Developmental Psychopathology Final

Psychosocial treatments have risk of contagion effect

getting kids with externalizing behavior together can be bad because kids will play off each others bad behavior

"Triple Bind" - First Prong

girls must still be "all girl" - if you're a girl, must be kind, nurturing, empathic - not much has changed here, for many millennia

Consequences: true self vs. false self

how to develop true self if I'm always looking outside for validation?

Bipolar II

hypomanias and depressions

Consequences: learned helplessness

if i can't do it all, learn to give up

Depression Treatments: CBT; Behavioral Therapy (activation)

immediate rewards for doing something good; the act of going through motions can activate a person

Causal Factors: Family

insecure attachment, coercion, abuse

With OCD _______ is often good, but doesn't prevent the symptoms

insight -rarer cases when little insight: bad sign (disordered thinking)

EC: Conduct disorder and parent, child interaction therapy

instructing parent how to make positive interactions with child through one way mirror

Parents tend to underestimate both ________ and ________ of children's stress reactions

intensity; duration

Causal Factors: media

is media violence causal or correlated?

BN onset

late adolescence on average

OCD onset

late adolescence/early adulthood but may begin in childhood -males typically have earlier onset

Treatment: medications

lithium, anticonvulsants (high nonadherence)

after ______, syndromes can develop later in life too

loss

Risk factors

loss events, critical parenting practices, peer isolation, ruminative cognitive style

Key differences at different ages: preadolescent

low self-esteem, guilt, hopelessness

Causal Factors: neighborhoods

lower SES neighborhoods

Vulnerabilities

female gender, genetic, early experiences related to attachment

When do the first symptoms of specific phobias usually occur?

childhood or early adolescence

Is the general rate of anxiety higher in males or females?

females (2:1 female to male)

SAD gender ratios are ________?

generally equal

Key differences at different ages: Infancy

"anaclitic depression" - the impairment of an infant's physical, social, and intellectual development following separation from its mother or primary caregiver

Overall Eating disorders can't be cultural messages exclusively but rather....

'fit' b/w idealized/internalized body image and frank distortion of that image, and issues of control

GAD is not just ________ anxiety, but rather a great many feared stimuli

'free-floating'

How linked (synchronous) are components of anxiety?

- Components: Physiological, Cognitive, Behavioral - OFTEN correlation is low (.2-.3) between them - BUT, when anxiety (or any emotion) is high, far greater synchrony emerges

Prevalence

- 1-2% in early childhood (equivalent boy:girl) - Up to >10% by adolescence (girls at least 2:1) - By age 20, 20% of women

Types of Specific Phobias

- Animal Type - Natural Environment Type (e.g. heights, storms, water) - Blood-Injection-Injury Type - Situational Type (e.g. airplanes, elevators, enclosed places) - Other Type (e.g. fear of choking, vomiting, or contracting an illness; in children, fear of loud noises or costumed characters)

Tripartite Model of Anxiety and Depression

- Anxiety characterized by high negative affect and physiological arousal - Depression characterized by high negative affect and low positive affect - Comorbid anxiety and depression characterized by high negative affect, low positive affect, and high physiological arousal

Rapid Cycling

- At least 4 episodes per year - Faster transfer between episodes

Childhood-Onset Bipolar Disorder

- Classic bipolar disorder is extremely rare in preadolescent youth (<1%) - more common (>1%) if the wide phenotype is applied (irritability, extreme aggression, low energy, grandiosity)

DSM Criteria: Separation Anxiety Disorder

- Developmentally inappropriate and excessive anxiety concerning separation from home or attachment figures - 3 or more symptoms, for at least 4 weeks: o Excessive distress upon separation/anticipated separation from attachment figures o Excessive worry about losing or harm befalling attachment figures o Excessive worry that an event will lead to separation from an attachment figure (ex: kidnapping) o Reluctance to attend school b/c of fear of separation o Reluctance to be alone or w/out attachment figures at home or other locations o Reluctance to sleep alone or away from home o Repeated nightmares involving separation o Repeated complaints of physical symptoms when separation occurs or is anticipated

Swimsuit study

- Do math problems in bathing suit alone - Female group did worse in bathing suit condition than sweater and pants condition - Reported feeling shamed and unhappy after taking test - Male group did better in bathing suit condition than sweater and pants condition - Male group felt happiness and pride

Protective factors to encourage

- General realization of the binds girls are in: you CAN be an athlete as a woman and not be a super-model as well - Availability of true alternatives: look out rather than in - Real goal of adolescence is to develop an identity, so have to fail at a couple things - Wider sense of community and sense of purpose: if you have to be perfect all the time you never get a chance to explore

Behavior Therapy: Graded Exposure

- Gradual exposure using Subjective Units of Distress Scale (1-10 or 1-100) beginning with least distressing stimulus - Create a hierarchy of exposures that are increasingly intense (look at pictures first, then look at dog through window, then have dog in room)

Relational Aggression

- Harm others indirectly, socially, indirect - Predominantly girls? - Girls doing this in elementary/middle school is as predictive as physical aggression in boys for later problems - There is a victim

Causal Models of Depression: Family depression

- Many aspects of familial transmission, over and above genes: - insecure attachment - modeling of passivity - dysregulation - non-contingent environment - blame self if no explanation is given for erratic of absent parental behavior

DSM Criteria: Social Anxiety Disorder (Social Phobia)

- Marked/persistent fear of one or more social or performance situations - Exposure to feared social situation almost always provokes anxiety; in children may be crying, tantrums, freezing, or shrinking from social situations with unfamiliar people - Feared social/performance situations are avoided or endured with intense anxiety/distress - Interferes significantly with functioning or causes marked distress - Duration is at least 6 months

