Assessment Framework for Generalized Anxiety Disorder

1. Assessment Framework forGeneralized Anxiety Disorder Jo Friesen, Stephanie Poole, Shawna Sjoquist, & Stacy Thiry APSY 660: Social, Emotional, & Behavioural Assessment

2. Outline for Discussion • Anxiety • Anxiety Disorders in the DSM-IV-TR • Overview of Generalized Anxiety Disorder (GAD) • Diagnostic Criteria • Differentiating Between GAD & other Anxiety Disorders • Theoretical Conceptualizations of GAD • Core Signs & Symptoms, Associated Characteristics, Co-Morbidity • Developmental, Gender, & Cultural Differences • Assessment Framework for GAD • Referral Questions, Interview Red Flags • History & Areas of Functioning • Assessment • Diagnosis

3. Anxiety • One of the most common psychiatric disorders affecting children & adolescents (Albano et al., 2003). • Fears and anxieties are part of typical childhood development (Albano et al., 2003). • Often disguised by co-morbid externalizing concerns, or undetected due to the externalizing behaviours of others (e.g. children in the classroom, siblings) (Albano et al., 2003). (Sattler & Hoge, 2006, pp.359)

4. Anxiety Disorders • 300.01 Panic Disorder Without Agoraphobia • 300.21 Panic Disorder With Agoraphobia • 300.22 Agoraphobia Without History of Panic Disorder • 300.29 Specific Phobia • 300.23 Social Phobia • 300.3 Obsessive-Compulsive Disorder • 309.81 Post Traumatic Stress Disorder • 308.3 Acute Stress Disorder • 300.02 Generalized Anxiety Disorder • 293.84 Anxiety Disorder Due to (indicate general medical condition) Substance-Induced Anxiety Disorder • 300.00 Anxiety Disorder NOS (American Psychiatric Association, 2000)

5. 300.02 Generalized Anxiety Disorder A) Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance). B) The person finds it difficult to control the worry. C) The anxiety and worry are associated with 3 (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note – only one item is required in children. 1. Restlessness or feeling keys up or on edge 2. Being easily fatigued 3. Difficulty concentrating or mind going blank 4. Irritability 5. Muscle tension 6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep). D) The focus of the anxiety and worry is not confined to features of an Axis 1 disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Post Traumatic Stress Disorder. E) The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. F) The disturbance is not due to the direct psychological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder. (American Psychiatric Association, 2000, p. 476)

6. GAD versus…. • Nonpathological Anxiety • Worries with GAD significantly interfere with functioning • More pervasive, distressing, have higher intensity, frequency, and duration • Anxiety Disorder Due to a General Medical Condition • Diagnosed through lab results, history, or a physical examination. • Substance-Induced Anxiety Disorder • Symptoms result from the exposure/consumption of a substance(e.g., caffeine) • Obsessive-Compulsive Disorder • Distinguishing excessive worry from obsessional thoughts (American Psychiatric Association, 2000)

7. Theoretical Approaches to GAD • Neurobiological theories • Involve the amygdala, hippocampus, GABA, norepinephrine, serotonin, CCK, and the LHPA axis. • Cognitive-behavioural models • Information processing theory • “Intolerance of Uncertainty” • Integrative Model (Behar et al., 2009)

8. Core Signs & Symptoms • Excessive worry about multiple situations • Perception that worry is uncontrollable • Physiological/ Cognitive Symptoms (American Psychiatric Association, 2000; Mash & Barkley, 2003; Mash & Barkley, 2006; Mash & Barkley, 2007)

9. Associated Characteristics (American Psychiatric Association, 2000, p. 473)

10. Co-morbid Conditions (American Psychiatric Association, 2000)

11. Risk & Resiliency Factors (Biederman et al, 2001; Mash & Wolfe, 2007; Rak & Patterson, 1996)

12. Risk & Resiliency Factors (Biederman et al, 2001; Mash & Wolfe, 2007; Rak & Patterson, 1996)

13. Resiliency Questionnaire (Rak & Patterson, 1996)

14. Developmental Differences

15. Gender Differences (Barrios, B, A., & Hartmann, D. P. in Mash and Terdal, 1997; Robinson, K. in Reynolds & Kamphaus, 2003)

