Substance use, anxiety and OCD Flashcards
(24 cards)
Definition -Substance Use Disorders
10 Different substancesoAlcohol, Cannabis, Opiods, Hallucinogens, Inhalants, Sedatives, Hypnotics, Anxiolytics, Tobacco, OtheroProblematic pattern of substance use leading to clinically significant impairment or distress as manifested by at least two symptoms occurring within a 12-month periodoExamples:oContinued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by useoImportant social, occupational, or recreational activities are given up or reduced because of alcohol useoUse is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol
Substance Use, Anxiety, & OCD DAY11-13PSYC412DR. CHRISTOPHE
Definition, Prevalence, and Treatment of Substance use Disorders
Definition -Substance Use Disorderso10 Different substancesoAlcohol, Cannabis, Opiods, Hallucinogens, Inhalants, Sedatives, Hypnotics, Anxiolytics, Tobacco, OtheroProblematic pattern of substance use leading to clinically significant impairment or distress as manifested by at least two symptoms occurring within a 12-month periodoExamples:oContinued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by useoImportant social, occupational, or recreational activities are given up or reduced because of alcohol useoUse is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol
(1) Substance is often taken in larger amounts or over a longer period than was intended.(2) There is a persistent desire or unsuccessful effort to cut down or control substance use.(3) A great deal of time is spent in activities necessary to obtain substance, use the substance, or recover from its effects.(4) There is a craving or a strong desire or urge to use the substance.(5) Recurrent substance use results in failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household).(6) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.(7) Important social, occupational, or recreational activities are given up or reduced because of substance use.(8) There is recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use).(9) Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.(10) Tolerance, as defined by either or both of the following:-A need for markedly increased amounts of substance to achieve intoxication or desired effect.-Markedly diminished effect with continued use of the same amount of the substance.(11) Withdrawal, as manifested by either of the following:-The characteristic withdrawal syndrome for a substance.-The same (or a closely related) substance is taken to relieve or avoid withdrawal sympto
Adolescence is a Risk Period for Substance Use Problems
Earlier use = higher risk for problematic use15.1% of kids who start drinking by 14 develop alcohol use disorder, compared to only 2.1% of those who start at 21+Research trying to disentangle the extent to which early onset is a risk marker versus a risk factorSubstance use in adolescence is associated with the three leading causes of death for adolescents: accidents/injuries, suicide/self-harm, and interpersonal violenceAlso, educational problems and legal problem
PrevalenceExperimentation is very commonoIn the United States, 2/3 of students in Grade 12 and nearly ½ of students in Grade 10 report drinking alcohol in the past yearLifetime prevalence of any substance use disorderNCS-A (national comorbidity survey –adolescent)Adolescents aged 13 to 18 years: 11.4%13-14 year olds: 3.7%15-16 year olds: 12.2%17-18 year olds: 22.3%https://monitoringthefuture.org/
Substance use among adolescents has decreased in the last 5 years. Below pre-pandemic levels.
Treatment Models
Early Brief InterventionsOutpatient TreatmentResidential Inpatient Treatment
Early, Brief InterventionsNorm-based interventions for college studentsNorms about drinkingInjunctive norms: How much others approve or disapprove of drinkingDescriptive norms: How much others actually drinkE.g. Alcohol EDU
Norm-Based InterventionsBrief Alcohol Screening and Intervention for College StudentsIndividualized feedback about:Actual drinking normsComparison between individual’s drinking pattern and the norm1) This is how much you drink2) This is how much you think others drink3) This is how much others actually drink4) Percentile ranking showing where you are relative to others on your campusChanges in perceived norms may mediate txeffects (Neighbours, Larimer, & Lewis, 2004)
Do they work?Network meta-analysis of 7 manualized brief alcohol interventionsMost programs generally worked well in reducing drinking frequency & quantity 0-6+ months post interventions
Outpatient TreatmentFamily TherapyAlcoholics Anonymous (12 Step Programs)
Outpatient Treatment -Family TherapyMultidimensional Family TherapyAdolescentE.g., Use as a means of coping with distressParentsE.g., increased parental monitoring
