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 forms
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.
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.
1 Moderate fear and anxiety are adaptive, and emotions and rituals that increase feelings of control are
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
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 commonly occur
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
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
2 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, other
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.
3 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 phobia.
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 mechanism.
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 single copy.
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 intense fear or discomfort accompanied by four or more physical and
cognitive symptoms characteristic of the fight/flight response. common in adolescence and knows why,
children do know cognitively. Its own diagnostic criteria but not quotable-not a diagnosis. puberty
Posttraumatic and Acute Stress Disorder
Panic disorder (PD):
Recurrent unexpected panic attacks followed by at least one month of persistent concern about
having another attack, constant worry about the consequences, or a significant change in
behavior related to the attacks. Cant go out for embarrassment, anticipatory anxiety.
May lead to agoraphobia: fear of alone or avoiding places with other people. Want a significant
other around them to help them.
Prevalence and Comorbidity- 3-4% in teenagers, panic disorder is 1%. Depression and anxiety
comorbid. Suicide and substance abuse. Panic attacks easy to treat. Panic disorder is difficult to treat-
low reemission rate.
Onset, course, and outcome- onset is stressful event doesn’t mean that maintains it.
PTSD: Persistent anxiety following an overwhelming traumatic event that occurs outside the range of usual
human experience. By dsm must have a traumatic event.
Three core features of PTSD: persisting event and re-experiencing (sound), persisting avoidance (loud
noises), numbing of general responsiveness (absent not being able to process around them), extreme
4 emotional arousal- panic attack. Consciously resurfacing the arousal become PTSD. Longer amount of time
with more symptoms than acute stress disorder.
Acute stress disorder: Development of at least three dissociative symptoms within one month after a
traumatic experience, lasting at least two days but not longer than a month. Mild version of PTSD.
Prevalence and Comorbidity
Although at least 2/3 of children in U.S. experience at least one potentially traumatic event by age 16,
most do not develop PTSD, except following several traumas or a history of anxiety. Rare development
of PTSD. 3% for boys, 6% for girls. 75% comorbid for depression and substance abuse.
Prevalence of symptoms is greater in children who are exposed to life-threatening events
Onset- most trauma is abuse- 1 in4 children. Can be delayed for months or years after traumatic abuse.
Course- correlated to degree of exposure ie. How long, intense, extreme severe of the trauma. When in
childhood it occurred- age of child. Younger they are, better off they are b.c cognitively not able to
process event so seen more in adults. Persistent and lifelong if untreated leading to suicide.
Outcome- recovery- need strong social support and CBT.
Children with anxiety disorders display a number of associated characteristics
Social and emotional deficits
Anxiety and depression
Cognitive Disturbances-when anxious, cognitive numbs, slower process, memory impaired, cant pay attention
or make sentences.Academic achievement- drop out rates are high. : cognitive disturbances.
Disturbance in how information is perceived and processed
Intelligence and academic achievement: despite normal intelligence, deficits are seen in memory,
attention, and speech or language.
Threat-related attentional biases.
Cognitive errors and biases: misread social situations. Ie.person walked away b.c not a good friend. See
yourself as deficient to manage your anxiety. Say lose your emotions easily which fuels problems.
Physical and Social Symptoms
90% have sleep-related problems, including nocturnal panic- abruptly wakening with panic, leads to
insomnia, and nightmares. Cycle common for anxiety.
High rates of anxiety in adolescence are related to reduced accidents and accidental deaths in early
adulthood. Don’t take risks but higher chance to die from non accidental- suicide, medical condition
with high cortical.
Social and Emotional Deficits- low social performance, are viewed as maladjusted. Shy, withdrawn, low
self esteem, loneliness and difficulty make friends.
Anxiety and Depression
Social phobia, GAD, SAD, and multiple anxiety disorders (not specific phobia) are commonly
associated with depression
Negative affectivity- persistent negative mood, nervous, high levels of sadness, anger, guilt
Positive affectivity- joy, enthusiasm and high energy experienced less- lower levels.
Physiological hyperarousal may be unique to anxious children- somatic tension, shortness of
5 Gender, Ethnicity, and Culture: no difference in ethnicity and culture, effects all. Difference is treatment
and perceive and understand is different. Ie/children in control.
Theories and Causes
Classical psychoanalytic theory- buried experience from the past, use defensives (anxiety) to
cope (block/avoid process). Teach new coping mechanisms that are functional and healthier so
you don’t experience anxiety any longer.
Behavioral and learning theories- classical conditioning, have a learned experience, been
exposed to a fear.Anxiety associated with that stimuli has been learned to be afraid. Long lasting
due to the strength of anxiety. Learning theory: talking through to cope ie/child to parent.
