Anxiety and Depressive Disorders

Child and Adolescent

Psychopathology

Historical Context:

Separation anxiety disorder (DSM-III-R)

Overanxious disorder (DSM-III-R)

Avoidant disorder (DSM-III-R)

Only separation anxiety disorder now (DSM-IV)

Definition

1) Dysregulation of normal

response system

2) Intense, disabling worry that does not help to anticipate true future danger

3) Intense fear reactions in the absence of a true threat

Definition: Primary and Secondary features of anxiety

• Primary: not specific to any particular diagnosis

• Secondary: content features of specific anxiety disorders:

• SAD: worry about separation from parents

• Social anxiety disorder: interpersonal concerns

• Panic disorder: uncued panic attacks

Definition

5) Expression of anxiety: behavioral, cognitive, physiological, social

6) High degree of comorbidity

Prevalence:

Short-term prevalence: 2-4% Lifetime prevalence: 10-20%

(Cont’d)

Risk Factors

Biological processes:

1) Behavioral approach system: involved in approach behaviors

2) Behavioral inhibition system: anxiety to novelty or impending punishment and avoidance

Risk Factors

Hypothalamic-pituitary-adrenal axis (HPA) axis: release of cortisol, which regulates behavioral and emotional responding

Risk Factors

Cortisol secretion protects when exposed to danger

Prolonged exposure is neurotoxic and related to anxiety: • “D” attachment

• Maltreated children diagnosed with PTSD

Risk Factors

Genetic Influences:

1) 33% of variance accounted for by genes: • physiological

reactivity • avoidance

behaviors

2) Temperamental inhibition: avoidance of novelty, dependence on parents, fearfulness, autonomic hyperarousal

Risk Factors

Psychophysiology: 1) Anxiety sensitivity:

belief that anxiety sensations (e.g. heart beat awareness, increased heart rate, trembling, shortness of

breath) have negative social, psychological, or physical consequences

2) Interpretation of

arousal symptoms influence experience of anxiety

Behavioral Learning Processes

Six Pathways:

1) Classical aversive conditioning (Wolpe & Rachman, 1960)

• Exposure to traumatic events

• 25-55% of maltreated children develop PTSD

• Pre-existing trait anxiety or D attachment?

Behavioral Learning Processes

2) Vicarious acquisition through observational learning or modelling (Bandura, 1982)

3) Verbal transmission of information 4) Operant conditioning

(Mowrer, 1960): withdrawal negatively reinforced by reduction of anxiety

Behavioral Learning Processes

5) Stages in cognition: encoding, interpretation, recall

a) interpretation and memory biases

b) attentional selectivity: over-allocating intellectual resources toward threat

6) Lack of control over external and internal threats: affect dysregulation because events and sensations are uncontrollable

Social and Interpersonal Processes

Attachment theory: anxiety related to insecure relationships to primary caregiver

• Separation anxiety disorder related to C attachment

• Overcontrolling parental behaviors influence childhood anxiety

• prevent children from facing fear-provoking events• conveys message that fear-provoking events are

threatening

• Short allele for serotonin transporter X low social support behavioral inhibition

Developmental Progression (heterotypic continuity)

• Childhood anxiety disorders are correlated with adult anxiety and depressive disorders

• Anxiety content related to development

• separation or loss of parents (6-9 years old)

• mortality, broader concerns (10-13 years old)

• social and performance concerns (adolescence)

Comorbidity

1) ADHD: 0-21%

2) CD and ODD: 3-13%

3) Depression: 1-20%

Culture

• Collectivist societies expect conformity and social inhibition, increasing anxiety

• Control of emotions stifles children's understanding and managing of internal states

