Lecture 16, 17, 18 + 19 - Anxiety Disorders

Question 1

When does anxiety (fear) become a disorder?

Answer 1

•Fear is a normative developmental event

It’s a disorder when it prevents them from everyday activities and cause impairment

Question 2

What is included under DSM-V anxiety disorders?

Answer 2

• GAD, social phobia, specific phobia, panic disorder, SAD, Selective mutism, agoraphobia

Question 3

what is Heller’s dimensional approach?

Answer 3

Two dimensions:

• Anxious arousal: somatic symptoms and acute fear
  ex: panic disorder, phobias
• Anxious apprehension: worry and fear of catastrophic consequences
  ex: GAD, OCD

Question 4

What is the Penn State Worry Questionnaire for Children

Answer 4

A way to measure anxious apprehension

Question 5

what is the dimensional approach?

Answer 5

Child Behavior Checklist

Question 6

Major features of SAD (separation anxiety disorder)

Answer 6

Developmentally inappropriate and excessive anxiety concerning separation from home or from whom they’re attached to - as evidenced by 3 symptoms…
Has to be present for at least 4 weeks in kids and 6 weeks in adults.

Question 7

Prevalence and characteristics of SAD

Answer 7

4-13% prevalence
Age of onset: 7-8 y.o
•Good prognosis, but it is common to go on to development other disorders, particularly panic disorder
•Often triggered by negative life event (death of a family member, etc)

Question 8

Major features of GAD (generalized anxiety disorder)

Answer 8

Disorder of worry
•Prevalence 3% to 6%
•Onset typically 10-14 years of age
•In young children, often comorbid with SAD and ADHD
•In older children, often comorbid with depression and specific phobias
•Severe GAD tends to persist over time, and is associated with poor social adjustment, low self-esteem and increased risk for suicide

Question 9

Major features of Specific Phobias

Answer 9

• Marked fear or anxiety about a specific object or situation (e.g. flying, heights, animals, receiving an injection, and seeing blood)
• Exposure to the phobic stimulus almost always provokes an immediate anxiety response
• The phobic situation is avoided or endured with intense fear or anxiety
• The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context
• The fear, anxiety, or avoidance is persistent, typically lasting 6 months or more
• The fear, anxiety, or avoidance causes clinically significant impairment in social, occupational, or other important areas of functioning
• Extreme, disabling fear of specific objects or situations that pose little or no danger
• Often leads to avoidance or disrupted routines
• Children may not realize the fear is extreme and unreasonable
• 5 general subtypes: animal, natural environment, blood-injection-injury, situational, “other”
• 4-10% of children
• Most childhood phobias have an onset between 7 and 9 years of age

Question 10

Social Phobia major features

Answer 10

• Marked, persistent fear of being the focus of attention or doing something humiliating.
• Children with social phobias are more likely to be highly emotional, socially fearful and inhibited, sad, and lonely
• Lifetime prevalence is 7-9 % of children and adolescents; more common in girls (2 X)
• Age of onset often early to mid-adolescence

Question 11

Panic disorder major features

Answer 11

• Panic disorder is defined as having recurrent unexpected panic attacks followed by at least 1 month of either
- persistent worry about having another attack
- persistent worry about the consequences of the attack
• A significant change in behavior (avoidance of situations where panic attack may occur)
• PD with agoraphobia: fear of having an attack in a situation where escape may be difficult or help unavailable (i.e. driving alone, going out in public places alone). —>In DSM-5, this is now called “agoraphobia”
• Prevalence 1-5%, although the occurrence of a panic attack is not uncommon (35%-65% of adolescent report at least one attack)
• Onset almost exclusively in adolescence, onset of 1st panic attack typically 15-19 yrs of age
• Worst prognosis of all anxiety disorders

Question 12

OCD (obsessive compulsive disorder) Major Features

Answer 12

• Lifetime prevalence around 2-3% of children; twice as likely in boys
• Onset typically 9-12 years of age
• Most common obsessions are concerns with dirt, germs or toxins, and something terrible happening (i.e. accidents, fire, death in the family)
• Most common compulsions are excessive washing, repeating actions (going through a door multiple times), and repeated checking.
• Comorbid disorders include other anxiety disorders, depression, Tourette’s Syndrome, as well as externalizing disorders
• Chronic course

Question 13

Developmental sequence of Anxiety Disorders

Answer 13

SA -> Specific Phobia -> OCD -> GAD –> Social Phobia —–> Panic disorder

This is time/age based.

