NSG 5720 Internalizing Disorders Part 1.pptx

NSG 5720 Psychiatric Management II Internalizing Disorders Part I Description of Anxiety Disorders Anxiety: a mood state characterized by strong negative emotion and bodily symptoms of tension in anticipation of future danger or misfortune Anxiety disorders involve experiencing excess...

NSG 5720 Psychiatric Management II Internalizing Disorders Part I Description of Anxiety Disorders Anxiety: a mood state characterized by strong negative emotion and bodily symptoms of tension in anticipation of future danger or misfortune Anxiety disorders involve experiencing excessive and debilitating anxieties; occur in many forms Many children with anxiety disorders suffer from more than one type Associated Characteristics  Children with anxiety disorders display a number of associated characteristics  Cognitive disturbances  Physical symptoms  Social and emotional deficits  Anxiety and depression  Cognitive Disturbances (1 of 3) Disturbance in how information is perceived and processed Intelligence and academic achievement Despite normal intelligence, deficits are seen in memory, attention, theory of mind and speech or language High levels of anxiety can interfere with academic performance Those with generalized social anxiety may drop out of school prematurely   Threat-related attentional biases Cognitive  Selective attention is given to potentially threatening Disturbanc information es (2 of 3)  Anxious vigilance or hypervigilance permits the child to avoid potentially threatening events   Cognitive errors and biases  Perceptions of threats activate Cognitive danger-confirming thoughts  Children with conduct problems Disturbanc select aggressive solutions in response to a perceived threat es (3 of 3)  Children with anxiety disorders see themselves as having less control over anxiety-related events than other children  Physical Symptoms Somatic complaints, such as stomachaches or headaches, are more common in children with GAD, PD, and SAD than in those with a specific phobia 90% with anxiety disorders have sleep-related problems, e.g., nocturnal panic High rates of anxiety in adolescence are related to reduced accidents and accidental deaths in early adulthood Social and Emotional Deficits  Anxious children  Display low social performance and high social anxiety  See themselves as shy and socially withdrawn, and report low self- esteem, loneliness, and difficulty initiating and maintaining friendships  Have deficits in understanding emotion and in differentiating between thoughts and feelings  A child’s risk for accompanying disorders will vary with the type of anxiety disorder Depression is diagnosed more often in children with multiple anxiety disorders Negative affectivity: persistent negative Anxiety mood, Positive affectivity: persistent positive mood and Negatively correlated with depression, but is independent of anxiety symptoms and diagnoses Depressio Physiological hyperarousal (somatic tension, shortness of n (1 of 2) breath, dizziness, etc.) may be unique to anxious children Predictors and environmental influences are different Gender, Ethnicity, and Culture Higher incidence of anxiety disorders in girls suggests genetic influences and related neurobiological differences The experience of anxiety is pervasive across cultures Ethnicity and culture may affect the expression, developmental course, and interpretation of anxiety symptoms  Theories and Causes: Early Theories Classical psychoanalytic theory Anxieties and phobias seen as defenses against unconscious conflicts rooted in the child’s early upbringing Behavioral and learning theories Fears and anxieties learned through classical conditioning and maintained through operant conditioning (two-factor theory)  Early Theories Bowlby’s theory of attachment Fearfulness is biologically rooted in the emotional attachment needed for survival Early insecure attachments lead children to view the environment as undependable, unavailable, hostile, and threatening Leading to development of anxiety and avoidance behaviors No single theory is sufficient   Variations in behavioral reactions to novelty result in part from inherited differences in the neurochemistry of brain structures Temperam  Amygdala: primary function is to react to unfamiliar or unexpected ent (1 of 2) events  Projections of amygdala to the motor system, anterior cingulate and frontal cortex, hypothalamus, and sympathetic nervous system  Temperament (2 of 2) Behavioral inhibition (BI): a low threshold for novel and unexpected stimuli Places an individual at greater risk for anxiety disorders Development of anxiety disorders in BI children depends on: Gender, exposure to early maternal stress, and parental response   Family and twin studies suggest  About one-third of the variance in childhood anxiety symptoms is genetic Family and  Serotonin and dopamine systems Genetic are related to anxiety  Genes are linked to broad anxiety- Risk related traits (e.g., behavioral inhibition)  No strong direct link between specific genetic markers and specific types of anxiety disorders Neurobiological Factors (1 