminobutyric acid (GABA)
Limbic system
amygdala

22. Etiology of Anxiety Serotonin
People with anxiety disorders may have a serotonin deficiency, or else the available serotonin in the patient's body isn't being used as efficiently as it should be.
This belief is strengthened by the success of SSRI (Selective Serotonin Reuptake Inhibitors) medications. These drugs increase the amount of available serotonin in the body by blocking presynaptic reuptake transporters from drawing serotonin out of the synaptic cleft.

23. Etiology of Anxiety Gamma aminobutyric acid (GABA):
a neurotransmitter that reduces activity in the central nervous system

24. Etiology of Anxiety Limbic system amygdala
almond shaped structure found in both the left and right temporal lobes of the brain.
An amygdala-based neurocircuit has been proposed to mediate the fear and anxiety response.
The amygdala is central to registering the emotional significance of stimuli and the development of emotional memories

25. Etiology of Anxiety
fear conditioning: the increased activity of the amygdala that causes the symptoms of anxiety and panic.
One reason why people develop panic disorders is that, once they have experienced a panic attack and all the distressing symptoms that accompany the attack, they then start to fear another attack occurring. The memory of the physical sensations they experienced is ingrained in the amygdala, so the fear of the next panic attack becomes an anxiety in itself. This triggers a vicious cycle of fear where the more the attacks occur, the more fearful the sufferer becomes of the next attack, which induces more frequent and regular panic attacks.

26. Etiology of Anxiety
Life-threatening challenges result in the permanent imprinting of the experience in the emotional circuits through the amygdala, capturing the full emotional memory of the experience.
Associated cues are stored through the declarative memory circuits involving the hippocampus.

27. Etiology of Anxiety
Abnormalities in the size or neural activity of various structures in their brains.
For instance, brain-imaging studies of combat veterans with PTSD show that when they listen to recordings that bring back their worst memories, their amygdala become more active than other people's.
Amygdala also appears to be involved in triggering panic attacks, through its central nucleus.

28. Etiology of Anxiety
Oxytocin is a neurosecretory nonapeptide synthesized in hypothalamic cells, which project to widely distributed sites in the CNS as well as the neurohypophysis. Central OT affects a variety of cognitive, grooming, affiliative, sexual, and reproductive behaviors in animals.
OCD includes a range of cognitive and behavioral symptoms that bear some relationship to dimensions of behavior associated with OT. Data provide evidence that some forms of OCD are related to OT dysfunction. Some forms of OCD are at the extreme end of a range of normal behaviors that are mediated by OT and related systems.

29. Etiology of Anxiety
The state of being in love (what is sometimes known as romantic love). This state is characterised by feelings of exhilaration, and intrusive, obsessive thoughts about the object of one's affection.

30. Etiology of Anxiety Degree of heritability mixed evidence GAD and OCD
age of onset
Patterns of inheritance

31. Etiology of Anxiety Biological influences OCD has higher heritability
family and twin studies
Familial association between OCD and Tourette’s syndrome
Neurobiological abnormalities

32. Etiology of Anxiety Temperament Behavioral inhibition
Negative affectivity
Effortful control

33. Etiology of Anxiety Temperament Behavioral inhibition Kagan:
inhibited children developed more fear at 5.5 year old

34. Etiology of Anxiety Behavioral Inhibition System (BIS)
BIS refers to a subsystem of the brain that produces anxiety and inhibits ongoing behavior in the presence of novel events, innate fear stimuli, and signals of non-reward or punishment.
linked with increased amygdala.

35. Etiology of Anxiety
BIS is considered to be responsive to cues of punishment, novelty, uncertainty, and non-rewarding stimuli.
Therefore, people with more active BIS are vulnerable to unpleasant emotions, such as: frustration, anxiety, fear, or sadness.

36. Etiology of Anxiety
Gray: postulated the presence of several distinct neuroanatomic circuits modulating different aspects of the anxiety reaction.
In this model, anticipatory anxiety is proposed to be analogous to the state of behavioral inhibition seen in animals who are presented with a threat.
In this state, the animal stops what it is doing and becomes vigilant for any sign of danger.

37. Etiology of Anxiety Temperament
Negative affectivity: general and persistent negative (nervous, sad, angry) mood.
Bias toward attending to threatening stimuli
Positive affectivity
High rates of co-occurence of anxiety and depression

38. Etiology of Anxiety Temperament
Effortful control: the ability to employ sef-regulative processes
Combination of low EC and high NA

39. Etiology of Anxiety Psychosocial influences
Child’s development of a sense of control
Experience and perception
Family and parenting
intrusive: excessive regulation of children’s activities, overprotection, autocratic parental decision making, or instruction about how to feel or think
Hudson and Rapee (2002)
Caution: bi-directionality

40. Etiology of Anxiety Psychosocial influences Parents model behavior
Reinforce for anxious behavior
Reinforce avoidant behavior
Cognitive styles and parenting
(Dadds et al., 1996): Social information processing in ambiguous social problems
perception of threat
choosing avoidant solutions

41. Etiology of Anxiety Psychosocial influences Early caregiving
Hane and Fox (2006): early sensitivity and intrusiveness were related with more fearful behavior
Security of attachment:
Anxious/resistant attachment is a risk factor