Anxiety Disorders

1. Anxiety Disorders Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1 from the National Institute of Mental Health and Project # U45 MC00174 from the Office of Adolescent Health, Maternal, and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services

2. Anxiety • Panic Disorder • Agoraphobia • Obsessive Compulsive Disorder • Specific Phobias • Separation Anxiety Disorder • Posttraumatic Stress Disorder • Generalized Anxiety Disorder • Anxiety Disorder NOS

3. Anxiety • 13% of youth ages 9 to 17 will have an anxiety disorder in any given year • Girls affected more than boys • ~1/2 of children and adolescents with anxiety disorders have a 2nd anxiety disorder or other co-occurring disorder, such as depression

4. Who is at risk? • Youth that have a parent with an Anxiety Disorder • Youth with shy or restrained temperaments • Youth that exhibited an excessive amount of anxiety between 6 and 8 years

5. What type of anxiety??? • Marcus has come for a follow-up appointment at the SBHC. He reported several anxiety symptoms during his comprehensive risk assessment, and screened positively for panic attacks during the Diagnostic Predictive Scales. Marcus indicates that the panic attacks are triggered by a fear of being called on in class. He experiences symptoms of panic (heart palpitations, nervousness, sweating, etc) on the way to school, while sitting in class, and even just thinking about being in class.

6. Panic Disorder - Diagnostic Criteria I. Recurrent unexpected Panic Attacks Criteria for Panic Attack: A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: (1) Palpitations, pounding heart, or accelerated heart rate (2) Sweating (3) Trembling or shaking (4) Sensations of shortness of breath or smothering (5) Feeling of choking (6) Chest pain or discomfort (7) Nausea or abdominal distress (8) Feeling dizzy, unsteady, lightheaded, or faint (9) Derealization (feelings of unreality) or depersonalization (being detached from oneself) (10) Fear of losing control or going crazy (11) Fear of dying (12) Paresthesias (numbness or tingling sensations) (13) Chills or hot flushes

7. Panic Disorder - Diagnostic Criteria II. At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: (1) Persistent concern about having additional attacks (2) Worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy") (3) A significant change in behavior related to the attacks

8. What type of anxiety??? • Philip was referred to the SBHC by his mother, because she has become increasingly concerned by his fears of going outside. Upon interview, Philip reveals that after being attacked by a neighborhood dog a few years ago, he has developed a fear of dogs. His fear is getting worse, and he is beginning to limit his outdoor activities. He reports getting nervous even when seeing dogs on television, even though he knows they cannot hurt him.

10. Specific Phobias • Marked and persistent fear of a specific object or situation with exposure causing an immediate anxiety response that is excessive or unreasonable • In children, anxiety may be expressed as crying, tantrums, freezing, or clinging. • Adults recognize that their fear is excessive. Children may not. • Causes significant interference in life, or significant distress. • Under 18 years of age – symptoms must be > 6 months

11. Specific Phobias • Animal phobias most common childhood phobia. • Also frequently afraid of the dark and imaginary creatures • In older children and adolescents, fears are more focused on health, social and school problems

12. What type of anxiety??? • Sally is brought to the SBHC by her parents, who are worried about her poor attendance in school. Sally has had some difficulty leaving her parents for the past several years, but her concerns have grown increasingly more intense. She reports having fears that if she goes to school, her parents will abandon her or something very bad might happen to them. She sometimes has dreams that they have died, and she wakes up in a panic. Sally has come to the SBHC several times in the past few months complaining of headaches and stomachaches, requesting that she be sent home.

13. Separation Anxiety Disorder Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following: • Recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated • Persistent and excessive worry about losing, or about possible harm befalling, major attachment figures • Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped) • Persistent reluctance or refusal to go to school or elsewhere because of fear of separation

14. Separation Anxiety Disorder • Persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings • Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home • Repeated nightmares involving the theme of separation • Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated

15. Separation Anxiety Disorder • Duration of at least 4 weeks • Causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning

16. What type of Anxiety??? • James walks into the SBHC for an appointment. He reports having great difficulty concentrating in his classes because of his increased worrying. He cannot pinpoint his worries; Rather, he reports being nervous about many things in his life, including his relationships with peers, his grades, and even his performance in basketball. His worries are beginning to impact his sleep, and he is finding himself becoming more irritable than usual.

17. Generalized Anxiety Disorder • Excessive anxiety and worry for at least 6 months, more days than not • Worry about performance at school, sports, etc. • DSM IV criteria less stringent for children (Need only one criteria instead of three of six): • Restlessness or feeling keyed up or on edge • Being easily fatigued • Difficulty concentrating or mind going blank • Irritability • Muscle tension • Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

18. What type of anxiety??? • Shelley’s teacher brings her down to the SBHC because he is concerned that her grades have been declining, and he has noticed that she has not been completing her homework. Shelley reports that she is being plagued by distressing thoughts of doing bad things, including hurting herself and others. In order to get rid of the thoughts, Shelley often has to engage in intricate routines, including counting to 1000 and backwards, and touching her desk at home in specific patterns. Although these routines decrease her anxiety, they are causing her to skip homework assignments and even lose sleep.