Variations in behavioral reactions to novelty result in part from inherited differences in neurochemistry
of brain structures
Amygdala, Projections of amygdala – responds the most with anxiety.
Behavioral inhibition (BI): children are often born with a low threshold for novelty and unexpected
stimuli. They react more intensely. Parents should set firm limits, help reduce stress and help cope with
difficulties. Parents are key to model emotion regulation.
Development of anxiety disorders in BI children depends on gender, exposure to early maternal stress,
and parental response.
Family and Genetic Risk
Family and twin studies suggest:
About 1/3 of the variance in childhood anxiety symptoms is genetic. No correlation to the type of
anxiety. OCD much more heavily driven by genes. Part of temperament that controls shyness and
inhibition is controlled by genetics.Adisposition to become anxious is inherited
Serotonin and dopamine systems are related to anxiety. Heavily regulated by your genes.
Genes are linked to broad anxiety-related traits (e.g., behavioral inhibition).Amygdala, left and
right hemisphere is asymmetrical with anxiety and limbic system- Neurobiological Factors
Parenting practices may be contributors to childhood anxiety disorders. Parents are controlling of the
children, tendency to be over protective, being very involved. Let child be independent and feel
confident. When parents model anxious behavior they produce anxious child. If parent is busy, there is
less time for bonding, having fun, and less energy with all other practices they are engaged in.
Prolonged exposure to high doses of family dysfunction associated with extreme trajectories of anxious
behavior. Ie/ parent has an addiction, anger management are directly associated with child’s anxiety.
Lower parental expectations for children’s coping abilities
Low SES: more stress in family is related to anxiety. Parents not realizing that young children
understand the stress, parents are dismissive of this.
Insecure early attachments (particularly ambivalent attachment) may be a nonspecific factor
Treatment and Prevention
Main line of attack for treating anxiety disorders is exposing children to anxiety producing
situations, objects, and occasions. But parents protect child from what they are afraid of. In
general when treating main technique is to make anxious- exposure.
Treatments for anxiety are directed at modifying:
Distorted information processing-exposure
Physiological reactions to perceived threat: teaching to control parts of the brain that make you
6 Sense of a lack of control: helping to manage not be in control ie/putting you in a situation with
no control of time. Challenging distorted ways, recording physiology reactions.
Excessive escape and avoidance behaviors- block, like a roller coaster: reach peak (most anxiety)
and come down. They avoid coming down, feel anxiety rising, use non-functional ways-panic
attack, crying, clinging, avoiding in order to stop anxiety and will not know how to ever stop it
so will become more anxious. So cannot cope and with same experience will be more anxious.
Main technique of behavior therapy is exposure to feared stimulus while providing children with ways
of coping other than escape and avoidance
Graded exposure- opposite of flooding-rate from 1 to 10 your feared stimuli. ie/ordering a coffee.
Systematic desensitization- teach child to relax. Use breathing techniques, visual, muscle relaxation.
Takes a long time- 7 to 8 sessions. Least anxiety provoking to most.As anxiety increases, coping
mechanisms, once back in equilibrium increase anxiety again.
Modeling and reinforced practice; in vivo exposure works best (real exposure, better stimulation for the
brain)- going to a public place and watch how do others manage with anxiety.
Cognitive-Behavior Therapy (CBT)- recreate functional cognitions to behave more functionally. 12-15 week
program. How to desentize and relax.
The most effective procedure for treating most anxiety disorders
Teaches children: To understand how thinking contributes to anxiety. How to modify their
maladaptive thoughts to decrease symptoms
Almost always used with exposure-based treatments
Coping Cat: emphasizes learning processes and the influence of contingencies and models, as well as
role of information processing
Skills training and exposure combat problematic thinking
Computer-based, computer-assisted, and online CBT have also been shown to be effective
All-or-nothing thinking: black and white world. Ie/if do bad on a test, then I am a failure. Very
convinced of a thing
Overgeneralization- signal negative effect is a never ending pattern of defeat. One negative experience
pollutes other events
Mental filter- dwell on it more excessively- filtering things through a single detail.
Disqualifying the positive-reject all positive insisting that they don’t count.
Jumping to conclusions – negative interpretation with no proof.
Mind reading – jumping to conclusions. Someone is reacting negatively to you without checking first.
The Fortune Teller Error- sub classifications- anticipating things will end badly and are convinced of it.
Already established fact.
Magnification (catastrophizing) or minimization: common. Exaggerating the importance of things ie/I
will never go to graduate school b.c of test
Emotional reasoning: negative emotions reflect the way things are. I feel it so it must be true. I feel
rejected so it is the emotion I am experiencing.
7 Should statements: motivate yourself with should and shouldn’t- like y