Outpatient Treatment -Alcoholics AnonymousVery popularPeople experiencing problematic alcohol use seek out AA more than all other forms of treatment combined12 stepsAcknowledge that alcohol is a problemRecommend abstinenceSupported by a peerEasily accessibleMore than 30 meetings in Montreal todayGlobalParticipation in AA →with less alcohol consumption & fewer substance related problemsThree hypotheses why
Results of randomized trials comparing AA to another form of treatment or to a no treatment control group suggest AA does not do better and may do worseHowever, there are very few well-done studiesIn several of the randomized trials, participants were coerced into treatment (e.g., court referred)
More recently …Study examining 2000 men seeking treatment for alcohol use at VA hospitalAll met criteria for a diagnosis of alcohol use disorderReceived treatment After finishing treatment, researchers followed them and collected data about their substance use and their attendance at AA meetings
3 hypotheses:
1) AA attendance →Lower alcohol useAA involvement at 1 year post treatment predicted less alcohol use at 2 years post treatment2) Lower alcohol use →AA attendanceAlcohol use at year 1 did not predict AA involvement at year 23) Good prognosis (e.g., better motivation, less co-morbid psychopathology) →Lower alcohol use and AAResults not explained by alcohol use severity, motivation, or co-morbid psychopathology
InpatientIn-patient treatmentShort duration (4 to 6 weeks)Range of treatment programsIndividual counselling, family therapy, treatment for comorbid disordersOften followed by outpatientVery few controlled studies have examined the efficacy of inpatient treatment for substance use in youth–couldn’t easily find a good meta-analysis focusing on youth as of Feb 2025
Summary
Substance use disorders are common for adolescentsEvidence that brief, norm-based interventions can reduce drinkingFamily-based therapy is an evidence-based intervention for substance use
Anxiety disorders
Internalizing symptoms
Cluster of interrelated problemsanxiety disorders mood disordersDevelopmental psychopathology framework Remember that we evaluate what is abnormal in the context of what is typical for children of that agefear and sadness are important emotions“normal” fears come and go over development
Anxiety DisordersAssociated with significant impairmentSocial impairmentExcluded, unliked, victimizedAcademic impairmentLow service utilizationAnxiety problems often go untreatedMost youth with mental health problems do not receive treatment
see table
1) Some Fear and Anxiety is NormalNearly all 1-year-olds become distressed when separated from MomMost children have very short lived specific fearsAbout half of children aged 6 to 12 have 7 or more fearsIs it causing disability, distress, or risk?2) Some Anxiety is AdaptiveStranger anxiety in young childrenText anxietyExcessive checking of homework and assignments3) It may not be as upsetting to adultsAnxiety may not be causing as much disruptionMay be associated with favourablecharacteristicsLess aggression
Core FeaturesFocus on threat or dangerAnxiety is future oriented“anxious apprehension”Note that this differs from fear, which is present-orientedStrong negative emotion or tension, displayed as: Physical sensationsCognitive shiftsBehavioral pattern
Anxiety disorder diagnoses
Many specific diagnosesvary on content of threatvary on balance of symptoms (e.g., worry versus physical)In DSM-5 anxiety disorders now separated from OCD –different sectionsAnxiety DisordersObsessive Compulsive and Related Disorders
Specific phobiaSpecific situations or thingsDiagnostic specifiersAnimal (e.g., spiders, insects, dogs)Natural environment (e.g., heights, storms, water)Blood, injection, injury (e.g., needles, invasive medical procedures)Situational(e.g., airplanes, elevators, enclosed places)Other(e.g., situations that may lead to choking or vomiting; in children, loud sounds or costumed characters)
———–20% prevalence in children
More common in girls
7-9 years old onset
Clinical level phobias more likely to persist than normal fears———-
Separation anxiety Separation from or harm coming to loved onesDo not want to be separated from parentsWorrying about events that might separate them from parentsOccurs in 4-10% of childrenMore prevalent in girls than in boyshttps://youtu.be/063CXAGEOv0?si=dtXCLZ-n09gjgqAY(1:45)
———–has to be out of proportion from norm
———–worry about bad things happen to parents when away
2/3 also meet criteria for other anxiety disorders
50% develop depression
1/3 kids some form of separation anxiety persists into adulthood———-
Social anxietyFear of negative evaluation by othersFear of social situations in which person will be evaluatedFor children, must occur in peer settings (not just with adults)
Selective MutismFailure to speak in specific situations and contexts in which speaking is expected, even though they may speak in other settingsReclassified as an anxiety disorder in DSM-5, but not clear that all children with selective mutism are anxious