Treatment for Children: off-label medications

- Medications that haven't been clinically tested to treat that specific disorder, but may relieve symptoms - Key issue in bipolar: all medications are off label for children

Causal Models of Depression: Heritability

- Moderate (30% - 40%) - much higher for bipolar - Gene x environment interactions

Trends: Girls and Women: Aggression

- More externalizing - down for boys sine 1995, but up dramatically for girls in last 15 yrs

Sex differences: Girls: Multifinality

- More than boys, girls with conduct problesm have high risk for... - depression, suicidality, low-quality relationships, somatization

CBT

- Most effective procedure for treatment -Teaches children and adults: o to understand how thinking contributes to anxiety (cognitive bias) o how to modify their maladaptive thoughts to decrease symptoms -Almost always used w/ exposure-based treatments

Right now the two disorders, considered distinct, can be diagnosed together

- ODD focuses more on uncontrolled: reactive emotions/behavior - CD more about serious behaviors/problems

Adults: ASP and Psychopathology: Psychopathology

- Personality characteristics - Callous, unemotional, manipulative, glib, remorseless, impulsive

Anxiety: What to look for...

- Physical complaints (headaches, upset stomach or nausea, increased hr, diarrhea or constipation, muscle tension, dizziness, chest pain, fatigue and exhaustion) - Sleep (early/middle insomnia, repeated visits to parent's room) - Avoidance of outside and interpersonal activities (school, parties, camp, safe strangers) -Excessive need for reassurance (new situations, bedtime, school, storms, "is is bad?") - Inattention and poor school performance -Explosive outbursts -Not necessarily pervasive (some areas of function remain intact)

OCD: Compulsions are defined by:

- Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly - Aimed at preventing or reducing distress or preventing some dreaded event or situation; not connected in a realistic way w/ what they are designed to neutralize or prevent or are excessive

DSM Classification of Different Forms of Anxiety

- Separation Anxiety Disorder - Selective Mutism - Specific Phobias - Social Anxiety Disorder (Social Phobia) - Panic Disorder - Agoraphobia - Generalized Anxiety Disorder - OCD (has own section in DSM-5) -PTSD (has own section in DSM-5)

SUDS graph

- Subjective units of distress; helps people quantify how much distress they're in; - With curve 2, anxiety shoots up, then there's a wash where the stimulus is removed, and then anxiety decreases - With curve 1 → anxiety increases more when dog isn't removed so flooded with anxiety then comes down when you realize nothing is wrong

Behavior Therapy: Systematic Desensitization

- Teaching child to relax, constructing anxiety hierarchy, presenting anxiety-provoking stimuli while child remains relaxed - Similar to graded but also teach person to relax

How to distinguish bipolar from ADHD?

- about 20% of children with ADHD have comorbid bipolar

Bipolar disorder: historical view

- adult condition - onset in late teens or 20s

Trends: Girls and Women: Depression

- age of onset used to be in 30's, now in 20's, with subset in early teens - epidemic? maybe or maybe not, but numbers are alarming

Trends: Girls and Women: Eating Pathology

- binge eating is way up (anorexia and bulimia relatively flat) - rates of body concerns and unhealthy eating are WAY up

Child depression - view today

- child depression does exist, with similar symptoms to those of adult depression - key differences may exist at different ages

What age group is anxiety very common in?

- children - however, most of these worries and stresses are outgrown or recede as children mature and develop

Types of presentations: Classic Bipolar (Bipolar I)

- clear onset of manic (and sometimes depressive) episodes (can have w/ or w/o depression) - at extremes, mixed states can occur

Child depression - history of concept: Through 1960s

- couldn't exist (psychodynamic) - superego development and self-reflection not fully developed before age 12, so depression not possible

BP is associated with?

- creativity and productivity - but person must be creative in the first place

Trends: Girls and Women: Self-harm

- cutting, self-mutilation, self-injury, release of deep pain - in rapid rise (abuse, depression, contagion)

Mechanism for this phenomenon

- empathy becomes guilt, and parentificaiton - fail to take care of self, fail to become appropriately assertive

Fear

- ex: Elephant is coming in room now - fight/flight response, cascade of biological effects in the body

Anxiety

- ex: concern that elephant may come in room when least expected - anticipation of negative outcomes; tension, negative effect - many of the same psychophysiological indicators as fear

Panic

- extreme fight/flight response in absence of actual danger - symptoms akin to suffocating, heart attack, completely losing control, major source of ER visits

Suicide risk

- extremely high in bipolar - if untreated, over half attempt, and 1 in 5 complete suicide

Family life and GAD

- family life beings to revolve around child's anxieties -constant need for reassurance

Medication: stimulants

- far less effective compared to ADHD - stimulants can increase proactive aggression (aggression with pre-thought) - for children with aggressive behaviors comorbid with ADHD, stimulants do reduce aggressive behavior (especially reactive, retaliatory aggression)

OCD Prevalence

- far more common than thought -from several in 10,000... to over 3% of population

Suicide rate

- fast rising in teen girls (girls attempt more, boys complete more) - lower in regions with SSRIs

Medication: second-generation antipsychotic meds or mood stabilizes

- for more complex and severe cases - issue of whether some aggression is related to bipolar - side effects can be sever, and hardly any real evidence here - as opposed to huge evidence base for stimulants and ADHD

Rise in girls at puberty

- hormonal surge, role expectations, ruminative style - is rumination (rehearsing things again, and again, and again) a trigger, a correlate, or a consequence?

Devices/blue light

- hurt sleep patterns - no escaping assignments or peers - where is down time?

