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Chapter 6

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Psychology 2320A/B
Alvin Segal

Ch 6 Psych Internalizing disorders – anxious, fearful, withdrawn, timid, depressed, unhappy, lack self-confidence - phobias, obsessions and compulsions, anxiety disorders, depression and mood disorders are likely used within clinical classification systems = DSM - particular risk factor may not be associated with one particular disorder - another concern = comorbidity - particular environments or experiences shape disposition into particular pattern of symptoms or disorders o cultural differences may be one influence that operates in manner  high rates of separation anxiety and of somatic/physiological symptoms in Hispanic than in European American children  Hispanic=high interdependence in family (collectivism) and on empathizing with others/agreeable (simpatia) Defining and Classifying Anxiety Disorders - anxiety = future-oriented emotion, characterized by perceptions of uncontrollability and unpredictability over potentially aversive events and a rapid shift in attention to the focus of potentially dangerous events or one’s own affective response to these events - fear + anxiety = common, terms used interchangeably - fear = reaction to immediate threat characterized by an alarm reaction - anxiety as a future-oriented emotion characterized by elevated level of apprehension and lack of control - three types of reactions to a perceived threat o behavioural response (running, closing eyes) o cognitive response (images of bodily harm) o physiological responses (heart rate, respiration) - worry = thoughts about possible negative outcomes that are intrusive and difficult to control = component of anxiety - anxiety = normal? Or atypical , anxiety is basic human emotion Normal Fears, Worries and Anxietys General Prevalence - children display large number of fears... - parents underestimate especially when older, can mask emotions Gender, Age, and Cultural Difference - girls exhibit more fears than boys - difference is clearer in older children - less clear in preschool and elementary school - greater intensity of fear in girls - gender-role expectations, and and girls displaying/admitting to fears - both number and intensity of fears decline with age - worry becomes prominent in children at 7 years of age , becomes more complex and varied as children develop - fear of strangers (6-9 months) - fear of imaginary creatures (age 2) - fear of dark (4 years) - social fears and fear of failure in older children and adolescents - preschoolers worry about imaginary threats - young children about physical safety - and older children about social situations and competence - worry reflect ongoing cognitive, social/emotional development - cross-cultural examinations of common fears suggest similarities - FSSC-R (fear survey schedule for children) = inventory of fear stimuli and situations o Girls have higher scores than boys, fears similar across countries Classification of Anxiety Disorders - anxiety/fear even if short-lived = sufficient discomfort or interferes with functioning , intervention justified DSM - child can be diagnosed with one or more included in DSM o separation, phobia, sOCD, PTSD, acute stress disorder Emprirical Approach - Achenbach describes anxious/depressed syndrome - Somatic complaints (dizzy, stomachaches), withdrawn/depressed = symptoms related to anxiety Epidemiology of Anxiety Disorders - common disorders - prevalence 2.5-5% - rates 12-25% cited sometimes Specific Phobias - phobias: contrasted with developmentally appropriate fears, concern because excessive, cannot be reasoned, beyond control, lead to avoidance and interfere with functioning Diagnostic Criteria - essential feature of diagnosis of specific phobia is a persistent fear of a specific object or situation that is unusual or excessive o immediate anxiety response occurs every time exposed to phobic stimulus o person realizes that fear is unreasonable or excessive o person must either avoid anxiety situations or endure any exposure with anxiety/distress - fear must produce marked distress, or interfere with normal routine, academic functioning or social relationships - fear must have duration of 6 months - express by crying, clinging or freezing - recognition that fear is unreasonable or excessive is not required for diagnosing phobia in children Description - youth try to avoid situation/object they fear - reactions occur when situation anticipated - change lifestyle Epidemiology - specific phobias most commonly diagnosed anxiety disorder in children/adolescents - prevalence = 3-4% - SP more prevalent in girls than boys - Similarities between ethnicities - Additional diagnoses = anxiety, depression, mood, externalizing disorders = oppositional defiant disorder - 50% meet criteria for another disorder and somatoform were common Developmental Course - begin early to middle childhood - phobias commonly believed to be relatively benign and improvement expected over time with/without treatment - German adolescents = sympotoms persist = impaired functioning - Carlos = 9 Hispanic America = fear of buttons after buttons fell on him Social Phobia (social anxiety disorder) Diagnostic criteria = marked persistent fear of acting in an embarrassing or humiliating way in social/performance situations - anxiety = social or evaluative rather than object/non-social situation - may not realize fears are excessive and unreasonable - able to display social relationships with familiar people - experience social anxiety with peers and not just adults - must interfere significantly with routine, academic, or social - must produce marked distress - duration of 6 months Description - fear social acitivies and situations = speaking, reading, writing, performing in public, initiating or maintain conversations, speaking to authority figures, interacting in informal social situations - avoidance of social situations that involve interactions or evaluation - avoid eating in public - somatic symptoms = restlessness, blushing, sweating, illness (stomachaches) - feelings of lesser self worth, sadness, loneliness - lesser educational achievement - Selective Mutism and Social Anxiety - young kindergarten girl does not speak in school or with peers - selective mutism = do not talk in specific social situations - onset = 2.5-4 years of age, may go unrecognized until 5 - shy, withdrawn, fearful and clingy - language problems and stubborn, disobedient and oppositional behaviour - SM = complex interplay of environmental and genetic influences - Extreme form of social anxiety - 90-100% of SM have social phobia - children with SM = more socially anxious than children with social phobia - Louis =12 white male, school refusal, social withdrawal, excessive reassurance, excessively fearful, timid, scared, mother had history of anxiety ...Social Phobia and Generalized Anxiety Disorder - Bruce=8, several siblings, only spoke to immediate family not extended, teachers or peers, prescribed Prozac, spoke for him, did not speak to family in public places, treatment helped (21 session) Epidemiology - social phobia present in 1-2% of children and 3-4% of adolescents, 9% lifetime prevalence for adolescence - 14.9% given assessment, 32.4% lifetime - middle, to late adolescence = onset age - prevalence increases with age - not clear if there are sex differences , higher rates for girls - most young people with social phobia meet criteria for other disorder (84% meet ages 7-10) - anxiety disorder = most common additional diagnosis - adolescents meet criteria for major depressive disorder - GAD (73) Separation (51) SP (36) ADHD (9) conduct (4) dysthymia (4) major depressive disorder (2) OCD (2) oppositional defiant disorder (2) PTSD (2) Developmental course - 6 mo and 3 years = stranger anxiety and separation anxiety - 4-5 years = embarrassment - 8 years = negative evaluation and concern - fears of social and achievement evaluation increased with age - 51% ages 12-17 reported at least one specific social fear Separation Anxiety - SAD = youth who have excessive anxiety regarding separation from maor attachment figure/home - 8 symptoms involving worry/distress and related sleep/physical problems - DSM requires presence of three or more symptoms for at least 4 weeks for positive diagnosis o Excessive distress when separation occurs or is anticipated o Persistent/excessive worry about losing major figures or possible harm (death, accident) o Excessive worry that untoward event will lead to separation (kidnap, lost) o Reluctance or refusal to go to school , work, elsewhere o Fear or reluctance to be alone or without major figures o Refusal to go to sleep without being near figure, or sleep away from home o Repeated nightmares involving theme of separation o Complaints of physical symptoms (headaches, stomachaches, nausea, vomiting) when separation occurs/anticipated - Problem must be present prior to age of 18 and must cause significant distress or impairment in social, school, other areas Description - clingy, express general fear/apprehension - experience nightmares or complain of somatic symptoms - older children complain about illness or tragedy that might befall them - apathetic and depressed - reluctant to leave home / participate in activities with peers - threaten to harm themselves = escape/avoid separation - serious suicidal = rare Epidemiology - estimates of prevalence = 3-12% in young people - 12%-33% receive primary diagnosis of SAD - prevalence higher in children than adolescents - disorder uncommon older adolescents - children/adolescents with SAD = criteria for other disorders - GAD = most common - Sex/ethnic = unclear - SAD higher among girls? - Greater rates in African American youth?? Developmental Course - anxiety from separation = normal in infants - problematic only when distress persists beyond expected age or is excessive - symptoms progress from mild to severe - in some symptoms persist , develop a later disorder (depression) - in adolescents SAD if present = more serious problems - KENNY =10, cried, tantrums, threatened to hurt himself, high levels of anxiety, number of specific fears, significant depressive symptomatology, problems appeared when father = drinking and was away from home School Refusal Definition - school refusal = when young people do not attend school, exhibit excessive anxiety - NOT A DSM diagnosis - However, is one of 8 symptoms for SAD - Most common school refusal = fear aspect of school experience = specific phobia? Academic performance, evaluation, speaking in public, conflict with peers, meeting new people - School refusal = heterogeneous and multicausal - Classify school refusal by the