COUN 575 Diane Shea, Ph.D.

1. COUN 575Diane Shea, Ph.D. Anxiety Disorders

2. DSM-IV-TR (P. 429) • Panic Disorder Without Agoraphobia • Agoraphobia Without History of P.D. • Specific Phobia • Social Phobia • Obsessive-Compulsive Disorder • Acute Stress Disorder • Posttraumatic Stress Disorder • Generalized Anxiety Disorder

3. DSM-IV-TR (p. 121-134) Other Disorders of Infancy, Childhood, or Adolescence • Separation Anxiety Disorder • Selective Mutism • Reactive Attachment Disorder http://www.youtube.com/watch?v=lTx8Ct43wPQ • Stereotypic Movement Disorder http://www.youtube.com/watch?v=POJ-YuXBk6I • Not Otherwise Specified

4. Defining Fear and Anxiety • Problems of anxious children much less obvious, more difficult to assess • Fear – strong emotional alarm reaction to real or perceived danger. Sympathetic nervous system stimulates flight or fight response • Panic – sudden overwhelming state of extreme terror or fear • Anxiety – persistent concern about danger in the future

5. Children’s Common Fears • 0-12 months – loss of support, loud unexpected, looming objects, strangers • 12-24 months – separation from parent, strangers, injury • 24-36 months – separation from parents, animals, darkness • 3-6 years separation from parents, strangers, animals, darkness, injury

6. Common Fears (Continued) • 6-10 years – darkness, injury, being alone, imaginary beings • 10-12 years – injury, social evaluations, school failure, ridicule, thunderstorms, death • 12-18 years – school failure, peer rejection, family problems, wars, future plans

7. Sources of fears • Physical and cognitive limitations • Observing other people’s fearful reactions • Adult’s warnings about potential threats

8. Phobias • DSM-IV-TR recognizes that children’s phobic symptoms differ from those of adults • Criteria for assessment includes age, duration, intensity, and type of fear

9. Specific phobia • Persistent and unreasonable fear cued by presence or anticipation of a specific object • Children may not realize their fear is unreasonable • Animal type • Natural environment ( storms, heights, water) • Blood-injection-injury • Situational type (public transportation, tunnels, bridges etc.) School Phobia • http://www.dailymotion.com/video/xhffk1_school-phobia-crippling-for-some-students_news • http://www.5min.com/Video/How-to-Treat-a-School-Phobia-66527717

10. Separation Anxiety Disorder http://www.cbsnews.com/stories/2004/08/20/earlyshow/living/parenting/main637427.shtml • When a child grows less rather than more tolerant of separations from one or both parents • One of most common childhood problems • Show excessive age-inappropriate worries about separation • School refusal can be a form (DSM-IV) although some classify as separate

11. Generalized Anxiety Disorder http://www.youtube.com/watch?v=dRmBJhtys9g&feature=fvw • Uncontrollable, excessive anxiety and worry, occurring consistently for 6 months, extending to many events and activities • Child shows one of following in extreme form: Irritability • Restlessness • Fatigue • Difficulty in concentrating • Muscle tension or sleep disturbance

12. GAD (continued) • Child may be insecure, perfectionist (resembles OCD) • Accompanied by depression • Widespread anxiety in many different situations http://www.youtube.com/watch?v=bnYWDHpFnFE&feature=related

13. Diagnosis • Difficult to diagnose • Overlap of symptoms of anxiety, mood and other internalizing disorders • Depends heavily on self-reported anxiety, fear or depression, difficult for young children

14. Social Phobia or Social Anxiety Disorder http://www.youtube.com/watch?v=npz3I6alycc http://www.socialanxietyinstitute.org/video-2.html • Average onset is 15 years • Marked by extreme self-consciousness and incapacitating anxiety in social situations • Occurs twice as often in women as men, but men are more likely to seek help

15. Social Anxiety Disorder • Complaining about pervasive fear of being observed, judged negatively • Constant concern about inadvertently doing things that are humiliating • Worry far in advance of social situations • Peaks at informal gatherings rather than at formal situations or presentations, which are highly scripted

16. Vicious Cycle • Social phobic children are less socially skillful • Draw negative reactions from peers • Undermines self-confidence, leading to further social failures

17. School-Related Avoidance Disorders • Not in DSM-IV as separate disorder, but as symptom of separation anxiety • Persistent avoidance of school motivated by intense fear and anxiety • Can stem from specific phobia • Can indicate generalized anxiety or separation anxiety

18. Two Types of Refusal • Mild acute school refusal • Affects younger children, little or no family discord, sudden onset • Severe chronic school refusal • Typical in children over 11 from unstable families

19. Etiology of Anxiety Disorders

20. Psychodymanic Theory • Freud – psychologically created tension, anxiety, guilt, sexual jealousy • Present day theory loosely based on psychoanalysis, but emphasizes importance of social rather than sexual interactions • Phobic person wants to be center of attention • Child develops specific phobia or anxiety as a way of expressing an unacceptable desire

21. Social Learning and Cognitive/Behavioral Approaches • Modeling • Classical Conditioning: http://www.youtube.com/watch?v=Xt0ucxOrPQE • Bandura’s Self-efficacy theory: • People don’t develop fears so much from fright paired with sight of feared object as from anxiety that they cannot successfully avoid feared object and protect themselves

22. Treatments for Anxiety Disorders • Biofeedback • Systematic Desensitization • Virtual Reality • Exposure therapy • http://www.youtube.com/watch?v=wE5F-FjbTRk • Medications • SSRIs • Beta-blockers • Benzodiazepines

23. Posttraumatic Stress Disorder • Experienced by people who have experienced an extremely devastating event • Persistent and unwilling re-experiencing of traumatic event, persistent attempts to avoid all thoughts and acts related to the event, and a high state of arousal

