Download Anxiety and Children

Anxiety and Children
(Albano, Chorpita, Barlow, 2005)
Anxiety and Youth
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Anxiety disorders are among the most common
Psychiatric disorders affecting children and
adolescents
Anxiety disorders tend to have an early onset in
childhood and adolescents and run a chronic
course well into adulthood
Anxiety symptoms may worsen over time (kindling,
Physiological effects and learning) and may lead to
depression, suicide, Substance use, and
Psychiatric hospitalizations. When do they worsen?
Yet Anxiety Disorders are not well understood with
youths
Normal Childhood Anxiety
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All children are expected to display
separation anxiety or specific fears at
various times in their lives
The intensity and duration of this “normal
anxiety” has not been well studied
Anxiety is a normal aspect of moving from
dependency to autonomy that resolves thru
repeated exposure to new experiences
(habituation) and successes (efficacy)
Pathological Anxiety
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Measured by:
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Intractability
Pervasiveness or fear and avoidance
Degree of interference on daily functioning
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For example: Continued school refusal
Assess:
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1) Avoidance of negative affect
2) escape from aversive social and evaluative situations
3) attention seeking
4) Positive reinforcement (TV Watching)
A note about Panic Disorder
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Adult Panic Disorder requires metathinking,
thus children tend to present differently prior
to adolescence (hormone shift tends to
exacerbate the disorder)
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Fear of becoming sick/vomiting
Refusal to eat
Avoidance of places where escape is difficult or
endured activities with a “safety person”
The Biopsychosocial Model
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As you have already begun to see,
psychopathology must be assessed in
context and I use the Biopsychosocial
model.
All aspects are important
None are independent of the others
We could argue chicken or egg……
Etiology-Triple Vulnerability or
BioPsychoSocial Model
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Heritable Biological Diathesis
Generalized Psychological
Vulnerability (Temperament)
Specific Psychological Vulnerability
(Psychosocial Factors)
Etiology-Genetics
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Anxiety is highly heritable
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A shared genetic risk factor may be
responsible for a general vulnerability
for anxiety or depression, and unique
experiences modify the specific
expression of this vulnerability.
Etiology-Temperament
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A general vulnerability may be
connected to temperament identifiable
at 21 to 31 months.
When exposed to unfamiliar settings,
people, or objects is the child:
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Inhibited
Uninhibited
Etiology-Temperament (2)
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Looking at the biological system that underlies motivation and
emotion, we can explore the behavioral inhibition system or BIS.
(hippocampus, hypothalamus, prefrontal cortex, locus coeruleus)
The BIS is activated by signals for punishment, nonreward and
novelty resulting in narrowing of attention, inhibition of gross motor
behavior, increased scanning/vigilance, increased central nervous
system arousal (alertness), and activation of the fight flight system.
This system becomes “primed” if the cortisal levels remain elevated
for long periods of time, thus reacting more quickly and not “shutting
down” as easily resulting in anxiety disorders.
If the BIS is activated over time…depression may develop.
Interestingly, we often see anxiety preceding depression, but not the
reverse.
Etiology-Psychological Factors
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Aspects that may increase the risk for
negative emotions
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Coping
Social/familial transmissions
Information processing
Perceptions of Control
Etiology-Psychological Factors
(2)
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A history of lack of control may lead to
vulnerability to stressful events leading
to anxiety disorders.
An early lack of control  high BIS 
processing of events as uncontrollable
higher BIS…
Etiology-Psychological Factors
(3)
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Parenting:
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Parent modeling, prompting and rewarding of
anxiety leads to learned anxiety.
Parental distress related to child trauma also
impacts the development of child anxiety
disorders.
Children in early years look to emotional
reactions of others to novel stimuli to determine
the meaning of the stimuli.
Empirical treatment that focus on family
interventions vs. child interventions have higher
response rates.
Etiology-Psychological Factors
(4)
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Attachment Theory:
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Insufficient emotional attention or over
control are problematic thus,
“Affectionless control”  Anxiety
Circular process: Anxious child may draw
intrusive and controlling parenting more
than non anxious child.