Question 14

How common are anxiety disorders?

Answer 14

Prevalence of any anxiety disorder in children and adolescents is high (5.7% -17.7%)

Most common:
SAD, specific phobia, GAD
Least common But most severe**:
PD, OCD

Question 15

Comorbidity of anxiety disorders?

Answer 15

Estimates of comorbidity are approximately 60%, with disorders like GAD at around 90%

Question 16

Life course outcomes of young people with anxiety disorders

Explain the study.

Answer 16

New Zealand - Longitudinal
Longitudinal study of a full birth cohort (n=1265) born in 1977
• Followed from birth to adulthood
• 24% Attrition
•Asked whether having an anxiety disorder in adolescence (14-16 yrs) was a risk factor for problems in early adulthood (16-21 yrs)

CONCLUSIONS
- risk factor for psychopathology and a host of psychosocial problems
• However, anxiety disorders are associated with all kinds of other risk factors such as family instability and low socioeconomic status
• risk factor for major depression, anxiety disorders, substance use problems, and less education in early adulthood
• This evidence is extremely important if one is to argue a need for early prevention and treatment of childhood anxiety disorders

Question 17

Etiology of anxiety disorders

Answer 17

• Prevailing view is that anxiety disorder arises from a combination of temperamental factors and early psychosocial influences

Question 18

What is different in temperament of kids with anxiety disorders?

Answer 18

behavioral inhibition and withdrawal( that is, a tendency to show much fear and distress when faced novel, unfamiliar objects, persons, or situations)

Question 19

How early can you detect anxiety?

Answer 19

If you look at temperament of babies (1.5 y.o) you can get an idea

Question 20

What factors are predictors?

Answer 20

Child temperament: “Difficult” temperament at 5 months of age
Lifetime history of maternal depression

Question 21

What is a developmental sequence of bad temperament and mother’s depression?

Answer 21

Maternal depression/anxiety –> Temperament (also affected by environment such as parents, stress exposure, adversity) –> elevated anxiety in childhood (also affected by env.) –> childhood anxiety disorders (aso env.) –> adult major depression/anxiety OR other problems

Question 22

What effect does the temperament of “Behavioural inhibition (BI) have?

Answer 22

• Temperamental trait, can be assessed by 20-30 months of age (Jerome Kagan)
  • Describes 15%-20% of toddlers
  • Show elevated physiological reactivity (cardiac and stress hormone elevations)
  • Longitudinal studies show that increased risk for anxiety disorders (particularly social phobia) in adolescence
  • Odds ratio for social phobia: 2.0 -4.0

Question 23

How is BI expressed across lifetime?

Answer 23

INFANCY: high distress to novelty
TODDLERS: Classic BI, slow to approach, avoidance
EARLY CHILDHOOD: Shy and withdrawn
LATER CHILDHOOD + ADOLESCENCE: anxiety disorders, particularly social phobia

Question 24

Amygdala activation and BI

Answer 24

Novelty activates this area

- people with BI had even greater changes in amygdala when presented a novel stimuli

Question 25

What is the Behavioral inhibition model of Anxiety disorders

Answer 25

Behavioral inhibition --> Withdraw, avoid, less socially competent OR Attentional biases to threat Withdraw, avoid, less socially competent --> Peer rejection Attentional biases to threat --> Increased sensitivity to signs of rejection ALL this leads to: Negative self-perceptions --> Increased avoidance/withdrawal and anxiety disorders

Question 26

What are some tests to assess anxiety?

Answer 26

Stroop effect (colour and words different) OR emotional stroop task (meaningful words - measures attentional bias) Dot probe task - have four boxes and two words, focus on word where cue is

Question 27

Results of tests

Answer 27

Dot probe: Reaction time is faster when there's one neutral word and one meaningful negative word and the cue is on the meaningful word (compared to 2 neutral words) Reaction time is slower when there's one neutral word and one meaningful negative word and the cue is on the neutral word (compared to 2 neutral words) ----> because focus on meaningful ``` Also: Controls had same attentional bias - threat words or depressed words depression: avoid to depressed words GAD: attentional bias to threat words PTSD: avoid depressed words ```

Question 28

Does BI predict social withdrawl?