Cyclothymia/cyclothymic disorder

- hypomanic symptoms and subclinical depression

Causal Models of Depression: Neurobiological

- left frontal lobe less activated - hippocampal (related to stress hormone) - consolidates short term memories into long term; part of limbic system; hippocampus shrinks by the day with depression

Causal and Maintaining Factors of Anxiety: Parenting Styles and Family Factors

-Authoritarian parenting restricts child's development of autonomy (child doesn't do anything for themselves and parents are too intrusive) -Parental rejection and criticism

Treatment for Children: meds

- mood stabilizers - Second generations/atypical antipsychotics - Antidepressants for refractory depressed mood - Anti-anxiety medications and sleep meds

Lack of sleep

- natural delayed onset in puberty - early school hours exacerbate - consequence of sleep deprivation - inability to consolidate memory - inability to suppress negative affect, mediated by inability of PFC to inhibit "emotional brain" - fMRI investigations, paralleling sleep deprivation studies

Life-Course Perspective: Adolescence Limited

- onset is limited prognosis usually • Closer to 1:1 boy:girl (but boys show more violence) • Appears to dissipate by late adolescence • High rates: up to 40-50%, depending on severity • Maturity gap earlier puberty, delayed access to social goals You feel mature, but you're not » engage in antisocial behavior to bridge the gap • Latest research Surprising persistence of this subgroup • Although never as violent as early onset group And some 'early starters' desist • Concept of SNARES There's something that catches you that makes you less likely to grow out of this behavior • Is it that there's no true adolescence limited or adolescence extending until mid twenties or later?

Behavior Therapy: Exposure w/ Response Prevention

- prevents child from engaging in escape/avoidance and rituals - ex) OCD, expose people to what makes them anxious; at each exposure the anxiety goes down; for many it has to be in a very controlled environment like a hospital

Puberty and Adolescence: Paradox

- puberty starts ever earlier due to nutrition - adolescence is the healthiest time of our lives both mentally and physically, but theres also a HUGE risk for accidental injury, physical problems, mental disorder

When major depression does exist in childhood...

- severe condition, with high likelihood of recurrence - major implications for switch into bipolar, and for suicide

What do girls do better than boys -- from an early age?

- show empathy, compliance, language skills, social skills; by age 3-4, far ahead of boys - these are PROTECTIVE FACTORS against girls' mental health problems in childhood

Correlates and Outcomes: Poverty, low SES

- tend to be more aggressive - But is it more mediated by more proximal factors? Like parenting

Puberty and Adolescence: Why the paradox?

- there's the maturity gap between frontal lobe development and hormonal deposition - hormones not only hit peripheral 'targets' but also cycle back to the brain increase in vulnerability to stress increase in sensation seeking/risk taking - frontal lobes ("breaks") take much longer to mature

Anorexia Nervosa

-Fear of weight gain or becoming fat, or behavior to prevent weight gain, despite being underweight -Distorted self-perception, undue influence of weight on self-evaluation, or denial of seriousness of low weight -Restriction of calorie intake relative to requirements leading to significantly lower weight than minimally expected o weight criterion is problematic -Restricted type and binge-eating/purging type

Sexualization/Objectification: APA Task Force on Sexualization of Girls/Women

- thongs for 8 yr olds - Victoria's Secret models for girls under 9 - Preoccupation with diet/looks well before puberty - half of third grade girls: worried about weight; a third: dieting

Specific phobias predisposing factors

- traumatic events, panic attacks, observation of others undergoing trauma or demonstrating fearfulness, and informational transmission (e.g. repeated parental warnings, media coverage) -feared objects are those which may actually represent some threat or have represented a threat during some point in human evolution

Trends: Girls and Women: Suicide

- tripled for teens from 1950's through 1988; went down with SSRIs - but, recently, up 76% in girls 10 - 14, up 32% in girls 15-18

Children may experience very rapid cycles called:

- ultra-rapid, ultradian (multiple within a day) - ex) kid who is feeling depressed or suicidal in English class then goes to algebra and back-talks or feels like a hot shot

DSM Criteria: Panic Disorder

-'Fear of fear' -Must have both: o Recurrent unexpected panic attacks o At least 1 attack has been followed by 1 month (or more) of one (or more) of the following ~persistent concern about having additional attacks ~worry about implications of the attack or its consequences (e.g. losing control, heart attack, "going crazy") ~significant change in behavior related to attacks o Not due to a substance or medical condition; not accounted for by another disorder

OCD Comorbidity

-Adults: MDD, eating disorders, GAD, and other anxiety disorders -Children: other anxiety, learning disorders, disruptive behavior disorders -B/w 20-30% of individuals with OCD report current or past tics

DSM Criteria: PTSD

-All of the following lasting at least 1 month: o Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of following ways: ~direct experience, witnessing, learning it happened to someone close, repeated or extreme exposure to event details o Intrusion symptoms (1 or more) o Avoidance of stimuli associated w/ event (1 or more) o Negative alterations in cognitions and moods assoc. w. event (2 or more) o Alterations in arousal and reactivity assoc. w/ event (2 or more)

Types of Eating Disorders

-Anorexia Nervosa -Bulimia Nervosa -Binge Eating Disorder

Family Interventions

-Anxiety disorders often occur in context of parental anxiety and problematic family relationships that influence treatment effectiveness -Child-focused treatments may have spillover effects into family -Addressing children's anxiety in a family context can result in more dramatic and lasting effects than focus on child -Family treatment for OCD provides education about disorder, helps families cope, reduce accommodation behaviors

Causal and Maintaining Factors of Anxiety: Temperament

-Behavioral Inhibition ("slow to warm up," "inhibited") -Low threshold for unexpected stimuli, tendency to be unusually withdrawn or timid and to show fear and withdrawal in novel/unfamiliar social and nonsocial situations -Predicts anxiety disorders on both children and adults -Development of anxiety disorders in BI children depends on parental response o parents who set firm limits teach children to cope w/ stress and reduce the risk

Early Theories of Anxiety

-Classic psychoanalytic theory -Behavioral and learning theories -Attachment theory -no single theory is sufficient

