Chapter 8: Anxiety Disorders in Adolescents Michael A. Mallott Deborah C. Beidel.
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Transcript of Chapter 8: Anxiety Disorders in Adolescents Michael A. Mallott Deborah C. Beidel.
Chapter 8: Anxiety Disorders in Adolescents
Michael A. Mallott
Deborah C. Beidel
Overview
Adolescence: physical, social, psychological changes
Prevalence of anxiety disorders: 12–20% (Costello et al., 2005)
Median age of onset appears to fall in early adolescence
In adolescents, prevalence is highest for: Specific phobia (19.3%)Social phobia (9.1%)Separation anxiety disorder (7.6%)Post-traumatic stress disorder (5.0%)Agoraphobia (2.4%)Panic disorder (2.3%)General anxiety disorder (GAD) (2.2%)
Evidence-Based Approaches
Cognitive behavioral therapy (CBT) recognized as treatment of choice for adolescents with anxiety disorders
Implementation of CBT interventions is often transdiagnostic Allows for implementation across the broad spectrum of
anxiety disorders
CBT protocols follow similar formats: psychoeducation, skills training (somatic management and problem solving), cognitive restructuring, exposure, and relapse prevention (Veltin et al., 2004)
Psychoeducation
First part of treatmentDidactic in natureProvides rationale for CBTPsychoeducation portion of treatment serves as
foundation for other components introduced later in treatment
Coping Skills Training
Typically after psychoeducation
Focuses on managing somatic symptoms through use of relaxation training and/or problem solving skillsE.g., C.A.T. project—adolescent version of the Coping
Cat protocol• Teaches adolescents how to engage in relaxation techniques (e.g.,
deep breathing) and identify the presence of somatic cues that indicate the need to implement coping responses
Cognitive Restructuring
Cognitive processes may play a causal role in the development and maintenance of post-traumatic stress disorder
Specific cognitive coping skills may be associated with problematic anxietyMay differentiate anxiety-disordered and nonanxious
adolescents
General goal: identification of thoughts that may serve to produce or perpetuate anxiety and use of techniques to challenge these thoughtsTherapists help identify inaccurate and negative thought
patterns
Exposure
Essential feature of treatment for anxiety reduction
Graduated: less feared situations are attempted before more challenging ones
Typically, individual is asked to remain in contact with the feared situation or object until a specific length of time has passed or until habituation occurs (i.e., reduction or elimination of anxiety in the situation)
If situation cannot be re-created in the clinic, can conduct imaginal exposureImagine feared stimuli using mental sensory cues to produce an
accurate and realistic depiction of the feared stimuli
Exposure Procedure
Develop list of anxiety-provoking situationsThrough self-report scales, interviews, diaries, and/or behavioral
observations
Rate identified situations according to amount of anxiety elicitedRate using a Subjective Units of Distress Scale (SUDS); use smaller
numbers (e.g., 0–8 scale) and visual aids (e.g., fear thermometer)SUDS ratings are used to determine which situations will be
addressed first in treatment (e.g., situations with smaller SUDS numbers will be addressed first)
Exposing the adolescent to these situations according to a graded hierarchy
Relapse Prevention
Last element of many CBT protocolsConsolidation of skills and experiencesIncreases independent implementation of
strategies by the adolescent Sessions become less frequent (e.g., weekly to
biweekly)“Booster” sessions may occur
CBT for Social Anxiety
Socially phobic children do not respond as well to transdiagnostic CBT protocols as children with other anxiety disorders (Crawley et al., 2008)
Often focus on the development of social skills
Example: Social Effectiveness Therapy for Children and Adolescents (SET-C)12 sessions Focus on teaching and practicing social skills (e.g., conversational
skills, establishing and maintaining friendships, appropriate assertiveness)
Many delivered in group formatSome include nonanxious peers (e.g., Beidel et al., 2000)
CBT: Panic Disorder and Agoraphobia
Panic control treatment (e.g., Mattis et al., 2001)Includes: psychoeducation, skills training, cognitive
restructuring, exposure, relapse preventionFocus of elements: specific to symptoms of panic
disorder and agoraphobic avoidance
Unique aspects of PCT: 1) Includes breathing retraining to counteract the
hyperventilatory response associated with panic disorder2) Focuses on interoceptive cues in exposure
CBT: Generalized Anxiety Disorder
Most transdiagnostic treatments for adolescent anxiety were developed to treat a cluster of anxiety disorders including GAD, and some have begun to be tailored for GAD (e.g., Payne et al., 2001)
Tailored treatments focus on individual elements of CBT most related to GAD clinical syndromeE.g., emphasize remediating problematic worry and develop
better tolerance to uncertainty in cognitive restructuring and exposure
Length of treatment and resources involved in implementing treatment protocols varies6–24 sessions most treatments 10-15 sessions
Parental Involvement
Mixed findings for adolescents
Some studies report that parental involvement in treatment may lead to better outcomes, but these better outcomes may be limited to younger children (Barrett et al., 1996)
Four relevant characteristics of parental anxiety: 1) Parental overinvolvement/overcontrol2) Parental assumptions/beliefs3) Modeling/reinforcement of anxiety behavior4) Family conflict/dysfunction
Adaptations and Modifications
Developmental issuesWide range of physical, cognitive, emotional maturation
found even among same-aged adolescents (Oetzel & Scherer, 2003)
Treatment deliveryUsing group format may reduce the cost and burden of
treatment vs. typical individual treatmentComputer-based delivery
• Preliminary evidence for effective delivery of anxiety treatments (e.g., BRAVE transdiagnostic anxiety treatment; March et al., 2009)
• Potential for technology to augment or replace typical delivery of CBT
Measuring Treatment Effects
Use of multiple informants provides the most robust outcome data (De Los Reyes et al., 2011)
ADIS: commonly used semistructured interview that assess the presence of anxiety, mood, and externalizing disorders
MASC: self-report measure that assesses overall anxiety and subscale scores for physical symptoms of anxiety, social anxiety, harm avoidance, and separation/panic
CBCL: self-, parent-, and teacher-report available on multiple symptom scales
Disorder-Specific Measures
SPAI-C: self-report to measure somatic, cognitive, and behavioral symptoms associated with social phobia
SAS-A: self-report measure for total social anxiety, fear of negative evaluation, social avoidance, distress specific to new situations, and generalized social avoidance and distress
CASI: self-report of anxiety sensitivity (related to panic disorder)
PSWQ-C: self-report measure of worry in children and adolescents; used to assess GAD
Clinical Case Example: Tyler
14 years oldDiagnosis: Social Anxiety DisorderPresentation: anxiety elicited by being evaluated
(e.g., speaking to boys his own age)
Clinical Case Example: Treatment
Social Effectiveness Therapy for Children (SET-C)Two sessions per week
Social skills training: social environment awareness, conversational skills, interpersonal skills enhancement
24 sessionsOutcome: developed friendships, reduction in
parent- and self-reported social anxiety