——-may speak in other settings
Generalized anxiety disorderExcessive, uncontrollable anxiety and worryWorrying can be episodic or almost continuousWorry excessively about minor everyday occurrencesSomatic (physical sx as well)
———–2.2% lifetime prevalence
equally common in boys and girls
comorbid
early adolescence onset
persistence over time————–
Panic DisorderPanic attack: period of intense fear or discomfort that develops abruptly and is accompanied by at least four symptoms (e.g., sweating, shortness of breath, feeling like you are choking, chest pain, nausea)DSM-5 Criteria for Panic DisorderRecurrent, unexpected panic attacksAt least 1 attack followed by one month+ of one of the following(a) persistent concern about having additional attacks(b) worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”)(c) a significant change in behavior related to the attacks^ Note, you can have panic attacks and not have panic disorder
————–has to be unexpected if panic disorder! not in just very anxiety inducing contexts—————
Obsessive-Compulsive Disorder (OCD)ObsessionsRecurrent, persistent thoughts, impulses, or images that are experienced as intrusive, inappropriate, and that cause marked anxiety or distressThe person attempts to ignore or suppress the thoughts or to neutralize them with another thought or actionThe person recognizes that the thoughts are a product of their own mindCommon obsessionsContaminationHarm to self or othersSymmetry
CompulsionsRepetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidlyThe behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded events or situationshowever, these behaviors/mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or they are clearly excessiveCommon compulsionsCountingCheckingWashing
——–NOT AN ANXIETY DISORDER
either obsessions or compulsions to get diagnosed (or both, but not necessary)
time consuming, 1 hour or more a day
Specifiers: good/fair insight, poor insight, absent insight, tic-related or not
Summary
Anxiety disorders are debilitating and often go untreatedDSM-5 includes many anxiety disorders that vary in terms of the focus of the threat and the balance of the symptoms (e.g., worrying versus physical symptoms)OCD is notclassified as an anxiety disorder, but has some related features
Prevalence
NCS-ALifetime prevalence of any anxiety disorder during childhood and adolescence is 32%Specific phobia: 19% (most do not get treatment)Separation anxiety: 8%Social Anxiety Disorder: 9%Generalized anxiety disorder: 2% Panic Disorder: 2%Estimated prevalence of OCD 1%-2%Estimated prevalence of selective mutism is 0.7%
Gender
——2:1 female to male ratio
at age 8-9-10 start to seeing that difference
For OCD, 2:1 male to female——
Socioeconomic Status & EthnicityNote that anxiety is present across socioeconomic strata and across culturesSpecific, contextual experiences may shape what anxiety looks likeNCS-ASocioeconomic statusLower levels of parental education and living in a single-parent headed household associated with greater likelihood of having an anxiety disorderEthnicityAnxiety disorders more common among Black youth than among White youthHowever, White youth receive services for anxiety more than Black youthRace-based rejection sensitivitymight be a contributor
Comorbidity: other Anxiety Disorders
Youth who have one anxiety disorder often meet criteria for othersE.g., Selective mutism 80% of youth with selective mutism meet diagnostic criteria for another anxiety disorder69% of youth with selective mutism meet diagnostic criteria for social anxiety disorderThere are youth with selective mutism who do not report experiencing significant anxietyLook to your book for more info on comorbidity within anx disorders
Comorbidity: DepressionDiagnostic co-morbidity can be as high as 75 to 80%Ontario Child Health Study6 month prevalence77% of adolescents who meet criteria for Major Depression also meet criteria for an anxiety disorder45% of adolescents who meet criteria for an anxiety disorder also meet criteria for major depression
—-often anxiety first, then depression—-
Comorbidity: Anxiety and DepressionSymptom overlapGAD and MDD: fatigue, sleep disturbance, irritability, concentration difficultiesNegative affectivity -Extent to which person feels distressNote that positive affectivity –extent to which person feels positive affect –is an independent dimension of affectPositive affectivity is negatively correlated with depression, but is independent of anxiety symptoms and diagnose
Clinical CorrelatesAcademic difficultiesYouth with anxiety disorders typically have IQs in the typical rangeSymptoms may interfere with academic functioningImpact of worry on concentrationSchool refusal/Difficulty remaining in schoolSeparation anxiety, social anxietySelective mutismWill not talk in specific social settingsSocial DifficultiesShy/withdrawn children become increasingly rejected by the peer group with ageMore likely to experience peer victimization