19. Obsessive Compulsive Disorder • Presence of Obsessions (thoughts) and/or Compulsions (behaviors) • Although adults may have insight, kids may not • Interferes with life or causes distress • One third to one half of all adult patients report onset in childhood or adolescence

20. What type of anxiety??? • Ginny comes to the SBHC for a sports physical. During her risk assessment, she reveals that her parents have a history of domestic violence, and that she witnessed her father attack her mother on several occasions. In the past few months, Ginny has been having nightmares about the abuse, and finds herself having flashbacks even during class. Ginny has been avoiding certain rooms in her house that remind her of the incidents. She also reports having difficult sleeping and concentrating in class.

21. Post-traumatic Stress Disorder (PTSD) The person has been exposed to a traumatic event in which both of the following were present: • (1) The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others • (2) The person's response involved intense fear, helplessness, or horror. (Note: In children, this may be expressed instead by disorganized or agitated behavior.)

22. Persistent Re-experiencing of event (1+) • Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. (Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.) • Recurrent distressing dreams of the event. (Note: In children, there may be frightening dreams without recognizable content.) • Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). (Note: In young children, trauma-specific reenactment may occur.) • Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

23. Avoidance and Numbing (3+) • Efforts to avoid thoughts, feelings, or conversations associated with the trauma • Efforts to avoid activities, places, or people that arouse recollections of the trauma • Inability to recall an important aspect of the trauma • Markedly diminished interest or participation in significant activities • Feeling of detachment or estrangement from others • Restricted range of affect (e.g., unable to have loving feelings) • Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

24. Increased Arousal (2+) • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response

25. Posttraumatic Stress Disorder (PTSD) • At least one month duration. • Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning • Note: Many students with PTSD meet criteria for another Axis I Disorder (e.g., major depression, Panic Disorder) – both should be diagnosed

26. Anxiety Disorder NOS • Disorders with anxiety symptoms BUT do not meet criteria for any specific Anxiety Disorder, Adjustment Disorder with Anxiety, or Adjustment Disorder with Mixed Anxiety and Depressed Mood • Example: mixed anxiety-depressive disorder • Also used in situations in which clinician has concluded that an anxiety disorder is present, but is unable to determine whether it is primary, due to medical condition, or substance induced

27. Screening Instrument

28. The Spence Children’s Anxiety Scale (SCAS) • 38 anxiety items • FREE! – available at http://www2.psy.uq.edu.au/~sues/scas/ • Parent and Child versions available

29. The Spence Children’s Anxiety Scale (SCAS) • Overall measure of anxiety with 6 subscales tapping specific aspects of anxiety • Panic attack/agoraphobia • Separation anxiety • Physical injury fears • Social phobia • Obsessive compulsive • Generalized anxiety/overanxious disorder • 4-point scale – “never,” “sometimes,” “often,” “always”

30. SCAS Norm Data (Muris et al., 2000) • Age 7-12 • Boys: M = 17.42 , Cutoff = 37 • Girls: M = 23.69, Cutoff = 44 • Age 13-19 • Boys: M = 13.54, Cutoff = 25 • Girls: M = 19.89, Cutoff = 36 • NOTE: Additional Norm information is available at • http://www2.psy.uq.edu.au/~sues/scas/#Normative_Data

31. What Works?

32. MH interventions shown to be EFFECTIVE for anxious or avoidant problems • “Cognitive Behavioral Therapy, Exposure, and Modeling continue to be the interventions of choice” • Hawaii Department of Health, Child and Adolescent Mental Health Division. (2004). Evidence Based Services Committee Biennial Report: Summary of Effective Interventions for Youth with Behavioral and Emotional Needs.

33. MH interventions with little or NO evidence of effectiveness for Anxiety: • Educational Support • Eye Movement Desensitization and Reprocessing (EMDR) • Play Therapy • Supportive Therapy • Hawaii Department of Health, Child and Adolescent Mental Health Division. (2004). Evidence Based Services Committee Biennial Report: Summary of Effective Interventions for Youth with Behavioral and Emotional Needs.

34. Anxiety: Practice Components

35. Anxiety: Practice Components • Exposure • Modeling • Cognitive/Coping • Relaxation

36. What is Exposure? • Techniques or exercises that involve direct or imagined experience with a target stimulus, whether performed gradually or suddenly, and with or without the therapist’s elaboration or intensification of the meaning of the stimulus

37. What is Modeling? • Demonstration of a desired behavior by a therapist, confederates, peers, or other actors to promote the imitation and subsequent performance of that behavior by the identified youth

38. What is Cognitive/Coping? • Any techniques designed to alter interpretations of events through examination of the child’s reported thoughts, typically through the generation and rehearsal of alternative counter-statements. • This can sometimes be accompanied by exercises designed to comparatively test the validity of the original thoughts and the alternative thoughts through the gathering or review of relevant information.

39. What is Relaxation? • Techniques or exercises designed to induce physiological calming, including muscle relaxation, breathing exercises, meditation, and similar activities. • Guided imagery exclusively for the purpose of physical relaxation is considered relaxation.