16. Cultural Differences (Barrios, B, A., & Hartmann, D. P. in Mash and Terdal, 1997)

17. Potential Referral Questions

18. Interview Red Flags (Albano et al., 2003)

19. Case Study: Bobby

20. Bobby: Parental Concerns

21. History & Areas of Functioning

22. Medical History • Utilization of Medical Services • Perceptions of General Health • History of Somatic Complaints • Sleep Disturbances (Behar et al., 2009; Suveg, Jacob & Thomassin, 2009)

23. Social History • Attachment and Past Trauma • Recovery from a Stressor • Personal Beliefs about Worry • Perception of Social Relationships • Nature of Stressors • Problem Orientation (Behar et al., 2009; Suveg, Jacob & Thomassin, 2009)

24. Educational History • Perfectionism • Performance • Social Situations • Community or World Events • Teacher Perceptions (Beharet al., 2009; Suveg, Jacob & Thomassin, 2009)

25. Developmental History • Temperament • Age of Onset • Progression through Normal Age Trends • Presence of Functional Impairments (Behar et al., 2009; Suveg, Jacob & Thomassin, 2009)

26. Familial History • Family History • Characterization of Caregivers • Familial History of GAD • Parenting Style (Beharet al., 2009; Suveg, Jacob & Thomassin, 2009)

27. Bobby: Medical

28. Bobby: Academic

29. Bobby: Development & Family

30. Major Decisions of Assessment (Southam-Gerow & Chorpita, 2010)

31. Major Decisions of Assessment (Southam-Gerow & Chorpita, 2010)

32. Major Decisions of Assessment (Southam-Gerow & Chorpita, 2010)

33. Diagnosis & Functional Assessment (Albano & Hack, 2004; Southam-Gerow & Chorpita, 2010)

34. Interviews: Semi-structured (Sattler & Hoge, 2006)

35. Interviews: Structured (Albano & Hack, 2004; Southam-Gerow & Chorpita, 2010)

36. Interviews: DSM-IV-TR Criteria • Does your child show excessive anxiety and worry about a number of events or activities, such as work activities, school performances or other situations? • Has this anxiety or worry occurred on more days than no for at least the last 6 months? • Does your child find it difficult to control his/her worry? • Has your child’s anxiety or worry been associated with any of the following behaviors for more days than no over the past 6 months? • Restlessness or feeling keyed up or on edge • Being easily fatigued or tired • Difficulty concentrating or mind going blank • Irritability • Muscle tension • Sleep disturbance or difficulties falling asleep, staying asleep or restless and unsatisfying sleep • Have these worries created distress for your child or impairment in any of the following area? • Social relations with others • Academic performance • Any other areas of functioning (McConaughy, 2005)

37. Questionnaires & Reports (Albano & Hack, 2004; Southam-Gerow & Chorpita, 2010)

38. Observations (Albano & Hack, 2004; Southam-Gerow & Chorpita, 2010)

39. Differential Diagnosis:Match Game You will be presented with four pairs of individual. For each pair, you will be asked to match which individual was diagnosed with which of two disorders based on considering both their common symptoms, and their unique symptoms. Once you have read through the info, type your answer, along with a brief explanation, into the chat box.