Treatment of Trauma

-Controversy over treatment: does recall/exposure desensitize or retraumatize? -Trauma-Focused CBT: exposure and trauma narrative -Prolonged Exposure for PTSD: imaginal and in vivo exposure ( Expose person to memory of trauma and triggers) -Cognitive Processing Therapy: changing attributions ( More cognitive, recognizing different types of thoughts leading to negative attributions)

DSM Criteria: Generalized Anxiety Disorder

-Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of activities or events -difficult to control worry -Anxiety/worry are assoc. w/ 3+ (for children 1+) of the following symptoms (w/ some symptoms present more days than not in 6 months): o Restlessness or feeling keyed up or on edge o Being easily fatigues o Difficulty concentrating or mind going blank o Irritability o Muscle tension o Sleep disturbance (difficulty falling or staying asleep, or restless/unsatisfying sleep)

Risk Factors: Biological

-Heritability: .5-.6 -What is inherited? o personality traits, mood dysregulation, etc. o serotonin efficiency: other puberty related risks -Different set of risk factors for bulimic symptoms than restrictor symptoms? -Biological features: consequences of EDs (e.g. amenorrhea, preoccupation w/ food) v. causes or risk factors o classic WWII-era Conscientious Objector study - shows effects of starvation

ED Treatments: CBT

-Identify and control triggers for binges or compensatory behaviors -Restrictor/AN: harder to treat- less specific triggers; more pervasive sense of lack of control/need for control

Child/Adolescent Anxiety Multimodal Study (CAMS)

-Improvements in: >80% of children who received combined treatment, 60% CBT only, 55% medication only, 24% placebo -No statistical separation b/w CBT and medication groups -all treatments more effective than placebo

Causal and Maintaining Factors of Anxiety: Cognitive Processes

-Information processing biases o attentional bias toward threat - acorn hits you in the back of head so you keep looking for them and believe this will happen again o interpretive bias toward threat - that dog has huge teeth and is so scary looking and I just know he's going to bite me (actually doesn't look too threatening) o overestimation of threat -perceived lack of control

Treatment of Anxiety and OCD

-Main: exposing child or adult to anxiety-producing situations, objects, occasions

Behavior Therapy

-Main: exposure to feared stimulus while providing ways of coping other than escape/avoidance -Teaching and practicing relaxation strategies -Role plays ad rehearsal -Modeling and reinforced practice -In vivo exposure works best, but can use imaginal exposure

DSM Criteria: Specific Phobia

-Marked/persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation -Exposure to stimulus almost always provokes immediate anxiety; in children, may be expressed by crying, tantrums, freezing, or clinging - Situation(s) is avoided or endured w/ intense anxiety/distress

OCD and Related Disorders

-OCD -Body Dysmorphic Disorder -Hoarding Disorder -Trichotillomania (Hair-Pulling Disorder) -Excoriation (Skin-Picking Disorder)

Trauma and Stressor Disorders

-Reactive Attachment Disorder - response to extreme neglect very early in life, child is detached and doesn't seek comfort from a particular caregiver -Disinhibited Social Engagement Disorder -PTSD -Acute Stress Disorder -Adjustment Disorders

OCD: Obsessions are defined by:

-Recurrent and persistent thoughts, impulses, or images experienced as intrusive and cause marked distress -The thoughts, impulses, or images are not simply excessive worries about real-life problems -Attempts to ignore or suppress or neutralize such thoughts, impulses, images -Person recognizes that the obsessional thoughts, impulses, images are product of his/her own mind

Bulimia Nervosa

-Recurrent binge episodes (at least 1x per week for 3 months) o large quantity of food in discrete period of time o Sense of lack of control -Recurrent compensatory behaviors to prevent weight gain (e.g vomiting, laxatives, fasting, etc.) -Self-evaluation is unduly influenced by body shape/weight

ED Treatments: Medications

-SSRIs as adjunctive -not primary treatment choice

Medications

-SSRIs especially for OCD -Anti-anxiety (Benzos) are controversial, may be useful for adolescents w/ panic -Beta blockers for social anxiety - block actions of epinephrine and adrenaline -most effective when combined with CBT (which is 1st line of treatment)

ED Treatments

-Should clinician work w/ adolescent, family, or both? -Medications -Inpatient -Family Therapies -CBT

Causal and Maintaining Factors of Anxiety

-Temperament -Attachment -Parenting Styles and Family Factors -Parental Anxiety -Genes -Neurobiological Factors -Cognitive Processes -Learned Responses

Impairments

-anxiety, social isolation, family distress, physical consequences -major health consequences (e.g imbalances and damage to heart) -medical consequences from laxatives, diuretics, etc. - teeth impaired too, in some cases

Effects of culture/ethnicity

-appears in cultures where: o main eating problem is obesity, w/ abundance of food o body ideal is thinness - formerly thought to be restricted to white, upper middle class (consider referral bias, like with autism) - Ethnic differences: smaller than once believed, though African American culture and different body ideal may be protective

Risk Factors: Families

-blamed as 'cause' in most 20th century accounts o lack of attachment, concern w/ appearance, not allowing girl's independence, enmeshment o enmeshment as family structural and process concept- lack of appropriate boundaries o But, are family factors causes, results, or maintaining factors?

What predicts who develops PTSD?