Answer 28

BI predicted social withdrawal in those children who showed attentional biases to threat, but BI did not predict social withdrawal in those who showed no attentional bias

Question 29

Explain attentional bias, interpretation bias, activation of schemas and behavioural response

Answer 29

Example: Attentional Bias: •Fast to detect signs of threat in the schoolyard •Slow to disengage from threat Interpretational Bias: •More likely to interpret ambiguous information as threatening Activation of Schemas: •World is a dangerous place •People want to hurt me •I have little control over what happens to me Behavioural Response: •Avoidance -staying away from other kids, makes me safe. •Non-assertive and lacking social skills–more likely to be refused, teased, etc

Question 30

Summary of Developmental Trajectories

Answer 30

* Early antecedents of anxiety-Behavioral inhibition * High sensitivity in the amygdala and behavioral inhibition * Probably a general risk for anxiety/depression, but some anxiety disorders have specific neurobiological substrates * Information processing and attentional bias: Possibly associated with the increased sensitivity in the amygdala, and it is an antecedents of later cognitive abnormalities and avoidance

Question 31

Evidence of a brain dysfunction in OCD

Answer 31

- cortico-striato-thalamocircuit • Basal ganglia (caudate nucleus, putamen) • Orbital frontal cortex • Cingulate • Thalamus • Important neural circuit linking the orbital frontal cortex to the thalamus • The circuit appears abnormally active • Hypothesized to disrupt inhibition or filtering of information

Question 32

Are anxiety disorder due to genetic factors?

Answer 32

* A small but substantial genetic component (h2: 25-37%) * Probably refers to temperament, behavioral inhibition * Sensitivity in limbic pathways, such as the amygdala (propensity to experience fear) * OCD has a stronger genetic component, h2: 40-50%)

Question 33

Three important influences for Anxiety Disorders

Answer 33

Learning mechanisms Insecure attachment Parenting

Question 34

how do learning mechanisms work

Answer 34

* Direct experience: bitten by a snake * Indirect experience: modelling and vicarious learning (watching father/mother express fear of snakes) * Transmission of information: hearing frightening stories

Question 35

How do insecure attachments influence?

Answer 35

Elevated childhood anxiety disorders in insecurely attached children than those securely attached • early insecure attachments lead children to view the environment as undependable, unavailable, hostile, and threatening

Question 36

How does parental factors influence

Answer 36

* Perceived overprotection (high control) and criticism/rejection * Meta-analysis (McLeod et al, 2007) indicates that parenting is important (significant), but only modestly (small effect size) * Control > rejection * Evidence that parents reinforce avoidant coping, and model anxious behaviors * For social phobia, social isolation may play a role

Question 37

what treatment is used for anxiety disorders

Answer 37

``` SSRIs BUT, none really APPROVD for use in kids... These are the only APPROVED: Fluoxetine (Prozac)MDD, OCD •Sertraline (Zoloft) OCD •Fluvoxamine (Luvox)OCD •Clomipramine (Anafranil)OCD ```

Question 38

Study treatment differences between CBT, meds, combination and control

Answer 38

* Percentage improved: * Combination therapy: 81% * CBT: 60% * Sertraline: 55% * Placebo: 24% * Combination therapy significantly better than both treatments alone * All treatment were better than placebo * Less adverse events (serious side effects) with CBT than sertraline

Question 39

Critique of treatment outcome studies

Answer 39

Sometimes there's invested interest for medications (funded by companies)

Question 40

CBT

Answer 40

``` • CBT aims to understand how maladaptive thinking contributes to anxiety, and attempts to provide news of responding to external and internal stimuli that elicit anxiety • CBT includes a number of techniques and strategies (exposure, modeling, identifying anxious thoughts) - Leads to cognitive restructuring - Coping cat: FEAR F: Feeling frightened? E: Expecting bad things? A: Actions and attitudes that can help R: Results and Rewards ```

Question 41

Exposure Therapy

Answer 41

* Exposure and response prevention (ERP) is as efficacious in treating OCD as medications * Each time someone responds with a compulsive behavior (hand washing) when they have an obsessive thought(contagious germs), anxiety decreases and the behavior is reinforced * Negative reinforcement * ERP is meant to reverse this process through the principles of habituation and extinction * anxiety will decrease following repetitive exposures to the feared stimulus * a behavior that is no longer reinforced will decrease * ERP also provides corrective learning experience, in that the feared outcome (becoming ill by touching a dirty glass) never occurs * Exposure is used for all anxiety disorders, particularly with OCD, the phobias and PTSD