function that the behaviour serves - functional analysis rather by symptoms Description - onset of problems = life stress (death, illness, change of school, new neighbourhood) - truancy = unlikely to be excessively anxious or fearful about attending school - absent without parental knowledge , intermittent VS school refuser absent for continuous which parents are aware - truants = poor students who exhibit other conduct problems such as stealing/lying Epidemiology - school refusal = 1-2% of general population, 5% of all clinic-referred cases - equally common in boys and girls - can be found in youth of all ages UNLIKE SAD - but like SAD more likely to occur at major transition points - younger children = related to SAD - adolescence = anxiety and depressive disorders - prognosis = best for children under 1- years - treatment = difficult for older children and those who are depressed - problems = untreated then long term serious consequences may result Generalized Anxiety Disorder (GAD) Diagnostic Criteria - excessive anxiety and worry about number of events /activities - find worries difficult to control - excessive anxiety that is not confined to a specific type of situation - DMS diagnostic criteria require 1 or more of six symptoms o Restlessness, keyed up/on edge o Easily fatigued o Difficulty concentrating o Irritability o Muscle tension o Disturbed sleep - Symptoms must be present most days for past 6 months (some symptoms) - Must cause distress/impairment - Need 3 symptoms for adults Description - excessively concerned with competence/performance (academic, peer relations, sports) - point of being perfectionistic and setting high standards - family finances, natural disasters - repeatedly seek approval and reassurance - exhibit nervous habits (nail biting) and sleep disturbances - physical complaints such as headaches and stomachaches are common - JOHN = low opinion of himself/abilities, difficult to cope, panic attacks overtook him, afraid of dark, ghosts, monsters, abandoned, alone, strangers, war, guns, knives, loud noises, snakes o Psychosomatic complaints = bladder, bowels, kidneys, intestines, blood o Suffered from insomnia , would not sleep until mother o Afraid to sleep alone or sleep without light o Regularly wet/soiled o Fearful of contact with others Epidemiology - youth of all ages 2-14% - GAD most common anxiety disorder among adolescence o 3.7-7.3% - more common in girls, no sex differences - median age of onset = 1- years - number/intensity of symptoms = increase with age - GAD = meet diagnostic criteria for additional disorders and rates of co- occurrence = higher for youth with GAD than for those with other diagnoses - Depression, separation anxiety and phobias are common comorbidity disorders - GAD may be overdiagnosed Developmental Course - GAD not transitory - Symptoms persist for many years , very likely for those with more severe symptoms - Increased impairment and increased risk of alcohol use have been reported - Young children = concurrent with separation - Adolescents = concurrent of depression or social phobia - GAD distinc disorder? Or heightened general vulnerability? Panic Attacks and Panic Disorder Diagnostic Criteria - intense, discrete experiences of extreme anxiety , seem arise quickly and often - discrete period of intense fear or terror that has suddne onset and reaches peak quickly in 10 minutes or less - DSM describes 13 somatic/cognitive symptoms, 4 must be present during an episode o Palpitations, pounding heart o Sweating o Trembling/shaking o Shortness of breath/smothering o Choking o Chest pain/discomfort o Nausea/abdominal distress o Dizzy/unsteady/lightheaded/faint o Derealization, depersonalization o Fear of losing control or going crazy o Fear of dying o Paresthesias (tingling/numbness) o Chills or hot flushes - Panic attacks differentiated by presence or absence of triggers - Unexpected (uncued), expected (cued) situationally bound, occur occasions when person exposed to or anticipates feared object/situation - Situationally predisposed panic attack = exposure to situational cue, not all the time, occur following exposure rather than immediately - NOT DISORDER WITHIN DSM, occur in context of several different anxiety disorders - FRANK = discrete episodes of heart beating quickly, shortness of breath, tingling in hands, extreme fearfulness, episodes lasted only 15-20 min, frank could not fall asleep in bedroom, tired during day, schoolword deteriorated Panic Disorder - recurrent unexpected panic attacks - to receive DSM diagnosis of panic disorder at least one of attacks has been followed by a month or more of o persistent concern about having other attacks o worry about implications of attack (going crazy/having heart attack) o significant change in hehaviour related to attacks - may occur with or without agoraphobia = situation which escape – difficult/embarrassing - ISSUES: o adults experience physiological/cognitive symptoms of panic (going crazy/dying), such cognitive symptoms may not occur in children o actually unexpected , or not aware? Epidemiology - panic attacks and panic disorder occur in adolescents , and to lesser degree prepubertal children - onset occurred during adolescence/earlier - 16% between 12-17 australian youth reported one panic attack in lifetime - similar rates reporte
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