Understanding Internalizing Problems and Anxiety Disorders

• Internalizing problems refer to anxiety and mood-related symptoms such as feeling panicky, moody, high-strung, or lonely
• The developmental psychopathology framework emphasizes evaluating abnormality based on what is typical for children of a certain age

Anxiety Disorders

• Important emotions like fear and sadness and "normal" fears should come and go during development
• Associated with:
• Social impairment like being excluded, unliked or victimized
• Academic impairment such as being too nervous to open textbooks
• Low service utilization

National Comorbidity Survey

• Only 14% of youth with non-severe anxiety receive treatment and only 30% of severe cases get treatment

Normal Anxiety and Adaptive Anxiety

• Nearly all 1-year-olds are distressed when separated from their mothers
• Most children have short-lived, specific fears
• About half of children aged 6-12 have 7 or more fears
• Consider disability, distress, risk, and age-appropriateness when determining if anxiety is normal
• Stranger anxiety in young children is an example of normal anxiety
• Test anxiety can be adaptive as it optimizes grades

Anxiety in Adults

• Anxiety may not be as upsetting to adults and might not cause as much disruption
• It may be associated with favorable characteristics such as less aggression
• Core features include focusing on threat or danger and future-oriented anxious apprehension
• Anxiety differs from fear as fear is present-oriented
• Anxiety is displayed as strong negative emotion or tension
• Diagnoses vary based on the content of the threat and the balance of symptoms like worry vs physical symptoms

DSM-5

• Anxiety disorders are now separate from Obsessive-Compulsive Disorder

Specific Phobias

• Specific phobias involve specific situations or things
• Diagnostic specifiers:
• Animal (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., choking, vomiting, loud sounds, costumed characters)
• Occurs in about 20% of children with onset age of 7-9 years with girls being more affected

Separation Anxiety

• Separation anxiety focuses on separation from or harm coming to loved ones
• Includes not wanting to be separated from parents and worrying about events that might separate them
• Occurs in 4-10% of children with it being more prevalent in girls than in boys
• About 33% of kids have persistent separation anxiety into adulthood

Social Anxiety and Selective Mutism

• Social anxiety is the fear of negative evaluation by others and social situations in which a person will be evaluated
• Children must experience this in peer settings, not just with adults
• Selective mutism is the failure to speak in specific situations and contexts where speaking is expected, despite speaking in other settings
• In DSM-5, selective mutism is reclassified as an anxiety disorder but it's unclear whether all children with it are anxious

Generalized Anxiety Disorder

• GAD involves excessive, uncontrollable anxiety and worry that can be episodic or almost continuous
• It involves excessive worry about minor everyday occurrences and somatic symptoms
• Lifetime prevalence is about 2.2% typically onsetting in early adolescence and persists and is equally common in boys and girls
• GAD is often comorbid with other anxiety disorders and depression

Panic Disorder

• Panic attack is a period of intense fear or discomfort that develops abruptly with at least four symptoms like sweating, shortness of breath, feeling like choking, chest pain, or nausea
• An individual can have panic attacks and not have panic disorder

DSM-5 Criteria for Panic Disorder

• Recurrent, unexpected panic attacks not due to context
• At least one attack followed by one month or more of:
• Persistent concern about having additional attacks
• Worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
• A significant change in behavior related to the attacks like avoidance

Obsessive-Compulsive Disorder

• Obsessions are recurrent, persistent thoughts that are experienced as intrusive, inappropriate, and cause marked anxiety or distress
• The person attempts to ignore or neutralize the thoughts
• The person recognizes that the thoughts are a product of their own mind
• Common obsessions - Contamination, Harm to self or others, Symmetry
• Compulsions are repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly
• Behaviors are aimed at preventing or reducing distress or preventing some dreaded events or situations
• The behaviors are not connected in a realistic way with what they are designed to neutralize or prevent, or they are clearly excessive
• Common compulsions - Counting, Checking, Washing