-closer physical proximity - how close you were physically such as in movie theatre shooting -closer emotional proximity (death) - do you know someone who died -more exposure to media coverage - people who were there and saw it have intense traumatic response to media over people that just saw on tv -cognitive factors o locus of control o negative appraisals, inappropriate coping styles -developing acute stress disorder first

ED Prevalence

-concern w/ thinness, dieting, etc. >50% -actual AN, <1% -actual BN, ~1% - of BED, 3-4% (on the rise)

Binge Eating Disorder

-similar to bulimia w/out compensatory behaviors

ED Comorbidities

-depression (cause, consequence, or independent factor?) -OCD or personality traits -Other anxiety disorders -Impulse-control disorders (e.g substance abuse)-particularly in BN

Goals of Anxiety & OCD Treatment Are to Change:

-distorted information processing -physiological reactions to perceived threats -perceived lack of control -excessive escape and avoidance behaviors

ED Treatments: Family Therapies

-enmeshment, boundaries, maintaining weight, etc

OCD Gender Ratio

-equally common in adults -in childhood onset more common in boys

Severity of OCD is predicted by

-extent of thought-action fusion

Developmental differences in child expression

-externalizing problems? Harder to measure 'alarm' -the "fight or flight" response is less adaptive in young children than adults -younger children seem to demonstrate more avoidance symptoms, whereas older children suffer more reexperiencing and arousal increases

Early Theories of Anxiety: Attachment theory

-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

Causal and Maintaining Factors of Anxiety: Genes

-heritability estimates 30-40% -disposition to become anxious is inherited, w/ form shaped by environment -Highest genetic influence for OCD (65%) -linked to broad anxiety-related traits (e.g. behavioral inhibition); small contributions from multiple genes, no specific gene

Do some individuals w/ ED show delusional thinking?

-how to maintain fear of fat/denial of body's realities in the face of evidence to contrary - some research shows delusional-level beliefs -but, only one's own body, not in general -relation to body dysmorphic disorder

Panic Attacks

-includes intense fear and rapid onset of physiological symptoms (utter terror) o major source of ER visits o minutes long to over an hour, usually peak w/in 10 minutes - not a disorder - can occur w/in context of other mental disorders and some general medical conditions

Panic Disorder and Agoraphobia Comorbidity with...

-major depression is high, w/ panic preceding depression -other anxiety disorders is common

How do children get PTSD?

-maltreatment -community violence -natural disasters -motor vehicle collisions -disasters -war and terrorism

Risk Factors: Abuse

-maltreatment -flurry of attention in 80s when prevalence of sexual abuse was known -moderately sensitive but not specific risk factor o means lots of false positives

ED Prevention

-media images -promotion of performance rather than appearance -self-image contingent on factors other than appearance

Cultural messages today: What are they?

-models, athletes, actors -differing men v. women -certain professions have higher rate of eating disorders

Causal and Maintaining Factors of Anxiety: Learned Responses

-most specific fears related to paired or mispaired internalization of cues w/ anxiety form previous exposure -escape and avoidance of feared stimuli -negative reinforcement - behavior such as hiding from dog is reinforced because negative symptoms of anxiety like increased heart beat are taken away

Risk Factors: Psychological

-need independence, control -puberty and denial of physical and psychological maturity? -relationship to: o disturbed thinking (body and self) o obsessional and compulsive patterns (restricting type) o impulse control problems (purging type)

Causal and Maintaining Factors of Anxiety: Parental Anxiety

-offspring of parents with anxiety have greater risk and high levels of functional impairment -modeling of anxious responding --> mom freaks out to cockroach so child learns this response; things are dangerous and don't know how to cope with this well

OCD and Family Life

-parents often become unwilling collaborators in the illness -Accomodation

Protective factors for PTSD?

-perceived social support

ED Treatments: Inpatient

-restore weight -how to maintain normal weight?

Agoraphobia

-retreating into home or restricted areas to avoid panic attacks - secondary reaction to fear of panic attacks, can take on life of its own so separate disorder

Causal and Maintaining Factors of Anxiety: Neurobiological Factors

-several interrelated systems work together to produce anxiety -limbic system o anxiety recognized at amygdala (overexcitable) o Hippocampus very sensitive to stress/damage o Strong assoc. b/w paired cues -GABA system (too much) is NT w/ issues linked to anxiety

What are vulnerabilities of PTSD?

-some evidence of heritable component -experience of prior traumas -prior mental disorders -female gender -childhood adversity (economic deprivation, family dysfunction, parental separation, etc.) - Cumulative effects

Developmental progression of anxiety disorders into adulthood:

-untreated childhood anxiety typically continues into adulthood -leads to an increased risk of depressive and other anxiety disorders

EC: Difference b/w time frame in PTSD and acute stress disorder

1 month for PTSD diagnosis to occur

Manic episodes duration and impairment?

1 week; 3+ symptoms; with impairment

Distinguishing Normal from Pathological

1. Object 2. Intensity 3. Impairment 4. Ability to recover/coping skills

3 Characteristic Types of Panic:

1. Unexpected (uncued) 2. Situation bound (cued) 3. Situationally predisposed

What ratio of people with PD have comorbid Agoraphobia?

1/3-1/2

What is the average age of onset for any anxiety disorder?

11 -is the earliest developing internalizing disorder

Panic Disorder and Agoraphobia prevalence

2-3%

Gender ratio of specific phobias

2:1 women:men

PTSD symptoms usually begin within first ______ months of trauma

3

Lifetime prevalence is....

3-13%

Prevalence of GAD

3-5%

Hypomanic episodes duration and impairment?

4 days; 3+ symptoms; without impairment

Prevalence of SAD in children?

4%

Rates of co-occurance with other disorders is ________

50-80% -common to have more than one phobia -phobias are common (7-9%), but rarely result in significant impairment -usually the comorbid condition causes more distress than the specific phobia

What's main body ideal in subsistence cultures?

A heavier body mass index

Causal Factors: comorbidites

ADHD (early onset), depression, LD

Correlates and Outcomes: poor school acheivement

ADHD as primary here

Who are typically over-concerned about their children and spouses?