——-often go see nurse for physical symptoms, manifestations of anxiety
as likely to have friends, more likely to rate these friendships as lower quality———-
Developmental course
Some fears, worries, and rituals developmentally appropriateDifferent “typical” age of onset for each fear2 years of age: Loud noises, animals, the dark, separation from parents5 years of age: Animals, dark, separation from parents, bodily injuries, “bad” people7 to 8 years of age: Dark, supernatural beings, staying alone, bodily injuriesWorries more complex as youth age
Developmental Course of Anxiety DisordersYoung children may not realize that their fears or behavior are excessive or atypicalAs children become older, they may become more embarrassedYoung children may not be able to tell you how they are feelingDefiance, acting out underlying anxiety
Different Anxiety Disorders Show Different Ages of OnsetSeparation Anxiety Disorder (7 to 8 years)OCD(9 to 12 years) technically not an anxiety disorder*Some children will show it very early –6 to 10 yearsGeneralized Anxiety Disorder(10 to 14 years)Social Anxiety Disorder –adolescencePanic Disorder–adolescence
—–selective mutism 2-4 years———–
Prognosis of Anxiety Disorders
Research is ongoing to determine what the long-term outcomes of anxiety disorders areHomotypic continuity (staying the same over time) –E.g., separation anxiety @7 →separation anxiety @ 17Heterotypic continuity (doesn’t stay the same all the time, morph into other things) E.g., social anxiety →depression, generalized anxiety
Summary
Anxiety disorders are commonGirls are more likely to have an anxiety disorder than are boysAnxiety disorders often co-occur, and are also highly co-morbid with depressionAdolescents with anxiety disorders are more likely to have anxiety disorders and major depression in young adulthood
Heritability of Anxiety
Evidence that tendencies towards anxiety are inherited(1)Children of parents with anxiety disorders ~5X more likely to have an anxiety disorder than are children whose parents do not have anxiety disorders(2)Twin studies indicate that 33% of variability in anxiety is heritable.
—–but not necessarily the same type of anxiety as their parents. Anxiety as a whole———-
Biological Predisposition to AnxietyInherit a general vulnerability (diathesis) to anxiety disordersTemperamentBehavioral inhibition Fear and distress in response to novel situationsWithdrawalNegative emotionality
Learning
Two-Stage Model of Fear AcquisitionEtiological and maintenance model for specific phobia (Mowrer, 1948)Stage 1: Fear develops through classical conditioningUnconditioned stimulus (US)A stimulus that leads naturally to the responseUnconditioned response (UR)Response to the unconditioned stimulusConditioned stimulus (CS)Neutral stimulusConditioned Response (CR)Response to the CS that results from reliably pairing the CS and the US
Stage 2: Operant ConditioningStage 2 Avoidance behavior maintained through operant conditioningRecall that operant conditioning involves adding and removing positive and negative stimuli to change rates of behaviorAvoidant behavior provides relief from anxietyThis is a powerful reinforcer(negative reinforcement)Avoidant behavior increasesNote that not only does this increase avoidant behavior, it increases the idea that that there was something there to fear in the first place
Maintenance Model of OCD
see image
Unwanted intrusive thoughts are typical293 undergraduate studentsRunning car of road –64% of women, 56% of menCutting off finger –19% of women, 16% of menLeft the stove on –79% of women, 66% of menImagining strangers naked –51% of women, 80% of menDifference is not in whether you have unusual obtrusive thoughts, difference is how important you think they arePurdon and Clark (1993)
Course of OCD
Mean age of onset 9-12 years old2 different peak onset periods ———-(bimodal)——– –early childhood (more likely to be boys, have family hxof OCD) and late adolescence/early adulthood50-66% of children with OCD still meet criteria 2-14 years later Symptoms do get slightly better with time, however<10% experience complete remission^ Risk factors for poor prognosis: earlier onset, poor first response to tx, tic disorder, parental psychopathology
Summary
Anxiety is heritableExperience shapes anxietyTwo-factor model of fear acquisition posits that fear is learned through classical conditioning and maintained through operant conditioningSimilarly, for individuals with OCD, operant conditioning serves to reinforce the compulsions and to increase the distress associated with the obsessive thoughts
Cognitive factors
