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Anxiety

Anxiety Disorders of Childhood & Adolescence

  • Anxiety as a concept I: elements/facets/dimensions
    • physiological arousal: activation of sympathetic aspects of autonomic nervous system
      • measures based on this perspective assess biological activation: Galvanic Skin Response (GSR), heart rate, respiration, muscle tension (EMG), perspiration
    • behavioral escape & avoidance: anxiety is noxious and motivates the organism to get away from anxiety provoking stimuli
      • measures based on this perspective assess avoidance (or approach) behavior: Behavioral Avoidance Test (BAT)
    • cognitive disruption: anxiety interferes with attention, problem solving, recall
      • measures based on this perspective assess errors in intellectual activities judged within the subject’s ability range
    • phenomenological dread: our private sense of tension, worry, nervousness
      • measures based on this perspective provide a means to report on our internal experience: Subjective Units of Disturbance (SUD) ratings, ratings scales, 100 mm lines, fear thermometer
  • Anxiety as a concept II: level/scope of interest
    • symptom: a characteristic response (e.g., hands trembling or feeling “scared”)
    • syndrome: a group of symptoms (e.g., tremor, and shaky voice, and feeling scared, and avoiding the situation)
      • internalizing symptoms; anxious-inhibited cluster
    • disorder: core symptoms of sufficient severity & duration to cause distress &/or maladjustment
      • Phobic Disorder, Generalized Anxiety Disorder, Panic Disorder, PTSD, OCD
  • Anxiety as a concept III: normal/functional/appropriate vs. . . .
    • Adaptive
      • fear 
      • worry 
      • tension
      • self-soothing 
    • Maladaptive
      • phobia
      • rumination
      • overanxious
      • compulsion
  • Patterns (diagnoses) of anxiety disorders in children
    • Phobias: “a special form of fear”
      • Mark’s 1969 definition of a phobia: A phobia is a special form of fear which, is out of proportion to demands of the situation, cannot be explained or reasoned away, is beyond voluntary control, leads to avoidance of the feared situation, persists over an extended period of time, and is unadaptive.
      • Miller, Barrett, & Hample (1974) offered a slight modification/addition to this definition for children: Is not age or stage specific.
      • AGE TYPICAL FEARS
birth – 6 months(Moro reflex)loud noise, loss of support
5 – .75 yearsStrangers
(1) 2 – 4 yearsSeparation
1.25 – 4 yearsCreatures, Bad people, Death, Being alone
2 yearsToilet
3 yearsAnimals
4 yearsDark
5 – 6 yearsSchool
11 yearsInjury, Natural events, Social, All fears
12 yearsSocial, Sexual
19+ yearsNatural events
  • Generalized Anxiety Disorder (GAD) (also known in children as: Overanxious Disorder of Childhood)
    • worry, threat sensitivity, chronic tension
    • Separation Anxiety Disorder
  • Obsessive-Compulsive Disorder (OCD)
    • obsessions: intrusive, repetitive thoughts, anxiety generating or anxiety reducing
    • compulsions: repetitive rituals and nonpurposeful behavior associated with anxiety reduction
    • PANDAS (Pediatric onset, Neuropsychiatric Disorder), group A streptococcal infections, and OCD behavior
  • Panic Disorder
    • Without Agoraphobia (avoidance of situations believed linked with probability of anxiety attacks)
    • With Agoraphobia
    • acute episodes (attacks) of fear, anxiety, panic; may lead to attempts to control future episodes by avoidance (agoraphobia)
  • Posttraumatic Stress Disorder (PTSD)
    • traumatic event (threat + fear/helplessness/horror)
      • leading to:
        • 1. over arousal
        • 2. avoidance / numbing of emotional responses
        • 3. re-experiencing (serial dreams, flashbacks, repetitive toy play)
      • may represent a failure of the General Adaptation Syndrome (GAS)
  • Acute Stress Disorder
    • time limited disorder
    • dissociative symptoms
  • Adjustment Disorder With Anxiety
  • other problems in which anxiety may play a role:
    • Hypochondriasis
    • Body Dysmorphic Disorder
    • Conversion Disorder
    • Dissociative Disorder
      • Dissociative Identity Disorder (DID) — formerly known as multiple personality disorder (MPA)

Treatment of anxiety disorders in children

  • General principle: confront your fears
    • reality based apprehension respond to knowledge and skills
    • irrational fears respond to exposure
  • gradual versus immediate, maximum exposure
    • systematic desensitization (in imagery, in vivo, in situ)
    • emotive imagery
    • modeling and guided participation
      • versus
        • flooding
        • response prevention (OCD)

School Phobia: differentiations

(4-3-06)

School Phobia vs. Reality Based Apprehension

  • Reality based fears reflect
    • Real threat
    • Reasonable degree of fear
  • Reality based fears can be decreased with:
    • knowledge
    • skill training

School Phobia vs. Truancy

Children showing school phobia:

  1. Linger at home with parents’ knowledge and/or consent
  2. earn average or better grades
  3. profess to like school
  4. bluntly refuse to go to school
  5. show more somatic signs of anxiety: abdominal pain, nausea, vomiting, disturbances of eating and sleeping.
  6. tend to come from stable homes with no history of parental absence.
    • Truancy: differs from school phobia on all of the above
      • Truancy is a symptom of conduct problems.

Subtypes of School Phobia: Two patterns of school phobia have been proposed, based on characteristics of the episode and the child’s family. Type 1 has been described as showing a more positive course (more likely to show spontaneous remission) and a more positive prognosis (good responses to treatment are often shown).

Type I School Phobia (“Acute”, “Neurotic”, “Neurotic Crisis”)

  1. Young (</= 10 years of age)
  2. First episode
  3. Monday onset, often following minor illness preceeding week
  4. Acute onset
  5. Expressed concern about death
  6. Child thinks Mom may be ill
  7. Good communication between parents
  8. Mom and Dad well-adjusted
  9. Father involved in home and housework
  10. Parents easy for school/counselor to work with

Clear presence of 6 characteristics out of 2-10 sufficient for classification.

Type II (“Chronic”, “Characterological”)

  1. Older (>/= 10 years of age)
  2. 2nd, 3rd, etc. episode
  3. No Monday onset pattern
  4. Incipient onset
  5. No death theme
  6. Mom’s health not an issue
  7. Poor communication between parents
  8. Mental health problems in parents: Mom may have anxiety probems or history of same; Dad may have substance abuse or criminal problems or history of same.
  9. Dad shows little interest/involvement in family, home, housework
  10. Parents difficult for school/counselor to work with

Clear presence of 6 characteristics out of 2-10 sufficient for classification.

Panic

DSM-IV defines a panic episode as a discrete period of intense fear or discomfort during which at least four of the following develop abruptly (criterion paraphrased):

  1. increased heart rate
  2. sweating
  3. trembling or shaking
  4. sensations of shortness of breath/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 flashes

ICD-10 discusses attacks of severe anxiety (panic) in the context of defining Panic Disorder (F41.0): “sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization) are common. There is also, almost invariably, a secondary fear of dying, losing control, or going mad.” (World Health Organization, 1992, p. 139).

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