Anxiety and Depressive Disorders

1. Child and Adolescent Psychopathology Anxiety and Depressive Disorders

2. Historical Context: Separation anxiety disorder (DSM-III-R) Overanxious disorder (DSM-III-R) Avoidant disorder (DSM-III-R) Only separation anxiety disorder now (DSM-IV)

3. Definition 1) Dysregulation of normal response system 2) Intense, disabling worry that does not help to anticipate true future danger 3) Intense fear reactions in the absence of a true threat

4. Definition: Primary and Secondary features of anxiety Primary: not specific to any particular diagnosis Secondary: content features of specific anxiety disorders: SAD: worry about separation from parents Social anxiety disorder: interpersonal concerns Panic disorder: uncued panic attacks

5. Definition 5) Expression of anxiety: behavioral, cognitive, physiological, social 6) High degree of comorbidity Prevalence: Short-term prevalence: 2-4% Lifetime prevalence: 10-20% (Cont’d)

6. Risk Factors Biological processes: Behavioral approach system: involved in approach behaviors Behavioral inhibition system: anxiety to novelty or impending punishment and avoidance

7. Risk Factors Hypothalamic-pituitary-adrenal axis (HPA) axis: release of cortisol, which regulates behavioral and emotional responding

8. Risk Factors • Cortisol secretion protects when exposed to danger • Prolonged exposure is neurotoxic and related to anxiety: • “D” attachment • Maltreated children diagnosed with PTSD

9. Risk Factors Genetic Influences: 1) 33% of variance accounted for by genes: physiological reactivity avoidance behaviors 2) Temperamental inhibition: avoidance of novelty, dependence on parents, fearfulness, autonomic hyperarousal

10. Risk Factors Psychophysiology: 1) Anxiety sensitivity: belief that anxiety sensations (e.g. heart beat awareness, increased heart rate, trembling, shortness of breath) have negative social, psychological, or physical consequences 2) Interpretation of arousal symptoms influence experience of anxiety

11. Behavioral Learning Processes Six Pathways: 1) Classical aversive conditioning (Wolpe & Rachman, 1960) Exposure to traumatic events 25-55% of maltreated children develop PTSD Pre-existing trait anxiety or D attachment?

12. Behavioral Learning Processes 2) Vicarious acquisition through observational learning or modelling (Bandura, 1982) 3) Verbal transmission of information 4) Operant conditioning(Mowrer, 1960): withdrawal negatively reinforced by reduction of anxiety

13. Behavioral Learning Processes 5) Stages in cognition: encoding, interpretation, recall interpretation and memory biases attentional selectivity: over-allocating intellectual resources toward threat 6) Lack of control over external and internal threats: affect dysregulation because events and sensations are uncontrollable

14. Social and Interpersonal Processes Attachment theory: anxiety related to insecure relationships to primary caregiver Separation anxiety disorder related to C attachment Overcontrolling parental behaviors influence childhood anxiety prevent children from facing fear-provoking events conveys message that fear-provoking events are threatening Short allele for serotonin transporter X low social support behavioral inhibition

15. Developmental Progression(heterotypic continuity) Childhood anxiety disorders are correlated with adult anxiety and depressive disorders Anxiety content related to development separation or loss of parents (6-9 years old) mortality, broader concerns (10-13 years old) social and performance concerns (adolescence)

16. Comorbidity ADHD: 0-21% CD and ODD: 3-13% Depression: 1-20%

17. Culture Collectivist societies expect conformity and social inhibition, increasing anxiety Control of emotions stifles children's understanding and managing of internal states

18. Sex Differences Girls to boys: 2:1 ratio Higher heritability estimates for girls than boys Girls more willing to report symptoms Girls more likely socialized to internalize symptoms

19. Theoretical Synthesis Dysregulation of anxiety response system Negative affect and distress/impairment from physiological arousal Contents of anxiety are developmentally based

20. Depressive Disorders • Depression is characterized by equifinality and multifinality • Controversies in diagnosis of depression: • Continuity: childhood depression does not predict adolescent or adult depression • Discreteness and boundaries • depression is continuous • are thresholds too narrow or two broad? • adolescents have normal negative mood states

21. Subtypes a) Unipolar versus bipolar disorder b) Psychotic versus not psychotic c) Course (e.g. age of onset, recurrent or chronic, seasonal)

22. Age-specific manifestations Younger children might appear sad but do not report their mood Pre-pubertal children might lose interest in friends, not libido Depression in very young children: shorter duration requirement modified DSM-IV criteria

23. Assessment: Low concordance among informants Self-reports more valid than reports by other informants Parents' reports more valid for children than adolescents Prevalence: Preschool children: 3 to 6 month prevalence = 1-2% Adolescents: lifetime prevalence = 15-20% (like adults)

24. Sex Differences Biological changes in hormones (increases in estrogen and testosterone) Physical changes associated with body dissatisfaction Adolescent females experience more interpersonal stress than adolescent males Adolescent females have greater pre-existing vulnerabilities than males adolescent females have greater affiliative needs than males adolescent females cope with adversity in passive, ruminative way, while adolescent males cope in active, avoidant way

25. Comorbidity Comorbidity might represent a different disorder (e.g. MDD and CD)  Common etiological factors between the two disorders  Causal influence of one disorder over another (e.g. anxiety in childhood predicts depression in adulthood)

26. Course and Outcome  Mean duration of MDD: 7-8 months  Mean duration of DD: 48 months  Double depression: superimposed episodes of MDD in DD  40-70% of depressed adolescents experience MDD in adulthood  Predictive of recurrence: severity, psychotic symptoms, suicidality, DD, subthreshold symptoms, depressotypic cognitive style, recent stressful life events, adverse family environments, family history of MDD

27. Risk Factors Genetics: a) Genetics plays a greater role in adolescent and adult depression than childhood depression b) Reuptake of serotonin c) Brain-derived neurotrophic factor (BDNF) 

28. Risk Factors d) Passive gene-environment correlations: genotype and environments are correlated e) Evocative gene-environment correlations: genotype evokes reactions in others  f) Active gene-environment correlations: genotype selects environments (niche-picking) 

29. Risk Factors g) Genes interact with environment to increase susceptibility to stress (diathesis-stress hypothesis)  h) Environment influences expression and regulation of genes (epigenesis)  • Genes  Temperament ( negative emotionality,  positive emotionality  depression)

30. Risk Factors Maladaptive parenting and abuse: Low parental warmth, high intrusiveness  Childhood depression: low emotional support, abuse, family stress Adolescent depression: early lack of emotional support

31. Risk Factors Biological Factors:a) Neuroendocrinology – dysregulation of HPA axis cortisol production b) Sleep architecture – increased REM density c) Neurotransmitters – dysregulation of serotonin and norepinephrine  d) Structural and functional brain correlates 1. smaller frontal white matter volume  2. larger frontal grey matter volume  3. larger left PFC white matter volume

32. Risk Factors Cognitive factors: a) Memory biases for negative information b) Low self-esteem, self-efficacy, self-perceived competence c) Are these factors antecedents or sequalae?

33. Risk Factors Peer Relationships: a) Peer rejection b) Social skills deficits c) Are these factors antecedents or sequalae?

34. Risk Factors Life Stress:a) Triggers depression in children with pre-existing disposition b) Depression can produce impaired functioning, which produces stress c) Negative interpersonal life events are particularly potent risk factors

35. Protective Factors: Variables that reduce risk in high-risk contexts:1)Presence shifts high-risk trajectory in a more positive direction2) Absence has no influence on risk trajectory

36. Fin