Social Information ProcessingWhat do I pay attention to? (encoding)What does it mean? (interpretation)What can I do? (response search)What will I do? (response decision)How well did I do it? (enactment)
Social Information Processing & Anxiety DisordersEncoding -Attention to threatDo anxious youth show an attentional bias for threat-related information?2019 annual review says…It is well-establishedthat those higher in anxiety show greater attention to potentially threatening stimuli (e.g., angry faces) than those low in anxiety^ shown across many different types of tasksHowever, attention to threat varies widely situation to situation among people high in anxiety as well^threat intensity, personal relevance of threat information, and current mood moderates people with anxiety’s attention to threat
Interpretation Biases in Pediatric Anxiety2020 review and meta-analysis of interpretation bias and social anxiety44 studies ~3700 people totalStrong association between social anxiety and negative interpretation biasinterpreting ambiguous social events negatively and catastrophizingeven mildly negative social events^ may lead to avoidance, which relieves anxiety in short term but increases anxiety around subsequent social situations and also leads to other social/occupational/educational costs (so negative long-term outcomes)Negative interpretational bias = significant maintenance factor for anxiety –not just social anxiety
Family factors
Family Factors in Pediatric AnxietyEnvironmentModelingParents demonstrate anxious responses to childrenSeeing someone else show fear may cause a child to develop fearMonkeys develop phobia by watching their parent experience fear (Mineka et al., 1984)Monkeys develop phobia by watching videotaped models experience fear (Cook & Mineka, 1989)InformationtransmissionBeing told that something is dangerous can make you fear it Parent Low expectationsExpect children to have difficulty or not be able to copeParental reinforcement of problematic behavior
Three groups of childrenClinically referred for anxietyClinically referred for ODDCommunity control groupPresented with 12 ambiguous situations“You see a group of students from another class playing a great game. As you walk over and want to join in, you notice they are laughing.”What would you do to solve the problem?Children and their parents discussed two of the situations for 5 minutes, afterwards children provided a final answerBarrett et al., 1996
See table of results
Parents ‘talked’ anxious children into engaging in avoidant responses!
Evocative
Summary
Unified model of anxietyBiological predisposition towards anxietyFamily factors contributeDiathesis-stress modelBiological diathesisFamily and environmental stressLife experience shapes the form of the disorderSocial cognitive processing plays a role in symptom maintenance
SSRIs
Selective Serotonin Reuptake InhibitorsPaxil, Prozac, Zoloft, CelexaWork by stopping the reuptake of serotonin into the presynaptic neuron OCD, GAD, SAD, social anxiety disorderNot many studies looking at use of these drugs in youth, but some evidence of effectiveness across these different disorders E.g.→
Core Components of Effective Intervention
Review: Core Features of Anxiety Disorders
Focus on threat or dangerfuture oriented“anxious apprehension”Strong negative emotion or tension, displayed as: cognitive shiftsphysical sensationsbehavioral patterns
(1) Reduce cognitive biasesSelf-talkAnxious feelingsThoughts that go with anxious feelings“This is so scary”“I can’t do this”Child learns to identify different thoughts and the behavior that goes with those thoughtsCoping self-talkI’m a brave girl. I can take care of myself in the dark.Nobody’s perfect. We all make mistakes
Novel cognitive interventions
Retraining threat biasRecall that anxiety is associated with attentional bias for threatCan we retrain that?
Novel Cognitive InterventionsDo a dot-probe taskMajority of trials the probe follows a neutral faceTrained to look away from threatEvidence from randomized trials with adults that this re-training reduces attention bias and internalizing symptom
Attention Re-training40 children seeking treatment for anxiety at a hospital based clinicPrimary diagnosis of separation anxiety, generalized anxiety, specific phobia, or social phobia75% met criteria for two anxiety disordersParticipants randomly assigned to:Attention-bias modification (ABM)Angry-neutral stimulus pairs, and target was always paired with neutralNeutral-neutralOnly see neutral-neutral pairsPlaceboAngry-neutral stimulus pairs, and target was paired with neutral 50% of the timeTrial is double-blind -Families and clinic staff are unaware of assignmentEldaret al, 2012
All participants received four training sessions over four weeks (one session a week)480 dot probe trials per sessionAfter treatment, had all participants complete a dot probe taskOnly participants in the ABM showed decrease in threat bias at post-testOther outcomes also decreased→Attention Re-trainingEldaret al, 2012