of 2)  The entire anxiety response system is controlled by several interrelated systems to produce anxiety  Hypothalamic-pituitary-adrenal (HPA) axis  Limbic system  Ventrolateral prefrontal cortex  Other cortical and subcortical structures  Primitive brain stem Neurobiological Factors (2 of 2) An overactive BIS may be shaped by behavioral inhibition early life stressors system (BIS) implicated Brain abnormalities have been implicated in children who are anxious and/or behaviorally inhibited Primary neurotransmitter γ-aminobutyric acidergic system implicated in (GABA-ergic) system anxiety disorders Family Factors  Parenting practices  Parents of anxious children are seen as overinvolved, intrusive, or limiting child’s independence  Prolonged exposure to high doses of family dysfunction associated with extreme trajectories of anxious behavior  Low SES  Insecure early attachments  Treatment and Prevention Overview Main line of attack for treating anxiety disorders is exposing children to anxiety- producing situations, objects, and occasions Treatments are directed at modifying: Distorted information processing Physiological reactions to perceived threat Sense of a lack of control Excessive escape and avoidance behaviors  Experiencing Anxiety Moderate amounts of anxiety helps us think and act more effectively Excessive, uncontrollable anxiety can be debilitating The neurotic paradox is a self-defeating behavior pattern - fear with no threat Immediate reaction to perceived danger or threat Fight/flight response aimed at escaping potential harm  Three Interrelated Anxiety Response Systems Physical system The brain sends messages to the sympathetic nervous system, fight/flight response Cognitive system Activation leads to feelings of apprehension, nervousness, difficulty concentrating, and panic Behavioral system Aggression is coupled with a desire to escape the threatening situation  Physical Increased heart Dizziness Blushing rate Fatigue Blurred vision Vomiting The Many Increased Dry mouth Numbness respiration Symptoms Nausea Muscle tension Sweating of Anxiety Stomach upset Heart palpitation (1 of 2) Cognitive Thoughts of Thoughts of Thoughts of being scared or incompetence or bodily injury Table 11.1 The Many hurt inadequacy Symptoms of Anxiety Thoughts or Difficulty Images of images of concentrating harm to loved monsters or ones wild animals  Self- Blanking out or Thoughts of deprecatory or forgetfulness going crazy self-critical thoughts Thoughts of Thoughts of contamination appearing The Many foolish Symptoms Behavioral of Anxiety Avoidance Trembling lip Avoidance of eye contact (2 of 2) Crying or Swallowing Physical screaming proximity Nail biting Immobility Clenched jaw Trembling voice Twitching Fidgeting Stuttering Thumb sucking  Anxiety Versus Fear and Panic Anxiety: future- May occur in absence of realistic oriented mood danger state Fear: present- Occurs in the face of a current danger oriented and marked by a strong escape emotional tendency reaction A group of physical symptoms of fight/flight response -unexpectedly Panic occur in the absence of obvious danger or threat  Moderate fear and anxiety are adaptive Emotions and rituals that increase feelings of control are common in children and teens Normal Fears, Anxieties Worries, and Rituals Normal fears A fear defined Fears that are as normal The number and normal at one depends on its types of fears age can be effect on the change over debilitating a child and how time few years later long it lasts  Common Fears and Anxieties (1 of 2) Table 11.2 Common Fears and anxieties of Infancy, Childhood, and Adolescence; Possible Symptoms; and Corresponding DSM-5 Diagnoses Developmental Age Common Fears and anxieties Possible Corresponding DSM-5 Period Symptoms Anxiety Disorders Early Infancy Within first Loss of Physical support, loss of __ __ weeks Physical Contact with caregiver 0-6 months Intense sensory stimuli (loud __ __ noises) Late Infancy 6-8 months Shyness/anxiety with stranger, __ Separation anxiety disorder sudden, unexpected, or looming objects Toddlerhood 12-18 months Separation from parent. Injury, Sleep disturbances, Separation anxiety disorder, toileting, strangers nocturnal panic panic attacks attacks, defiant behavior 2-3 years Fears of thunder and lightning, Crying, clinging, Specific phobias (natural fire, water, darkness, nightmares withdrawal, freezing, environment), panic attacks avoidance of salient stimuli, night terrors, enuresis Fears of animal __ Specific phobias (animal) Early Childhood 4-5 years Separation from parents, fear of death Excessive need for reassurance Separation anxiety disorder, or dead people generalized anxiety disorder, panic attacks Primary/Elementary 5-7 years Fear of specific objects (animals, --- Specific phobias School Age monsters, ghosts) Fear of gems or of getting a serious --- Obsessive-compulsive disorder illness (OCD) Fear of natural disasters, fear of --- Specific phobias (natural traumatic events (e.g., getting burned, environment), acute stress being hit by a car or truck) disorder, post-traumatic stress disorder, generalized anxiety disorder 