Anxiety and Children

(Albano, Chorpita, Barlow, 2005)

Anxiety and Youth

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

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

Measured by: Intractability Pervasiveness or fear and avoidance Degree of interference on daily functioning

For example: Continued school refusal Assess:

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

Adult Panic Disorder requires metathinking, thus children tend to present differently prior to adolescence (hormone shift tends to exacerbate the disorder) 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

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

Heritable Biological Diathesis Generalized Psychological

Vulnerability (Temperament) Specific Psychological Vulnerability

(Psychosocial Factors)

Etiology-Genetics

Anxiety is highly heritable

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

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: Inhibited Uninhibited

Etiology-Temperament (2)

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

Aspects that may increase the risk for negative emotions Coping Social/familial transmissions Information processing Perceptions of Control

Etiology-Psychological Factors (2)

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)

Parenting: 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)

Attachment Theory: 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)

Trauma Abuse Loss Oppression, Discrimination/Isms

Overt Covert

Other events

All have aspects of lack of control, punishment, injury to self

Diagnosis and Treatment of Anxiety

Diagnosing Anxiety Disorders

Anxiety Disorders

Panic Attack Agoraphobia Panic Disorder

w/out agoraphobia Agoraphobia w/out

hx of panic disorder Specific Phobia

Social Phobia OCD PTSD Acute Stress Disorder GAD Anxiety due to Medical condition Substance induced Anxiety NOS

Anxiety due to a Medical Condition

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

Four or more that develop abruptly and peak with in 10 minutes 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

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 triggers- leading 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

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

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

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

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

With agoraphobia or without agoraphobia

Agoraphobia w/out history of Panic Disorder

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)

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

Animal Type, Natural Environment Type, Blood-Injection-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

Desensitization: exposure, relaxation, mental rehearsal, supportive therapy

Flooding, graduated exposure, systematic desensitization

MAOIs and SSRIs

Social Phobia 300.23

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

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

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

SSRIs Beta Blockers for performance Social Skill training and Assertiveness

training Exposure CBT

Obsessive Compulsive Disorder

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

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

Washers Checkers Doubters and Sinners Counters and Arrangers Hoarders

OCD

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

OCPD- ego syntonic No true obsessions/compulsions

OCD- ego dystonic

OCD Presentation

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

SSRIs Need Continued medication due to

chronic nature of disorder Behavior therapy with graded

exposure and response prevention Address catastrophic thoughts

PTSD

Exposure to trauma that involved actual or threatened death or serious injury, or threat to physical integrity of self or others

A stressor is followed by either 1) reexperiencing (intrusion) 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

2) avoidance of the event 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

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

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

Auditory hallucinations and paranoid ideations can occur in severe cases

PTSD Diversity

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

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

Briefer form of PTSD lasting 2 days to 4 weeks

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)

Persistent reexperience of trauma

Avoidance of triggers

High Anxiety

Impairment

Not substance or medical

Generalized Anxiety Disorder

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

Chronic worry warts

Tense Highly distractible Irritable Restless On edge

Fatigued and mildly depressed

Physical complaints

Depression and Anxiety

50% comorbid Treat depression with antidepressants

and this will help with anxiety

GAD Treatment

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

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

Anxiety due to a general medical disorder

Substance-induced anxiety disorder Anxiety Disorder NOS

Treating Anxiety

Teaching Relaxation Breathing Techniques Desensitization (Approach vs. Avoidance) Cognitive Triad

All/Nothing Future Focus Catastrophyzing

Internal Conflicts