Adults with SAD

Bipolar definition

Alternating manic episodes with depression - also, mixed states

Major Depressive Disorder

At least one major depressive episode (must have one of the first two symptoms: - depressed mood - diminished interest or pleasure -must have for 2 weeks and impairment

Correlates and Outcomes: Family factors

Authoritarian and permissive parenting; coercion - Coercive discipline (persuading someone to do something using threats) one of the biggest predictors Crucial, but do we always separate genetic from social influence

Issues of Adolescence: Sex differences in psychopathology general rule

Boys predominate, if psychopathology has onset early - Autism, ADHD, Conduct Disorders Girls predominate, if pathology has surge in teen years - Depression, eating problems, self-injurious behavior

Adults: ASP and Psychopathology: Antisocial Personality Disorder

Conduct problems in childhood PLUS persistence into adulthood

Risk/protective factors differ or are the same with development for early onset vs. adolescent onset conditions based on sex

Different

Distinguishing Normal from Pathological: Impairment:

Does this interfere with the child's daily life? - Social functioning: unable to make friends - Academic functioning: failing classes - Family functioning: creating conflicts, limiting family choices

These conditions are heritable, but what also changes overall level?

Environment/culture

Why are boys more likely for early onset and girls adolescent onset disorders? Environments

Environments? - at puberty, many factors conspire to place girls at risk - genetic "vulnerability" = susceptibility to environmental stress

Psychiatric Classification: CD (conduct disorder)

Far more serious pattern of assault, rule violations, and covert ASB Hard to get a diagnoses before late childhood because of severity of problem Definition includes a blend of overt and covert problems Distinguish child onset (10 or below) from adolescent onset

Why are boys more likely for early onset and girls adolescent onset disorders? Genes

Genes? - y chromosome only has a handful of genes on it - with vulnerability alleles on X chromosome, but you have 2 X's, protection, but if you have XY, far less protection - at puberty, sex hormones activate genes, especially in girls - girls are born with more developed brains - early on testosterone poisoning in boys

If environment is more toxic, this is bad for everyone, but especially for those with vulnerability/risk: ex) girls in tobacco-smoke-filled-room

Girls placed in a room with lots of smoke will all cough and exhibit difficulty breathing, but only those girls with genetic vulnerability to lung cancer etc. will be at more risk for developing

EC: When is her birthday?

Halloween

Higher prevalence in?

Higher social classes

Psychiatric Classification: Progression of ODD to CD

How many children progress from ODD to CD? fewer than half Delete ODD from DSM because of false positives? Or, keep as early warning system, rather than waiting for severe CD later in childhood or adolescence? - balance of false positives vs. false negatives

Broadest class: externalizing

Hyperactive/impulsive, oppositional, aggressive, delinquent

Causal and Maintaining Factors of Anxiety: Attachment

Insecure attachment relationships w/ caregivers (specifically resistant/ambivalent attachment) increases risk of childhood anxiety

Distinguishing Normal from Pathological: Ability to Recover/Coping Skills:

Is the child able to recover from distress when the event is not present? - tend to worry about future outcomes of event/object - distress occurs across multiple settings

Distinguishing Normal from Pathological: Intensity

Is the degree of distress unrealistic given the child's developmental stage and the object/event?

Distinguishing Normal from Pathological: Object

Is this something a child of this age should be worrying about?

Delinquent

Legal term: includes status offenses and substance abuse

Persistent Depressive Disorder (Dysthymia)

Longer term, can be lower grade

Child depression - history of concept: 1970s

Masked depression - depression can exist, but its symptoms are usually masked - bedwetting, aggression, learning problems, etc. are actually ramifications of masked depression

Antisocial (breaks social rules/norms)

May include non-aggressive actions as well as aggressive

Domains affected

Mood, cognition, somatic, motivation, interpersonal, suicide

Causal Models of Depression: Sociocognitive

Negative Triad - self, world, future Distortions Negative Attributional Bias - internal, global, stable for native events Global nature and pervasiveness of low self-esteem

DSM Criteria: OCD

Obsessions AND/OR Compulsions -time consuming, more than 1 hr/day

What disorder resulting from infection can cause OCD?

PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) -inflammation of child's brain leads to OCD

What kind of therapy has the parent instruction?

Parent-child interaction therapy

Psychiatric Classification: ODD (oppositional defiant disorder)

Persistent pattern of negative, oppositional, defiant behavior Criticism: are we labeling boyhood Yet, at extremes, quite impairing for child, family, and school Developmental question: Is it a predictor of later ASB?

Overt aggression (harming others)

Physical v. verbal • Physical: if persists comes to clinical attention • Verbal: comes to clinical attention if develops earlier than it should Reactive v. proactive • Reactive: don't know how to react well, retaliate if called a name • Proactive: for a purpose- more so bullying, plan to assault somebody- intentional

If a girl has other risk factors -- maltreatment, depressed mother -- early compliance, empathy, and verbal ability are now what?

RISK FACTORS for later depression, anxiety, and eating disorders

Life-Course Perspective: Early-Onset/Persistent

Relatively rare (<5% boys, <1% of girls) • But may account for more than 50% of crime Childhood ASB, maintains over time Predictable from extremes of temperament <3 years Heterotypic continuity • Tantrums, swearing, fights, sexual assault, robbery, fraud, partner abuse, across development Clear evidence of pathology

SIG-E-CAPS

Sleep, Interest, Guilt/Worthlessness, Energy, Cognition/Concentration, Appetite, Psychomotor Agitation/Retardation, Suicide/Death Preoccupation

Covert Antisocial Behavior (under cover of darkness)

Stealing, property destruction, cheating, substance abuse • No direct victim, but against social norms • Substance abuse: against the law but whose it harming?

Physiological Components of Anxiety

Sweat, high heart and respiration rate, somatic markers (e.g dry mouth), startle, hormone release

Developmental Sequences of Anxiety Across Ages: Toddlers

fears of imaginary creatures, darkness, and animals, normative separation anxiety

Exam Q: What's the difference between PTSD and Acute Stress Disorder?