5-11 years School anxiety, performance anxiety, Withdrawal, timidity, extreme Social anxiety disorder (social physical appearance, social concerns shyness with unfamiliar adults phobia) and peers, feeling of shame Adolescence 12-18 Personal relations, rejection from Fear of negative evaluation Social anxiety disorder (social years peers, personal appearance, future, phobia) natural disasters, safety Common Fears and Anxieties (2 of 2)   Anxieties are common during childhood and adolescence  Common examples Normal  Separation anxiety  Test anxiety Anxieties  Excessive concern about (1 of 2) competence  Excessive need for reassurance  Anxiety about harm to a parent  Normal Anxieties (2 of 2) Girls display Nervous and Some specific more anxiety anxious anxieties than boys, but symptoms may decrease with symptoms are remain stable age similar over time  Normal Worries Children of all ages worry Worry serves a Moderate worry can help function in normal children prepare for the development future Children with anxiety disorders do not They worry more intensely than other necessarily worry children more  Normal Rituals and Repetitive Behavior Normal routines help children gain control and mastery of their environment Many common childhood routines involve repetitive behaviors and doing things “just right” Neuropsychological mechanisms underlying compulsive, ritualistic behavior in normal development and those in OCD may be similar  Seven Categories of Anxiety Disorders Separation Generalized anxiety anxiety Specific disorder disorder phobia (SAD) (GAD) Social anxiety Panic disorder Agoraphobia disorder (PD) Selective mutism  Separation Anxiety Disorder (SAD) Separation anxiety is important for a young child’s survival It is normal from about age 7 months through preschool years Lack of separation anxiety at this age may suggest insecure attachment SAD is distinguished by: Age-inappropriate, excessive, and disabling anxiety about being apart from parents or away from home  Prevalence and Comorbidity SAD is one of the two most common childhood anxiety disorders Occurs in 4-10% of children It is more prevalent in girls than in boys More than 2/3 of children with SAD have another anxiety disorder and about half develop a depressive disorder  Onset, Course, and Outcome SAD has the earliest reported age of onset of anxiety disorders (7-8 years of age) and the youngest age at referral Progresses from mild to severe Associated with major Examples: moving to a new neighborhood or entering a new stress school SAD persists into adulthood for more than 1/3 of affected children and adolescents  School Reluctance and Refusal Refusal to attend classes or School refusal behavior difficulty remaining in school for an entire day Occurs most often in ages 5-11 Fear of school may be fear of leaving parents (separation anxiety), but can occur for many other reasons Serious long-term consequences result if it remains untreated  Specific Phobia Prevalence and comorbidity About 20% of children are affected at some point in their lives, although few are referred for treatment More common in girls Onset, course, and outcome Onset at 7-9 years - phobias involving animals, darkness, insects, blood, and injury Clinical phobias are more likely than normal fears to persist over time  Social  A marked, persistent fear of social or Anxiety performance requirements that expose the child to scrutiny and possible embarrassment  Anxiety over mundane activities Disorder  Most common fear is doing something in front of others (Social  More likely than other children to be highly emotional, socially fearful; and inhibited, Phobia) sad, and lonely   Lifetime prevalence of 6-12% of children Prevalenc  Twice as common in girls  Two-thirds also have another e, anxiety disorder Comorbidi  20% also suffer from major depression and may self- ty, and medicate with alcohol and Course other drugs  Most common age of onset is early to mid-adolescence, and is rare under age 10  Selective Mutism Failure to talk in specific social situations, even though they may speak loudly and frequently at home or other settings Estimated to occur in 0.7% of children Average age of onset is 3-4 years May be an extreme type of social phobia, but there are differences between the two disorders Panic  Panic attacks  Characteristics: sudden, overwhelming period of intense fear or discomfort accompanied by four or more physical and symptoms characteristic of the fight/flight response  Are rare in young children; common in adolescents  Young children may lack the cognitive ability to make catastrophic misinterpretations  Are related to pubertal development Panic Disorder  In severe cases, high anticipatory anxiety and situation avoidance may lead to agoraphobia  Fear of being alone in and avoiding certain places or situations  Fear of having a panic attack in situations where escape would be difficult or help is unavailable  Does not usually develop until age 18 or older   Panic attacks are common (16% of teens) Prevalenc  Panic disorder is less common (about 2.5% of teens 13-17 years) e and  Panic attacks are more common in