24. Post Traumatic Stress DisorderPTSD • Persistent avoidance of stimuli associated with trauma and numbing of general responsiveness • Avoids thoughts, feelings or conversations associated with trauma • Avoids activities, places, people that arouse recollections of the trauma • Inability to recall an important aspect of trauma • Diminished interest in significant activities • Detachment or estrangement of others • Restricted range of affect • Sense of foreshortened future

25. Post Traumatic Stress Disorder • Persistent symptoms of increased arousal • Difficulty falling/staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response • http://www.pbs.org/now/shows/339/index.html • http://www.ncptsd.va.gov/ncmain/information/videos.jsp http://mefeedia.com/tags/emdr http://www.ncptsd.va.gov/ncmain/ncdocs/videos/emv_hoperecovery_gpv.html Adapted from: DSM-IV-TR, American Psychiatric Association, 2000

26. Biological Contributors • Hints in recent research suggests that there may be complex multiple gene contributions to anxiety and panic disorders • Children of mothers, but not fathers, who have a lifetime history of anxiety disorder are doubly at risk • Research suggests that stable differences in brain activity may characterize certain children as susceptible to anxiety disorders

27. Prognosis for Children with Phobias and Anxiety Disorders • Most early phobias are quickly and effectively treated by • Prognosis is worse for those with severe anxiety disorders • When they persist only 20% are eventually overcome • Fear of physical illness and social anxiety disorder tend to persist throughout life

28. Psychological Interventions • Psychodynamic Therapies • Child encouraged to act out fears and fantasies in therapy sessions • Analyst interprets meaning of fantasies • Childs troubling unconscious feelings transferred from parent to analyst • Phobic reactions disappear without specific intervention when psychological conflicts have been resolved

29. Psychological Interventions (continued) • Critique: • Expensive and time consuming

30. Systematic Desensitization Therapy • Takes place in gradual steps • Focus on child’s learning to relax in stress-inducing circumstances by going through fear hierarchies from mild to most severe • Relaxation used to counteract the muscular tension of anxiety • http://www.youtube.com/watch?v=TwCITgdBzI4&feature=related • Drawback: doesn’t teach child to deal with what they fear, so needs to be coupled with other treatments

31. Modeling and Guided Participation • Effective in treating children's specific phobias especially when limited to a particular situation • Modeling: Child’s confidence built by watching someone else deal with feared stimulus • Guided Participation: Carefully supervised confrontations with feared stimulus in natural environment

32. Cognitive-Behavioral Treatments • Multifaceted cognitive-behavioral treatment very effective, and rigorously tested. Techniques include • Modifying anxious self-talk • Teaching problem solving and behavioral strategies • EMDR • http://vodpod.com/watch/1264747-emdr-effective-for-trauma-ptsd • Virtual Reality

33. Obsessive-Compulsive Disorder • Common rituals or routines reassure young children and provide sense of security • Pathological obsessive-compulsive behavior consists of attempts to reduce severe anxiety and involves unusual activities • Hand washing • Bathing • Scrubbing already spotless surroundings

34. Compulsive Children • Compulsions can develop without obsessions • Rituals involving washing, repeatedly arranging objects, or checking on location of certain objects over and over • Compulsive children may develop phobias, depression, and neurological conditions

35. Obsession • Obsessions usually accompany other problems (phobias, depression) • Likely to persist through life

36. DSM-IV-TR for OCD • Obsessions and compulsions are senseless repeated thoughts, images, or impulses (obsessions) or repetitive acts (compulsions) that are: • Unrealistic and dysfunctional • Experienced as unwelcome but irresistible • Experienced as products of one’s own mind rather than external threats • Ritualistic and stereotyped • Time-consuming • Disruptive of everyday activities

37. Typical features for youngsters • Obsessive themes – contamination, aggression, maintaining ultra strict order, fear that family members might be killed • Compulsions – checking under bed constantly, wipe possessions repeatedly, tapping. Most engage in rituals at home and try to hide them

38. Treatment of Obsessive-Compulsive Disorder • Cognitive-Behavioral therapy – most recommended treatment, alone or combined with an SSRI • Contact with anxiety-provoking event followed by guided, prolonged exposure to feared stimulus, or • Sudden exposure to feared stimulus. To demonstrate that compulsive behavior is not necessary

39. Posttraumatic Stress Disorder http://www.pbs.org/now/shows/339/index.html http://www.ncptsd.va.gov/ncmain/ncdocs/videos/emv_child_trauma_gpv.html?opm=1&rr=rr1541&srt=d&echorr=true#/ncmain/ncdocs/videos/children_trauma/c_t2_children_trauma_5mb.mov • Experienced by people who have experienced an extremely devastating event • Persistent and unwilling re-experiencing of traumatic event, persistent attempts to avoid all thoughts and acts related to the event, and a high state of arousal

40. PTSD Symptoms • May develop immediately or months/years after event • Disorganized, agitated behavior • Persistent mental experiencing of event followed by long periods of avoidance and emotional numbing • Avoidance of anything associated with event • Exaggerated startle responses, hyper alertness

41. PTDS Treatment • Limited research suggests immediate relief comes from support of teachers and classmates • Parents and teachers need to convey sense of calm and control • Cognitive-behavioral therapy • Family/group treatment

42. PTSD (continued) • Children can develop PTSD even if not directly physically threatened • Children who lose a parent at particular risk

43. Treatment for PTSD • Virtual Reality • EMDR • Medication • National Center for PTSD: • http://www.ncptsd.va.gov/ncmain/ncdocs/videos/emv_child_trauma_gpv.html?opm=1&rr=rr1541&srt=d&echorr=true#/ncmain/ncdocs/videos/children_trauma/c_t2_children_trauma_5mb.mov