The time frame

Are risk factors for ODD, or for early onset CD, the same as for the risk factors for maintenance of ODD over time?

Think of ADHD: Is parenting a primary risk factor or a maintaining risk factor

Developmental Sequences of Anxiety Across Ages: Adolescents

fears related to school, social competence, and health issues

What response is characteristic of Blood-Injection-Injury Type?

Vasovagal fainting response (about 75% report fainting in such situations)

Heritability is

Very high (>.8)

Conduct Problems and Aggression: A topic for sociology, anthropology, and/or biology?

When in aggression normative or adaptive? When is it pathological? Which model? Statistical, social norms, moral?

Developmental challenge:

Why does serious disorder emerge in relatively small group?

Panic attacks are quite common among ______, rarer in ________

adults; children

Biggest risk factor for conduct disorder is _________

age of mother

Key differences at different ages: Grade school

angry, defiant, poor concentration, irritable

Early Theories of Anxiety: Classic Psychoanalytic Theory

anxieties and phobias seen as defenses against unconscious conflicts rooted in the child's early upbringing --> If you have snake phobia maybe that represents some sort of sexual dysfunction or abuse from earlier in life

Comorbidity

anxiety disorders, conduct disorders, ADHD, learning problems

PTSD Lifetime Prevalence

approx. 8% of adults

Psychosocial Treatments: most evidence is for which type?

behavioral management or cognitive-behavioral,

Body as object

being objectified takes away mental energy from other issues, focusing on inadequacies

Vulnerabilities are...

biological, psychological, and cultural ("triple bind")

Child depression - history of concept: next view

child depression as equivalent to adult depression - use structured interviews, DSM symptom lists

TADS Study

combo treatment > meds only > cognitive therapy

_______ conditions are common in PTSD

comorbid

Children with SAD are often viewed as ________

demanding

Short term outcomes

depends on recognition of problem and receipt of treatment

Gender Ratio of GAD

diagnosed somewhat more in women than men (55-60%)

"Triple Bind" - Third Prong

do so while looking "hot," constant pressure for perfection, no real alternatives - if a guy is good at all three things he's amazing; a girl is expected to pull off all three things without trying

SAD has the ______ age of onset among anxiety disorders

earliest

AN onset

early adolescence

Social Anxiety Disorder (Social Phobia) emerges in _________, median onset of _______

early to mid-adolescence; 13

Panic Disorder and Agoraphobia median age of onset______

early-mid 20s -but panic attacks commonly begin in early adolescence, at puberty

Strong risk of recurrence

episodic condition

Key is terror of performance and __________

evaluation (e.g. speech, going out, playing a sport)

Developmental Sequences of Anxiety Across Ages: Infants:

fear of loud noises, being startled, and strangers (around 8-10 months)

Early Theories of Anxiety: Behavioral and learning theories

fears and anxieties learned through classical conditioning and maintained through operant conditioning (two-factor theory) - Classical conditioning → Ex) little albert and fear conditioning to white rat - Operant conditioning → avoid the rat and never go back to it shows negative reinforcement → the aversive stimulus is taken away by avoiding or getting away from the rat

Treatment: CBT/family/support groups

may help keep a person medicated, potential for recognizing incipient episodes

Causal Factors: poverty

mediated by family patterns

GAD is frequently comorbid with...

mood, anxiety, substance-related disorders

Gender ratio of Social Anxiety Disorder (social phobia)

more common in women than men, but smaller difference than other anxiety disorders

Gender ratio

more prevalent in females 3:1-10:1 -10:1 for most severe forms

"Triple Bind" - Second Prong

must now be "all boy" - Now, must be competitive, all A's, sports - How to do so while being nurturing, too? Compete to win race while looking back the whole time to see if others are okay? not possible

Treatment: psychotherapy

not helpful during manic episodes, but good for someone between episodes

Panic Disorder and Agoraphobia Correlation with...

numerous general medical symptoms, including: dizziness, arrhythmias, hyperthyroidism, asthma, COPD, IBS: however, nature of assoc. is unclear

Race/Ethnicity Differences, African American and Latino youth

o Apparently higher rates of ASB o But nearly vanish when SES controlled • Thus race/ethnicity may be spurious risk factor for ASB

Sex differences: categories of early onset vs. adolescent onset

o Boys 5:1 or more for early onset o Closer to 1:1 for adolescent onset, though girls less violent

Implications

o Dividing ASB/CD on symptoms hasn't provided as much value as dividing re. age of onset o Very early onset ASB is marked y substantive evidence of psychopathology • Insecure attachment, bad temperament, neuropsychology, family coercion, verbal deficits, peer rejection • But not all early onset have these risk factors o Adolescent onset much more "normative"

Sex differences: dimension of overt vs. relational aggression

o Girls more likely to display relational forms o Yet violence in females does exist, and boys do exclude

Adults: ASP and Psychopathology: 2x2

o High ASB, high psychopathic traits: psychopathic criminal • Used skills learned in treatment to become more criminal o High ASB, low psychopathic traits: regular criminal • After treatment stayed out of prison, treatment helpful o Low ASB, high psychopathic traits: white collar criminal, politician o Low ASB, low psychopathic traits: normal

Mixed States

o Manic and depressed symptoms coincide o Extreme energy, but morbid mood (many combinations) - Have extreme energy or manic symptoms but accompanied by feeling of worthlessness

Depression Treatments: Medications

o No efficacy re: TCAs in children/adolescents o Some evidence for SSRIs o Depression is very responsive to placebo o Black box warnings - early stages of taking antidepressant can be a risky time; activation, underlying bipolar, or disinhibitory effect

