Chapter 7Anxiety 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 children with anxiety disorders suffer from more than one type
Excitement is often associated with anxiety. There are bodily physical symptoms. State of
anticipating the future that may be dangerous or scary which fuels the feeling of anxiety.
Occurs in many forms. Ie.exam time causes anxiety but functions normally. Have
comorbid issues-another diagnoses, another type of anxiety usually or depression.
Moderate amounts of anxiety are adaptive; we act more effectively and cope with
potentially dangerous situations. We behave effectively if we have moderate levels of
anxiety and cope better in dangerous situations. Ie/get in car and practice safe driving
fueled by moderate level of anxiety.
Excessive, uncontrollable anxiety can be debilitating- balance is very fine. Getting right
amount of anxiety, also genetic driven. Use coping mechanisms or get professional help
The neurotic paradox is a self-defeating behavior pattern- individual will know little to be
afraid of the even that they are a part of happens to a lot of people but are still terrified
and will try to avoid and escape that situation. Ie/not get in a car, to avoid accident.
Fight/flight response. Immediate reaction when you perceive threat and want to escape
potential harm. To help people make decisions when appropriate to use fight/flight
response. Alot of people have difficulty with make an appropriate choice.
Three interrelated (all work with one another) anxiety response systems:
Physical system: brain is involved to send messages to sympathetic nervous
system, produces fight/flight response and activates strong chemicals in order to
deal with the perceived danger. Brain release cortical, need in small doses. Good
at absorbing and lowering levels. People with anxiety will release too much
cortical that has side effects- a response from physical system. Ie/increased heart
rate, fatigue, upset stomach, dizzy, numb, lower blood pressure, sweating
Cognitive system: subjective feelings, activate panic, will not be able to
concentrate, IQ drops by 20 points, feel like they are having a heart attack or
going crazy, imagining harm-side effects
Behavioral system: become aggressive b.c they don’t know what else to do or
avoid threat and escaping it in the process.Avoidance- avoid anything to do with
anxiety increasing ie/school refusal. Try to act in a way to create a balance, body
and brain needs to be in homeostasis so will try to achieve by any means-
avoidance, crying, aggression, nail biting, tapping-happens with too much
cortical, pacing, clenching jaw.
Future-oriented mood state, which may occur in absence of realistic danger; (on
average most people are in danger-chance will fail but not realistic to think
definite) characterized by feelings of apprehension and lack of control over
upcoming events. Ie/going to fail final even though studying convincing that you
will fail. Fear:
Present-oriented emotional reaction to current danger, characterized by strong
escape tendencies and surge in sympathetic nervous system. Ie/ fear of airplanes,
emotions arise on the plan but if thinking about it then anxiety. Immediacy ignited
fear if see a spider but no anxiety when thinking about it.
Group of physical symptoms of fight/flight response that unexpectedly occur in
the absence of obvious danger or threat. Feel calm initially, no danger. Blurred
vision, five senses are heightened-clearer vision, hear louder, smell and taste more
vivid. Difficult to manage.
Moderate fear and anxiety are adaptive, and emotions and rituals that increase feelings of
control are common
Normal fears? NormalAnxiety? Normal Worry? Normal rituals?
Will vary with developmental stage person is in. normal for child to be anxious for a four
year old when parents leave but not for 10 year old. Consider mental age, children fear
animals but not normal for adult. Normalcy about age and intensity of child experiences
and frequency. 3 yr old anxious at day care, how intense is the anxiety- cry for 15 mins,
able to adjust or cannot be left.
Anxiety Disorders According to DSM-IV-TR
Nine categories define the features of anxiety disorders. Most common.Assessment is
tricky b.c of overlap, so diagnosis not reliable. Diagnosis depends on clincians- problem
with anxiety group.
Separation Anxiety Disorder (SAD)- need this for child to survive, reaction they
need, obtain proximity to caregiver for survival. 7 months to 4 years old
(preschool). Insecure attachment if no SAD-have not bonded emotionally so feel
no anxious (problem). Diad needs intervention for secure attachment.
GeneralizedAnxiety Disorder (GAD)
Social Phobia (SocialAnxiety Disorder)
Obsessive-Compulsive Disorder (OCD)
Panic Disorder (PD)
Panic Disorder with Agoraphobia
Posttraumatic Stress Disorder (PTSD)
Acute Stress Disorder
Significant associations exist between nearly all anxiety disorders
Separation Anxiety Disorder- SAD
Age-inappropriate, excessive, and disabling anxiety about being apart from
parents or away from home. Need 3 or more symptoms if 2 strong ones can’t be
diagnosed. If anticipated, the idea of caregiver leaving is enough. Excessive worry
about possible harm, persistent. DSM problem-no definition so criticism of
diagnosis, varies to clinicians. Clinical opinion of consensus-reliable.
Prevalence and Comorbidity
SAD is one of the two most common childhood anxiety disorders
Occurs in 4-10% of children-population based sample. Prevalent in girls than boys. More than 2/3 of children with SAD have another anxiety disorder either concurrently or
future. 50% for depression sometime in their life. Justify intervention before symptoms
Children with SAD may also display specific fears of getting lost, or of the dark
School reluctance or refusal is common in older children with SAD- not a diagnosis,
major functioning as arguing criteria. Major in older kids.
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. Manifests first, average is 7-8 so deferred until school age. Lack
of referral until kids are older.
Progresses from mild, moderate, severe. Triggered my major stress ie/moving houses,
new school transition, divorce, death- occur before onset.