adolescent females than adolescent males Comorbidi  Comorbidity adolescents with PD  Most commonly have another anxiety ty disorder or depression  At risk for suicidal behavior; alcohol or drug abuse   Onset, course, and Onset, outcome Course,  Age of onset for first and panic attack 15-19 years; 95% of PD Outcom adolescents are post- e pubertal  Lowest remission rate for any of the anxiety disorders  Generalized Anxiety Disorder Excessive, uncontrollable anxiety and Generalized worry Worrying can be episodic or almost anxiety continuous disorder (GAD) Worry excessively about minor everyday occurrences Accompanied by at least one Headaches, stomach aches, muscle somatic tension, and trembling symptom, such as:  TABLE 11.8: Diagnostic Criteria for Diagnostic Generalized Anxiety Disorder (GAD) Criteria for (A) Excessive anxiety and worry (apprehensive expectation) occurring more days than not for at least 6 months, about a number of events or activities (such as Generalize work or school performance). (B) The individual finds it difficult to d Anxiety control the worry. (C) The anxiety and worry are associated Disorder with three (or more) of the following six symptoms (with at least some symptoms (1 of 3) present for more days than not for the past 6 months).  Note: Only one item is required for Diagnostic children. Criteria for (1) Restlessness or feeling keyed up or on edge. (2) Being easily fatigued. Generalize (3) Difficulty concentrating or mind going blank. d Anxiety (4) Irritability. Disorder (5) Muscle tension. (2 of 3) (6) Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep). Diagnostic (D) The anxiety, worry, or physical symptoms cause clinically significant Criteria for distress or impairment in social, occupational, or other important areas of functioning. Generalize (E) The disturbance is not due to the general physiological effects of a d Anxiety substance (e.g., a drug of abuse, a medication) or a another medical Disorder condition (e.g., hyperthyroidism). (3 of 3) (F) The disturbance is not better explained by another mental disorder.  Generalized Anxiety Disorder (2 of 2) Prevalence and comorbidity National survey: lifetime prevalence rate is 2.2% Equally common in boys and girls Accompanied by high rates of other anxiety disorders and depression Onset, course, and outcome Average age of onset is early adolescence Older children have more symptoms Symptoms persist over time Obsessive-Compulsive Disorder (1 of 2)  An unusual disorder of ritual and doubt  Characterized by recurrent, time- consuming, and disturbing obsessions and compulsions  Obsessions: persistent and intrusive thoughts, urges, or images - experienced as intrusive and unwanted  Compulsions: repetitive, purposeful, and intentional behaviors or mental acts performed to relieve anxiety Obsessive-Compulsive Disorder (2 of 2) OCD is extremely resistant to reason OCD children often involve family members in rituals Normal activities of children with OCD are reduced, and health, social and family relations, and school functioning can be severely disrupted   Prevalence and comorbidity  Lifetime prevalence in children and Prevalenc adolescents is 1-2.5%  Clinic-based studies find it twice as e and common in boys Comorbid  Comorbidities most common are other anxiety disorders, depressive ity (2 of disorders, disruptive behavior disorders 2)  Substance-use, learning and eating disorders, vocal and motor tics are also overrepresented   Onset, course, and outcome Onset,  Average age of onset 9-12 years with peaks in early Course, childhood and early adolescence and  Chronic disorder: as many as Outcome two-thirds continue to have OCD 2-14 years after initial diagnosis  Behavior Therapy Main technique is exposure While providing children with ways of coping other than escape and to feared stimulus avoidance Systematic desensitization Flooding: prolonged repeated exposure Response prevention prevents child from engaging in escaping or avoidance stimuli Modeling and reinforced practice  Cognitive-Behavioral Therapy (CBT) The most effective procedure for treating most anxiety disorders Almost always used with exposure-based treatments Coping Cat Skills training and exposure combat problematic thinking Computer-based CBT has also been shown to be effective Family Interventions Child-focused treatments may have spillover effects into the family Addressing children’s anxiety disorders in a family context may result in more dramatic and lasting effects Provides education about Family treatment for the disorder OCD: Helps families cope with their feelings   Medications can reduce symptoms, especially for OCD  The most common and effective Medicatio medications are selective serotonin reuptake inhibitors (SSRIs), ns especially for OCD  Medications are most effective when combined with CBT  CBT is the first line of treatment  Psychopharmacological Treatment SSRIs Fluvoxamine; 8-17 y/o (50-200mg/daily qd-bid) for OCD Sertraline; 6-12 y/o (25-200mg daily) for OCD Clomipramine; 10 y/o (100-200mg po qhs) for OCD Fluoxetine; ≥ 5 y/o (20mg daily) for Social Anxiety Disorder Avoid Paxil, Benzodiazepines