Sex differences in rates of externalizing behavior

o Sex differences are small up to age 3 o Boys rise quickly at that time o Girls increase covert ASB in early adolescence • But never as violent as boys o Later adolescence: boys escalate again

Kindling Effect

o With enough heat the log will catch fire o There's a genetic vulnerability, but once you kindle that first episode then there is more likelihood to push over edge and have manic episode again o May need less external triggers over time o Extremely recurrent • After one manic episode, 90% chance of another or of a depressive episode

Causal Factors: Other Biological Factors

o birth complications, teratogenic effects

Causal Factors: Heritable? Depends...

o most chronic forms are more heritable (early onset > adolescent onset) o overt is more heritable than covert o ADHD is higher than both

GAD worries are _______

omnipresent -yet worries may serve as avoidance mechanism

Key differences at different ages: Preschool

oppositional, irritable, clingly

Symptoms can be near _______ level with _______ stimulus

panic ; feared

Correlates and Outcomes: social-cognitive deficits

processing and attributing information, then acting on the interpretation different patterns for reactive, and proactive aggression - Hostile attribution bias: if you have a bias that the world is out to get you, tend to think that accidents are on purpose and fight back

Behavior Therapy: Flooding

prolonged repeated exposure

If mania is serious enough, then?

psychosis emerges - commonly misdiagnosed as schizophrenia

Panic Disorder and Agoraphobia have low _______

rates of referral -coming to office may cause symptoms, so less likely to come in

Correlates and Outcomes: peer relations

reactive aggression/ADHD: rejection proactive : controversial - both liked and disliked

What is a particularly severe consequence of SAD relating to education?

school refusal

Cognitive Components of Anxiety

search for threat, vigilance, low concentration, images of harm to self or others

Categorical or continuous?

seems to be its own category, but it's a continuum, like nearly all other disorders

Causal Models of Depression: Life events

selection versus truly causal - How do we know whether someone vulnerable to depression is more responsive to negative life events or if the life event causes the depression?

OCD Impairments

social, developmental, physical (hand washing, etc.)

Consequences: Internalization

something wrong with me if I'm not constantly perfect

Depression Treatments: Interpersonal Therapy

somewhat psychodynamic, somewhat behavioral: relationships crucial - change social environment to change depression

Children with SAD are extremely _____ for family

stressful

Anorexia= loss of appetite but in Anorexia Nervosa....

symptom of anorexia is usually not present

Partial _______ is common in PTSD

symptomatology

Consequences: Media pressure and Lack of sleep

takes toll to be bombarded with unattainable images and permanent record of failure

Psychosocial treatments: Anger Management and Social Skills Training

teaching child to control anger with others and by himself

Psychosocial treatments: parent-child interaction therapy (PCIT)

therapist usually not in room but may be watching and guides with bug in ear; guides with how to have normal authority and improves externalizing behavior

Psychosocial treatments: parent management training: PMT

training parents how to respond to children

Behavioral Components of Anxiety

trembling, fidgeting, crying avoidance of feared stimulus

OCD Severity

unbelievably high in some cases

What percent of children and teens suffer from anxiety?

up to 30% by adolescence -difficult numbers b/c subthreshold anxiety can also cause severe disability -anxiety is among the most prevalent mental health disorders in children ands teens

Psychosocial treatments: Multisystemic Therapy (MST)

usually used with teens who've been convicted and are having major problems; therapist works for like 6 months with a select few families, therapist is very involved "all hands on deck mentality"

Long term outcomes

variable course -despite improvements in many tendency for patterns to persist and recur -underlying dynamics do not necessarily disappear -similar pattern to ADHD, depression, bipolar, anxiety, etc.

Thought-action fusion

when one believes thinking about an action is the same as carrying it out

Developmental Sequences of Anxiety Across Ages: School-age Children

worries about injury and natural events (e.g. storms, lightening), fears of ghosts, and staying home alone

Symptoms of OCD commonly exist for _______ before reaching clinical attention

years

DSM Criteria: PTSD: Avoidance of Stimuli

~avoidance of assoc. memories, thoughts, or feelings ~avoidance of external reminders

DSM Criteria: PTSD: Negative Alterations

~inability to remember an important aspect of event ~exaggerated negative beliefs or expectations about oneself, others, the world ~persistent self blame ~persistent negative emotional state ~disinterest in significant activities ~ feelings of detachment from others ~inability to experience positive emotions

DSM Criteria: PTSD: Intrusive Symptoms

~intrusive memories/play w/ themes of trauma ~distressing dreams ~dissociative reactions (e.g. flashbacks) ~intense distress at exposure to internal or external reminders of event ~physiological reactions to reminders of event

DSM Criteria: PTSD: Alterations In Arousal and Reactivity

~irritability/angry outbursts ~hypervigilance ~exaggerated startle response ~problems w/ concentration ~sleep disturbance

Taking a harmful perspective

• Aggression is usually harmful to others, not necessarily oneself • Age norms, severity of problems • Legal perspective: violate rights of others • But when is it simply social deviance, when is it dysfunctional?

Risk Factors: Early Onset

• Biggest predictor: (young) age of mother • Male sex, insecure attachment, low verbal IQ, language delay, executive functioning deficits, early ADHD, negative harsh inconsistent discipline coercion, abuse, antisocial history of parent, witnessing domestic violence, early peer rejection, later hanging out with deviant peers, violent neighborhoods, poverty, access to weapons (US/New Zealand have highest rates & highest access to weapons)

Implications...

• Sheer number of risk factors means that we may need to combine across risk factors and look for underlying patterns o Cumulative risk profiles are important o But they may signal gene-environment correlation • It also means that we need to look at reciprocal/transactional models o EG coercive parenting in a context of a difficult child, stressed family, and dangerous neighborhood, with deviant peer models