SAD persists into adulthood- one third continue to have SAD.
As adults, more likely to experience? Relationship difficulties, mood disorders, functional
impairments in social interactions,
School Reluctance and Refusal-not a diagnosis
School refusal behavior:
Refusal to attend classes or difficulty remaining in school for an entire day
Equally common in boys and girls btw ages 5-11. If difficulty in grade 1, hard in
preschool too, peaks at second grade- academic pressure, social demands in kindergarten.
Fear of school may be fear of leaving parents (separation anxiety), but can occur for
many other reasons
Serious long-term consequences if it remains untreated
Difficult to treat- parents biggest issue have a hard time watching their child meltdown,
Some worry is a part of normal development
Generalized anxiety disorder (GAD):
Excessive, uncontrollable anxiety
Worrying can be episodic (stopped and started again) or almost continuous (never
stops)- worried about many things daily.
Worry excessively about minor everyday occurrences- making person miserable
and others a person would say and shouldn’t worry about it.
Accompanied by at least one somatic symptom- long lasting, can withstand
without medical attention ie/chronic headache, muscle pain, continuous shaking-
can live with these. If life threatening then not associated with GAD. Must have 3
symptoms out of 6. Fatigue, irritable.
Anxiety is pieced with worry not depression
Prevalence- 3-6% will be diagnosed. No difference btw girls and boys, slightly higher in
teenage girls. No difference until adulthood b.c hormonal, environment. More socially
acceptable for girls to externalize and express anxiety whereas in boys it is not.-by
product of social acceptance and if girls can have these types of symptoms then girls will
come to help and boys will keep it to themselves.
Comorbidity- GAD highly comorbid to other disorders and depression
Onset- 10-14 years of age. Not high school years- grade 5, 6,7,8 Course- older you get more symptoms develop. When 10 meet criteria at 14 if continue to
meet then more intense. Consider early intervention.
Outcome- depression. Persist overtime if left untreated.
Age-inappropriate persistent, irrational, or exaggerated fear that leads to avoidance of the
feared object or event and causes impairment in normal routine- maladaptive behavior.
Needs to last atleast 6 months. Ie.After tsunami, children having phobias to extreme
weather, cant diagnose b.c normal covered in media. So not disorder. Needs to last
longing and disabling: minimal threat. Belief system needs to be persistent: parents done
research to show no tsunami of living location but still feared.
Evolutionary theory: infants are biologically predisposed to learn certain fears: age
appropriate for fear then not sure not misdiagnosing.
Five DSM-IV subtypes: animal, natural environment, blood-injection-injury, situational,
Prevalence- 4-10% in children have specific phobia some point in their life. Before age of
18, common in girls, last over 6 months.
Comorbidity- other anxiety disorders, has least amount comorbid b.c this is specific to
something that doesn’t have a general predisposition.
Onset- no age where inappropriate, 4 years.
Social Phobia (SocialAnxiety Disorder)
Amarked, persistent fear of social or performance requirements that expose the child to
scrutiny and possible embarrassment ie/ playing a game with spectators, around peers,
over daily situations
Generalized social phobia: most severe, around some type of performance of social
engagement. Involves all social situations, person ends up being alone all the time.
View of social anxiety disorder as existing on a continuum. Lifetime prevalence is 6-12
months. Twice as common in girls than boys b.c girls concerned with competancy, others
perceptions, internalized. FMRI differences in amygdala- emotion regulation.
Prevalence, comorbidity-panic attach, course: last 6 months, persistent, excessive
thinking about it all the time. Common when person needs to do something in front of
others. 20% go on to panic disorder. Onset- middle adolescence-autonomy, want to be
accepted, under age 10 no signs. Peer rejection highly correlated, will develop social
Selective Mutism- rare, child has social skills but selects not to talk to certain people (only
family), situational (mute at events), times (afternoon wont speak) anxiety is controlled by the
choice not to talk-coping mechanism to stay in homeostasis. Children only control what they eat,
what they eliminate, sleep and when to speak.
Failure to talk in specific social situations
Estimate to occur in 0.5% of children
Average age of onset is 3-4 years
May be an extreme type of social phobia b.c often have social anxiety if mute, but there
are differences between the two disorders. Social treatment effective- exposure
Obsessive-Compulsive Disorder: DSM 4 and 5 small changes: OCD used to be under anxiety
disorder now own category b.c research shows OCD has its own neurophysiological. Recurrent, time-consuming, disturbing obsessions (persistent and intrusive thoughts,
ideas, impulses, or images) and then leads to
compulsions (repetitive, purposeful, and intentional behaviors or mental acts) performed
to relieve anxiety-action when obsessive thought is present. Maladaptive coping
If children have this then involve family into their rituals ie.everyone flicking light three
times. Problem with rituals is that compulsions don’t work long term. Short term relief
but if compulsion come back then anxiety peaks. No long term relief, time consuming
engaging in their rituals. Results in life disturbances, relations suffer, lose their job, health
suffers, drops out of school.
Prevalence: rare 1-3%. Boys are twice as likely then girls b.c genetics so boys have a
Common with other anxiety disorders- depressive anxiety disorder. Loss of family, job
Lots of substance abuse, eating disorders, learning issues b.c cognitively to more capacity
to learn. Motor and verbal tics-no control, genetic comorbidity. 9-12 years of age.
Chronic two thirds continue to have OCD when diagnosed as children to adulthood.
Panic attack: pressure cooker effect.
Sudden, overwhelming period of inten