Etiology-Psychological Factors
(5)
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Trauma
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Abuse
Loss
Oppression, Discrimination/Isms
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Overt
Covert
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Other events
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All have aspects of lack of control, punishment,
injury to self
Diagnosis and Treatment of
Anxiety
Diagnosing Anxiety Disorders
Anxiety Disorders
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Panic Attack
Agoraphobia
Panic Disorder
w/out agoraphobia
Agoraphobia w/out
hx of panic
disorder
Specific Phobia
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Social Phobia
OCD
PTSD
Acute Stress
Disorder
GAD
Anxiety due to
Medical condition
Substance
induced
Anxiety NOS
Anxiety due to a Medical
Condition
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Cardiopulmonary disorders
Hyperthyroidism-may include heat
intolerance and tremor
Hypoglycemia- reduced by eating candy
Alcohol ingestion
Caffeine overdose
Must cause distress or impaiment
Specify: with generalized anxiety, with panic
attacks, or with oc symptoms
Panic Attack- not a diagnosis, but
specified with anxiety diagnosis
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Four or more that develop abruptly and peak with in 10
minutes
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Pounding, racing, palpitating heart
Sweating
Trembling, shaking
Short of breath or smothering
Feeling of choking
Chest pain, discomfort
Nausea/abdominal stress
Dizzy, lightheaded, faint
Derealization (detached from reality) or depersonalization
(detached from oneself)
Fear of losing control or going crazy
Fear of dying
Paresthesias (numbness/tingling)
Chills/hot flashes
Panic Attacks
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After the first one, people tend to become
afraid of further attacks, making symptoms
worse and causing anxiety between attacks
(anticipatory anxiety)
If cued, people begin avoiding triggersleading to agoraphobia at times
Teach to breath (they are hyperventilating)
or use paper bag. Educate about attacks
and cycles. Ensure they are not going
crazy.
Agoraphobia- also not codable,
but occurs with other disorders
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Anxiety about being in places from which
escape might be difficult: Being outside the
home alone, being in a crowd, on a bridge,
on a bus, train or car, etc.
Situations are avoided, endured with much
distress, or require a companion
Not a social or specific phobia
Panic Disorder
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Usually begins prior to 35 yrs
Separation anxiety or childhood loss may
predispose
Runs in families
Has fluctuating course and tx has not failed
if some symptoms persist or reoccur
Catastrophobic thinking needs to be
addressed
Imipramine, SSRIs, MAOIs,
Benzodiazepines
Presentation of Panic Disorder
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In some cultures: Intense fear of
witchcraft or magic
More often in women than men
Onset is typically between adolescents
and mid-30’s
Chronic, but waxes and wanes
Familiar pattern
Panic Disorder
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Presence of recurrent, unexpected
panic attacks with at least 1 month of
persistent concern about having
another, consequenses, or sig
behavior change related to attack
Not substance or medical
Not social, specific, OCD, PTSD, or
Separation Anxiety
Panic Disorder
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With agoraphobia or without
agoraphobia
Agoraphobia w/out history of
Panic Disorder
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Focus of fear is on having panic like symptoms or
embarrassing/incapacitating symptoms (no full
panic attacks)
Does not meet criteria for Panic Disorder
Not Substance or Medical
Not better accounted for by another disorder or Axis
II avoidant
More often diagnosed in females
May persist for years and has much impairment
Specific Phobia (formerly
Simple Phobia)
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Marked and persistent fear of an object or situation
Exposure provokes anxiety response
Avoided or endured with dread
Realization in adolescents and adults that the fear
is excessive (as opposed to delusions)
Marked distress or interference with functioning
Not better accounted by another mental disorder
If under 18, at least 6 months
Specific phobia subtypes
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Animal Type, Natural Environment Type, BloodInjection-injury type (may have genetic link),
Situational Type, Other Type
Often results in restrictive lifestyle
Children may express with crying, tantrums,
freezing, or clinging and do not have the cognitive
abilities to recognize the fears are excessive
Predisposing factors: traumatic events, pairing w/
unexpected panic attacks, or informational
transmission
Familial link
Specific Phobia researched
Treatment
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Desensitization: exposure, relaxation,
mental rehearsal, supportive therapy
Flooding, graduated exposure,
systematic desensitization
MAOIs and SSRIs
Social Phobia 300.23
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Marked and persistent fear of social or performance
situations in which embarrassment may occur.
May also be hypersensitive to criticism, negative
evaluation, or rejection, trouble with assertiveness,
low self-esteem and feelings of inferiority, poorer
social skills
Typical onset in mid-teens, but can begin in
childhood and may be continuous depending on
environmental demands
Familial link
Social Phobia & Culture
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Japan and Korea: fears of giving
offense to others in social situations
(blushing, eye contact, or one’s body
odor will offend others)
Social Phobia Criteria
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Fear of social or performance situations, and
provoke anxiety. Situations are either avoided or
endured with extreme distress.
Person recognizes the fear is excessive
The avoidance or distress impairs functioning
Under 18, must last at least 6 months
Not substance or medical
Specify Generalized if fears include most social
situations ( and consider avoidant personality
disorder)
Tx of Social Phobia
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SSRIs
Beta Blockers for performance
Social Skill training and Assertiveness
training
Exposure
CBT
Obsessive Compulsive
Disorder
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Obsessions- persistent, disturbing, intrusive, thoughts or
impulses which the patient finds illogical but irresistible
These obsessions are considered absurd and client’s actively
resist them
Compulsions- obsessions expressed in action. Rituals used to
prevent or reduce anxiety (repetitive behaviors)
Both are used to reduce anxiety
Symptoms take up time, interfere with routine or functioning,
and marked distress
Not specific to another mental disorder
Specify with poor insight if excessiveness is not recognized
OCD Presentation
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People keep symptoms a secret, due
to embarrassment
Thoughts or images can be violent or
disgusting. “I want to stab my cat”
which disturb the client.