40. SAD or GAD: The Sedin Twins

41. Social Phobia or GAD: The Olsen Twins

42. ADHD or GAD: Bart & Lisa

43. Depression or GAD: Edward & Jacob

44. Bobby: Assessment

45. Bobby: Assessment Cont’d

46. Bobby: Diagnosis

47. References Albano, A. M., & Hack, S. (2004). Children and adolescents. In Heimberg, R.G., Mennin, D.S., & Turk, C.L. (Eds.), Generalized Anxiety Disorder (pp. 383-408). New York, NY: Guilford Press. Albano, A. M., Chorpita, B. F., & Barlow, D. H. (2003). Childhood anxiety disorders. In E. J. Mash & R. A. Barkley (Eds.), Child psychopathology (2nd ed., 279-329). New York, NY: Guilford Press. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition: Text Revision. Washington, DC. Barrios, B, A., & Hartmann, D. P. (1997). Fears and anxieties. In E.J. Mash & L. G. Terdal, Assessment of childhood disorders (3rd ed., 230-278). New York, NY: Guilford Press. Behar, E., DiMarco, I., Hekler, E. B., Mohlman, J., & Staples, A. M. (2009). Current theoretical models of generalized anxiety disorder (GAD): Conceptual review and treatment implications. Journal of Anxiety Disorders, 23(8), 1011-1023. doi:10.1016/j.janxdis.2009.07.006 Biederman, J., Hirshfeld-Becker, D.R., Rosenbaum, J. F., Herot, C., Friedman, D., Snidman, N., Kagan, J., & Faraone, S. V. (2001). Further evidence of association between behavioral inhibition and social anxiety in children. American Journal of Psychiatry, 158 (10), 1673-1679. Codd, I., Twohig, M. P., Crosby, J. M., & Enno, A. (2011). Treatment of three anxiety disorder cases with acceptance and commitment therapy in a private practice. Journal of Cognitive Psychotherapy, 25(3), 203-217. doi:10.1891/0889-8391.25.3.203 Comer, J. S., Kendall, P. C., Franklin, M. E., Hudson, J. L., & Pimentel, S. S. (2004). Obsessing/worrying about the overlap between obsessive–compulsive disorder and generalized anxiety disorder in youth. Clinical Psychology Review, 24(6), 663-683. doi:10.1016/j.cpr.2004.04.004 Edwards, S. L., Rapee, R. M., Kennedy, S. J., & Spence, S. H. (2010). The assessment of anxiety symptoms in preschool-aged children: The revised preschool anxiety scale. Journal of Clinical Child & Adolescent Psychology, 39(3), 400-409. doi:10.1080/15374411003691701

48. Ehrenreich, J. T., Micco, J. A., Fisher, P. H., & Warner, C. (2009). Assessment of relevant parenting factors in families of clinically anxious children: The family assessment clinician-rated interview (FACI). Child Psychiatry & Human Development, 40(3), 331-342. doi:10.1007/s10578-009-0128-y Hazlett-Stevens, H. (2008) Psychological Approaches to Generalized Anxiety Disorder. Springer Science + Business Media. doi:10.1007/978.0.387.76870.0 Mash, E. J. & Barkley, R. A. (2006). Treatment of childhood disorders. New York, NY: Guilford Press. Mash, E. J. & Barkley, R. A. (2007). Assessment of Childhood Disorders. New York, NY: Guilford Press. Mash, E.J., & Wolfe, D.A. (2007). Abnormal Child Psychology (3rd ed.). Toronto, ON: Nelson. McConaughy, S.H. (2005). Clinical interviews for children and adolescents: Assessment to intervention. New York, NY: Guildford Press. Rak, C.F., & Patterson, L. E. (1996). Promoting resilience in at-risk children. Journal of Counseling & Development, 74, 368 – 373. Robinson, K. (2003). Assessment of childhood anxiety. In C. R. Reynolds & R. W. Kamphaus, Handbook of psychological & educational assessment of children (2nd ed., 508-525). New York, NY: Guilford Press. Sattler, J .M., & Hoge, R. D. (2006). Assessment of children: Behavioral, social and clinical foundations (5thed.). La Mesa, CA: Jerome M. Sattler, Publisher. Southam-Gerow, M. A., & Chorpita, B. F. (2010). Anxiety in children and adolescents. In Mash, E.J., & Barkley, R.A. (Eds.) Assessment of Childhood Disorders (4th ed., pp. 447-397). New York, NY: Guildford Press. Suveg, C., Jacob, M., & Thomassin, K. (2009). Generalized Anxiety Disorder in Youth. Behavioral Psychology/PsicologiaConductual, 17(1), 41-66.