2) Reduce bodily tensionDiaphragmatic breathingProgressive muscle relaxationGuided imagery
3) Exposure and habituationFacing feared stimuliControlled exerciseUsually graded (baby steps)Key technique in CBT for anxiety
Why is Exposure Important?Stage 1: Fear develops through classical conditioningUnconditioned stimulus (US)A stimulus that leads naturally to the responseUnconditioned response (UR)Response to the unconditioned stimulusConditioned stimulus (CS)Neutral stimulusConditioned Response (CR)Response to the CS that results from reliably pairing the CS and the US
Stage 2: Maintenance of avoidant behaviorWhat happens if you do not avoid?HabituationThink about:Walking into a dark roomJumping into a cold poolWatching “The Exorcist” for the 15thtime
Extinction paradigmUS: DangerUR: FearCS: DogCR: FearCS-: CS presented in the absence of the USRepeated exposure to CS-will extinguish the relationship between CS and CR
Flooding: intense experience, cant physically avoid. can only be at max anxiety for so long
graded exposure: gradual
Developing a Graded Exposure HierarchyList anxiety triggersRate each trigger“Subjective Units of Distress” from 0-10May use a Mood Thermometer (faces) with young childrenRank order triggersOrganize from easiest to hardest tasksBuild a good ladder
———-want it to be detailed—————
PlanWhere to start?Towards the bottom of the hierarchy —-but not a 0—–
Keep trackRate anxiety during exposureKeep track of anxiety across exposuresPracticePractice each exposure until habituationMove up the hierarchy
—————repeat exposure many times———–
CBT for OCDWhere can we break into this system?What happens when we stop the ritual?Treatment Goals(1) Normalize OCD and Intrusive Thoughts(2) Exposure and response preventionhttps://youtu.be/Z6bnD-IwFKg2-minute
SSRIs, CBTFor youth, cognitive-behavioral approaches usually recommended firstMedication does not cure anxietySuppresses symptomsLearning may be context specific
——–worry that doing behavior work (like exposure) while SSRIs won;t generalize to when not SSRIs———–
Summary
Major treatment approaches for pediatric anxiety disorders are CBT and SSRIsHistorically, cognitive therapy for anxiety has focused on modifying self-talk, but novel interventions re-training attention have shown efficacyExposure is a core component of CBT for anxiety disorders and OC
Major RCTs Testing Efficacy of Treatments for Pediatric AnxietyChild/Adolescent Anxiety Multimodal Study (CAMS)Pediatric OCD Trial (POTS)
CAMSMajor RCT for youth anxiety Test efficacy of SSRICBTCombined6 sites 488 youth with GAD, separation anxiety, social anxiety disorderDiagnoses made using a semi-structured interview
Randomly assigned to receive:SSRIPill PlaceboCBTSSRI + CBTTreated for 12 weeksClinician ratings of anxiety symptomsClinicians do not know what treatment group the child was in
Outcome: Anxiety symptoms at 12 weeksCombined, CBT, SSRI > PlaceboCombined > CBT, SSRICBT = SSRIModerator: Anxiety diagnosesCombined is associated with best outcomes across all three diagnosesSocial anxiety disorder: SSRI > CBTGAD: CBT > SSRIWalkupet al., 2008
Anxiety symptoms at 12 weeks (end tx)Combined, CBT, SSRI > PlaceboCombined > CBT, SSRICBT = SSRIModerator: Anxiety diagnosesCombined is associated with best outcomes across all three diagnosesSocial anxiety disorder: SSRI > CBTGAD: CBT > SSRIWalkupet al., 2008This general pattern of differences maintained at 3-and 6-month follow-upsPiacentiniet al., 2014
CAMELS (Extended Long-term Study) –follow up 3-11 years post-txImprovements in functioning (overall, family dysfunction, caregiver strain) during CAMS led to long term improvements in anxiety severityImprovements in psychopathology during CAMS (anxseverity and parent psychopathology) associated with long-term increases in overall functioningImprovements/txresponse related to long-term outcomes(nonspecific to condition)Crane et al., 2021
POTSPediatric OCD Treatment Study (POTS)112 youth with OCDRandomly assigned to one of four groupsSSRIPill placeboCBTCBT + SSRIMeasured OCD symptomsRated by an observer unaware of treatment condition
Combined treatment > CBT, meds, placeboCBT = Meds*CBT, Meds > PlaceboBUT ….This study was done at two different sites
PennU vs. DukeU
At PennU, not significant difference between Combined and only CBT
Suggests if high quality CBT, not added gain to medication
Summary
CAMS trial and POTs trials found that CBT and SSRI are both better than placebo for reducing symptoms of anxiety/OCDIn both trials, combined treatment (CBT + SSRI) was more effective than either treatment in isolation for reducing symptoms of anxiety/OCDImportant nuances in both trials:CAMS: type of anxiety disorder moderated efficacy of treatmentPOTS: effect of CBT and SSRI varied across treatment sit