Compulsions must be completed or
the client believes something bad will
happen.
Forms of OCD
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Washers
Checkers
Doubters and Sinners
Counters and Arrangers
Hoarders
OCD
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2/3rds had symptoms prior to 15, and most
had some symptoms in childhood.
Chronic, lifelong, waxing and waning illness
Attempts to resist obsessions and
compulsions increases anxiety
Familial link
Obsessions are overvalued ideas, not
delusions
OCD vs OCPD
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OCPD- ego syntonic
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No true obsessions/compulsions
OCD- ego dystonic
OCD Presentation
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May avoid situations related to obsessions,
such as dirt/germs
Guilt and sleep disturbances may be
present
Excessive use of substances or sedatives
may occur
Equal in males and females
Onset: males 6 to 15, females 20-29.
Chronic, waxing and waning course
Familial link
OCD Treatment
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SSRIs
Need Continued medication due to
chronic nature of disorder
Behavior therapy with graded
exposure and response prevention
Address catastrophic thoughts
PTSD
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Exposure to trauma that involved actual or threatened death or
serious injury, or threat to physical integrity of self or others
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A stressor is followed by either 1) reexperiencing (intrusion)
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Hypervigilant, on edge, flooded by intrusive images (hallucinations,
nightmares, mental images), poor sleep and concentration, ruminate
about stressor, cry “without reason”, emotionally labile, easily startled,
somatic anxiety, fear going crazy and are unable to think about anything
except the stressor
And
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2) avoidance of the event
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May deal with denial w/ psychic numbing, minimizing the significance of
the stressor, forgetting it, feeling detached from others, losing interest in
life, constricted affect, daydream and abuse drugs
PTSD
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Increased arousal: difficulty falling or
staying asleep, irritable or anger
outbursts, poor concentration,
hypervigilance, exaggerated startle
response
Lasts more than 1 month
Significant distress or impairment
PTSD
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Acute: less than 3 months
Chronic: 3 months or more
With delayed onset: 6 months after
stressor (worst prognosis)
Triggers worsen symptoms
Natural events cause less distress
than People distress (torture)
PTSD
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Auditory hallucinations and paranoid
ideations can occur in severe cases
PTSD Diversity
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In Men, more common military/war
In women, more common rape, sexual
and physical abuse
Immigrants from war areas may be
hesitant to talk about experiences
PTSD Treatment
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Debriefing immediately after event can
prevent PTSD
Support groups
Confronting feared memories/topics
Examining misinterpretations of events
Development of coping
EMDR, TFT
Trazodone for sleep
Acute Stress Disorder
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Briefer form of PTSD lasting 2 days to 4 weeks
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Plus 3 symptoms immediately after stressor (with in 4 weeks):
subjective numbing, reduced awareness of surroundings “being in a
daze”, derealization, depersonalization, dissociative amnesia
(inability to remember important aspects of the trauma)
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Persistent reexperience of trauma
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Avoidance of triggers
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High Anxiety
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Impairment
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Not substance or medical
Generalized Anxiety Disorder
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Excessive anxiety and worry occurring more days
than not for at least 6 months, about a number of
things. Person has trouble controlling the worry.
3 or more: Restless/keyed up/on edge, easily
fatigued, difficulty concentrating, irritability, muscle
tension, sleep disturbance
Anxiety or worry not confined to other Axis I
disorder
Cause distress or impairment in functioning
Not substance or medical
GAD Presentation
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Chronic worry
warts
Tense
Highly distractible
Irritable
Restless
On edge
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Fatigued and mildly
depressed
Physical
complaints
Depression and Anxiety
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50% comorbid
Treat depression with antidepressants
and this will help with anxiety
GAD Treatment
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ID stressors that exacerbate anxiety
Eliminate dietary and physical sources
of anxiety
Increase exercise with physician’s
approval
Deep Muscle relaxation, meditation,
biofeedback
Buspar, SSRIs, Benzos
Generalized Anxiety Disorder
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Culture: In many cultures, anxiety is
expressed somatically or cognitively
Children: performance in school, sports,
punctuality, catastrophying about
war/earthquakes/etc, seek excessive
approval and reassurance, things need to
be perfect
Somewhat more frequent in women
Chronic but fluctuating course
Familial association
Others
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Anxiety due to a general medical
disorder
Substance-induced anxiety disorder
Anxiety Disorder NOS
Treating Anxiety
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Teaching Relaxation
Breathing Techniques
Desensitization (Approach vs. Avoidance)
Cognitive Triad
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All/Nothing
Future Focus
Catastrophyzing
Internal Conflicts