OCD Diagnosis

• To be diagnosed you need either compulsions or obsessions
• Obsessions or compulsions must be time-consuming, causing clinically significant distress or impairment
• Specificers in severity is based on the presence of good/fair insight, poor insight, or absent insight/delusions and may overlap with tick disorders

Summary of Anxiety and OCD

• Anxiety disorders are debilitating and often go untreated
• DSM-5 includes many anxiety disorders that vary by focus of the threat and the balance of symptoms
• OCD is not classified as an anxiety disorder, but has some related features

Prevalence of Anxiety Disorders

• NCS-A estimates a lifetime prevalence of any anxiety disorder at one point during childhood and adolescence as 32% by age 18
• Specific phobia: 19%
• Social Anxiety Disorder: 9%
• Separation anxiety: 8%
• Generalized anxiety disorder: 2%
• Panic Disorder: 2%
• The estimated prevalence of OCD is 1-2% (2:1 ratio male-female)
• Estimated prevalence of selective mutism is 0.7%
• Girls are more likely than boys to meet criteria for an anxiety disorder at a ratio of 2:1 with major differences appearing around age 9-10

Anxiety is Universal

• Affects people from all socioeconomic and cultural backgrounds, but individual context shapes how it appears

Socioeconomic Status and Ethnicity

• Lower parental education and living in single-parent households are linked to a higher chance of anxiety disorders
• Anxiety disorders are more common among Black youth compared to White youth
• White youth tend to receive more anxiety treatment than Black youth
• Past experiences of discrimination may contribute to anxiety in Black youth

Comorbidity

• Youth with one anxiety disorder often meet criteria for others
• 80% of youth with selective mutism meet diagnostic criteria for another anxiety disorder and 69% of youth with selective mutism meet diagnostic criteria for social anxiety disorder

Depression

• Diagnostic comorbidity can be as high as 75-80%
• Ontario Child Health Study:
• 77% of adolescents who meet criteria for Major Depression also meet criteria for an anxiety disorder
• 45% of adolescents who meet criteria for an anxiety disorder also meet criteria for major depression
• Symptom overlap exists between GAD and MDD with fatigue, sleep disturbance, irritability, concentration difficulties, and negative affectivity

Clinical Correlates

• Negatively correlated with depression, but not correlated with anxiety
• Academic difficulties:
• Youth with anxiety disorders typically have IQs in the typical range
• Symptoms may interfere with academic functioning
• Impacts of worry on concentration
• School refusal/Difficulty remaining in school:
• Separation anxiety and social anxiety
• Manifestation of anxiety symptoms as stomach aches/headaches
• Social Difficulties:
• Shy/withdrawn children become increasingly rejected by the peer group with age and are more likely to experience peer victimization
• May view the friendships they do have as lower quality than average

Age of Onset for Fears

• Different "typical" age of onset for each fear:
• 2y: Loud noises, animals, the dark, separation from parents
• 5y: Animals, dark, separation from parents, bodily injuries, "bad" people
• 7 to 8y: Dark, supernatural beings, staying alone, bodily injuries
• Worries become more complex as youth age
• Must be differentiated with fears that are out of proportion with the context, higher in frequency, intensity or impairment
• Young children may not realize that their fears or behavior are excessive or atypical but will become more embarrassed as they get older
• Young children may not be able to tell you how they are feeling, instead defiance or acting out can manifest to express that anxiety

Age of Onset for Disorders

• Separation Anxiety Disorder: 7 to 8 years
• OCD: early = 6 to 10 years and typical = 9 to 12 years
• Generalized Anxiety Disorder: 10 to 14 years
• Social Anxiety Disorder: adolescence
• Panic Disorder: adolescence
• The long-term outcomes of anxiety disorders are still being researched

Prognosis

• Homotypic continuity such as separation anxiety @7 predicting separation anxiety @ 17
• Heterotypic continuity such as social anxiety and depression and generalized anxiety
• The disorder morphs into related or comorbid disorders over time