Sex Differences

Girls to boys: 2:1 ratio Higher heritability estimates for girls

than boys Girls more willing to report symptoms Girls more likely socialized to internalize

symptoms

Theoretical Synthesis

1) Dysregulation of anxiety response system

2) Negative affect and distress/impairment from physiological arousal

3) Contents of anxiety are developmentally based

Depressive Disorders

• Depression is characterized by equifinality and multifinality

• Controversies in diagnosis of depression: • Continuity: childhood depression does not

predict adolescent or adult depression • Discreteness and boundaries

• depression is continuous • are thresholds too narrow or two broad? • adolescents have normal negative mood

states

Subtypes

a) Unipolar versus bipolar disorder

b) Psychotic versus not psychotic

c) Course (e.g. age of onset, recurrent or chronic, seasonal)

Age-specific manifestations

• Younger children might appear sad but do not report their mood

• Pre-pubertal children might lose interest in friends, not libido

• Depression in very young children:a) shorter duration requirement b) modified DSM-IV criteria

Assessment:

Low concordance among informants Self-reports more valid than reports by other

informants Parents' reports more valid for children than

adolescents

Prevalence:

Preschool children: 3 to 6 month prevalence = 1-2%

Adolescents: lifetime prevalence = 15-20% (like adults)

Sex Differences

1) Biological changes in hormones (increases in estrogen and testosterone)

2) Physical changes associated with body dissatisfaction

3) Adolescent females experience more interpersonal stress than adolescent males

4) Adolescent females have greater pre-existing vulnerabilities than males

o adolescent females have greater affiliative needs than males

o adolescent females cope with adversity in passive, ruminative way, while adolescent males cope in active, avoidant way

Comorbidity

• Comorbidity might represent a different disorder (e.g. MDD and CD) 

• Common etiological factors between the two disorders 

• Causal influence of one disorder over another (e.g. anxiety in childhood predicts depression in adulthood)

Course and Outcome 

• Mean duration of MDD: 7-8 months • Mean duration of DD: 48 months • Double depression: superimposed episodes of

MDD in DD • 40-70% of depressed adolescents experience

MDD in adulthood • Predictive of recurrence: severity, psychotic

symptoms, suicidality, DD, subthreshold symptoms, depressotypic cognitive style, recent stressful life events, adverse family environments, family history of MDD

Risk FactorsGenetics:  

a) Genetics plays a greater role in adolescent and adult depression than childhood depression

b) Reuptake of serotonin 

c) Brain-derived neurotrophic factor (BDNF) 

Risk Factors

d) Passive gene-environment correlations: genotype and environments are correlated

e) Evocative gene-environment correlations: genotype evokes reactions in others 

f) Active gene-environment correlations: genotype selects environments (niche-picking) 

Risk Factors

g) Genes interact with environment to increase susceptibility to stress (diathesis-stress hypothesis) 

h) Environment influences expression and regulation of genes (epigenesis) 

i) Genes Temperament

( negative emotionality, positive emotionality depression)

Risk Factors

Maladaptive parenting and abuse: 

a) Low parental warmth, high intrusiveness 

b) Childhood depression: low emotional support, abuse, family stress

c) Adolescent depression: early lack of emotional support

Risk Factors

Biological Factors: a) Neuroendocrinology – dysregulation of HPA axis cortisol production b) Sleep architecture – increased REM density c) Neurotransmitters – dysregulation of serotonin and norepinephrine  d) Structural and functional brain correlates 

1. smaller frontal white matter volume 2. larger frontal grey matter volume 3. larger left PFC white matter volume

Risk Factors

Cognitive factors: a) Memory biases for negative information b) Low self-esteem, self-efficacy, self-perceived competence c) Are these factors antecedents or sequalae?

Risk Factors

Peer Relationships: a) Peer rejection b) Social skills deficits c) Are these factors antecedents or sequalae?

Risk Factors

Life Stress:a) Triggers depression in children with pre-existing disposition b) Depression can produce impaired functioning, which produces stress c) Negative interpersonal life events are particularly potent risk factors

Protective Factors:

Variables that reduce risk in high-risk contexts: 1) Presence shifts high-risk trajectory in a more positive direction 2) Absence has no influence on risk trajectory

Fin