Summary

• Anxiety disorders are common and girls are more likely to have them than boys
• They often co-occur, and are also highly comorbid with depression, as well, adolescents with anxiety disorders are more likely to have anxiety disorders and major depression in young adulthood
• Evidence shows that tendencies towards anxiety are inherited

Heritability of Anxiety

• Children of parents with anxiety disorders are five times more likely to have an anxiety disorder
• Twin studies indicate that 33% of variability in anxiety is heritable (can be different types of anxiety disorder)
• A general vulnerability to anxiety disorders can be inherited:
• Temperament
• Behavioral inhibition
• Withdrawal
• Negative emotionality
• Etiological and maintenance model for specific phobia (Mowrer, 1948)

Two-Stage Model of Fear Acquisition

Stage 1

• Fear develops through classical conditioning
• Unconditioned stimulus (US): stimulus that leads naturally to the response
• Unconditioned response (UR): Response to the unconditioned stimulus
• Conditioned stimulus (CS): Neutral stimulus
• Conditioned Response (CR): Response to the CS

Stage 2

• Avoidance behavior is maintained through operant conditioning
• Adding and removing positive and negative stimuli to change rates of behavior
• Avoidant behavior provides relief from anxiety which is reinforcing (negative reinforcement)
• Avoidant behavior increases the idea that there was something to fear
• Unwanted intrusive thoughts are typical

Purdon & Clark 1993

• Results from 293 undergraduate students:
• Running car off the road: 64% of women, 56% of men
• Cutting off finger: 19% of women, 16% of men
• Left the stove on: 79% of women, 66% of men
• Imagining strangers naked: 51% of women, 80% of men
• Difference lies in how important you think intrusive thoughts are and what you do after having them (i.e. compulsions to self-soothe)

OCD Course

• Mean age of onset 9-12 years old
• Two different peak onset periods:
• Early childhood onset is more likely to be boys or people who have a family history of OCD
• Late adolescence/early adulthood
• 50-66% of children with OCD still meet criteria 2-14 years later and symptoms get slightly better with time while less than 10% experience complete remission
• Risk factors for poor prognosis:
• Earlier onset
• Poor first response to treatment
• Tic disorder
• Parental psychopathology

Anxiety Cognitive and Family Factors

• It is well-established that those higher in anxiety show greater attention to potentially threatening stimuli (e.g., angry faces)
• Attention to threat varies widely situation to situation with many moderators including threat intensity, personal relevance of threat, and current mood
• Strong association between social anxiety and negative interpretation bias involving interpreting ambiguous social events negatively and catastrophizing even mildly negative social events which may lead to avoidance

Interpretation Biases

• May lead to avoidance, which relieves anxiety in the short term but increases anxiety around subsequent social situations
• Negative interpretational bias is a significant maintenance factor for anxiety, not just social anxiety

Family Factors

• Modeling such as Parents demonstrating anxious responses
• Seeing someone else show fear may cause a child to develop fear and monkeys develop phobias by watching their parent/videotaped models experience fear
• Information transmission such as being told that something is dangerous making you fear it
• Parent low expectations
• Expect children to have difficulty or not be able to cope leading to soothing or giving attention to anxious fearful reactions
• This is parental reinforcement of problematic behavior

Ambiguous Situations

• Studies presented three groups of children with 12 ambiguous situations
  • Clinically referred for anxiety
  • Clinically referred for ODD
  • Community control group
• Example situation: "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"
• Children and their parents discussed two of the situations for 5 minutes, afterwards children provided a final answer
• Results - Most kids increased in avoidance solution AFTER talking with their family
• Indicate socialization based on parent's own levels of anxiety/low expectations and may be an evocative reaction to their kid's anxiousness to provide a solution/soothing

Unified Model of Anxiety

• A unified model of anxiety involves a biological predisposition for anxiety and family factors contribute

Diathesis-Stress Model

• Biological diathesis, family and environmental stress, and life experience shapes the form of the disorder

Social Cognitive Processing

• Plays a role in symptom maintenance