Substance Use Disorders and Addiction: Biological and Social Perspectives, Exams of Nursing

Download Substance Use Disorders and Addiction: Biological and Social Perspectives and more Exams Nursing in PDF only on Docsity! PSYC 3604 – Lecture 9 – Chapter 12 – Substance Use Disorders What is Addiction? • Addiction is the tendency to persist with an appetitive or rewarding behaviour that produces s=pleasure states and desire, despite have negative consequences that outweigh these more positive effects • The person feels overwhelmed by this appetitive behaviour so they don’t want to or cannot seem to moderate or stop it • Negative consequences include preoccupation and compulsive engagement with the behaviour, impairment of behavioural control, persistence with or relapse to the behaviour, and craving and irritability in the absence of the behaviour o Mental or substance use disorders prevalence in Canada is 33% Stanton Peele (1978): psychoactive chemicals are perhaps the most direct means for. But any activity that can absorb a person in such a way affecting a person’s consciousness and state of being as to detract from the ability to vary through other involvements in potentially addictive. It is addictive when the experience eradicates a person’s awareness; when it provides predictable pain and unpleasantness; when it damages self-esteem; and when it destroys other involvements. When these conditions hold, the involvement will take over a person’s life in an increasingly destructive cycle Concept of Behavioural Addictions: • What causes a person to lose control is not the substance (cocaine) • It’s the underlying neural circuity that fires when presented with the reward the substance provides • In substance addiction, seeing a drug stimulus (e.g., the dealer or syringe) can activate the brain reward system and thus become reinforcing • In gambling and gaming, related stimuli (e.g. sounds, visuals also activate the brain reward systems and become reinforcing The Experience of Addiction Addiction as a “Disorder”: DSM-V: Substance-related and addictive disorders Substance Use Disorder (SUD): each specific substance is addressed as a separate use disorder (e.g. alcohol use disorder, stimulant use disorder, etc.) • Nearly all substances are diagnosed based on the same overarching criteria Addictive Disorders (non-substance behavioural addictions): • Gambling disorder: persistent and recurrent problematic gambling behaviour leading to clinically significant impairment or distress by exhibiting 4 or more symptoms in a 12- month period Theories Behind Addiction: 1. Biological Perspectives: o Genetic influences: substance use disorders and addictive behaviours are influenced by genetics o Neurobiological influences: abused substance affects the internal reward system of the brain • Neurobiology of Reward: o When certain areas of the brain were electrically stimulated the rats behaved as they received something very pleasant o Exact location in the human brain is still not known but believed to involve the dopaminergic system and its opioid-releasing neurons • Amphetamine: similar in structure to dopamine o Can move from outside the neuron into the cell via dopamine transporters or directly by diffusing through the neural membrane o Once inside amphetamines force dopamine out of their storage vesicles and expel them into the synapse Dopamine and Addiction: addiction is thought to be the repeated stimulation of the mesolimbic system, which triggers reorganization in the brain’s neurocircuitry • These changes in the brain may mediate positive reinforcement, motivation, craving and relapse for the drug • As people become more driven to use the drug, the drive can also progress to a state of negative reinforcement (i.e. to alleviate negative symptoms associated with withdrawal, or stressful life events • Results demonstrate that conscientiousness was associated with less severe alcohol use due to lower enhancement and lower coping depression motives • Greater agreeableness was associated with less severe alcohol use due to lower enhancement, social, and coping depression motives • Greater extraversion was associated with more severe alcohol use due to greater social and conformity motives • Greater neuroticism was associated with more severe alcohol use due to coping depression motives • Openness was not related to severity of alcohol use due to drinking motives Limitations of the Study: • Cross-sectional research design • Did not statistically control for shared variance between the personality traits • Did not examine interactive effects of personality on drinking motives and severity of alcohol use • Did not examine interactive effects of drinking motives on severity of alcohol use Social Perspectives: • The immediate interpersonal environment of a person who develops an addictive disorder o Social support, friends, family • Broader socio-structural properties of the environment o Social disadvantage due to race, poverty, culture • Community health and the globalization of addiction (Bruce Alexander) A Dislocation View of Addiction: (page 48) Adverse Childhood Experiences (ACE): (page 49) Multiple Risk and Protective Factors Model: (page 50) Risk and Protective Factors for Drug Use and Abuse: (page 51-53) Protective Factor Index Risk Factor Index High GPA Low educational aspirations Low depression High perceived adult drug use Having supportive relationships at home High perceived peer drug use Perceiving many sanctions for drug use Many deviant behaviours High religiosity High perceptions of community support for drug use High self-acceptance Easy availability of drugs High law abidance Low perceived opportunity Predicting Concurrent Drug Use: • Risk Factor Index by Protective Factor Index Identification was not predictive of all outcomes o Only for hard drug frequency (both sexes) o Cocaine and cigarette use (women only) • Buffering effect o High risk and low protection linked to high drug use o Low risk and high protection linked to low drug use Predicting Prospective Drug Use 4 & 8 Years Later: • Risk Factor Index by Protective Factor Index Identification was not predictive of all outcomes o Predicted greater cocaine and cannabis use 4 years later o Predicted greater alcohol problems 8 years later Multiple Risk and Protective Factors Model: • Addiction cannot be fully accounted for by any one or even a few etiological factors • Addiction increase as numbers of vulnerability conditions to which a person is exposed and with which they must cope increase • Buffering effects Summary: • SUDs and addictive disorders are multifaceted and complex • A single model cannot account for the heterogenous and complex pathways to addiction • A biopsychosocial perspective is helpful for conceptualizing the complex and varied pathways to addiction • The experience of stress and trauma are linked to the development of addiction Biological Treatment Approaches: • Agonist substitution: replacing one drug with a similar one (methadone for heroin) • Antagonist substitution: block one drug’s effects with another (naltrexone for opiates or alcohol) • Aversive treatments: make taking the drug very unpleasant • Drugs to help recovering person deal with withdrawal symptoms include clonidine for opiate withdrawal or sedatives for alcohol “All or nothing” service delivery approaches: • Require abstinence prior to receiving treatment • Rooting in belief that change is motivated by the experience of negative consequences from substance use • Continued substance use is a sign that the person is unmotivated to change • Providing service to persons who have not abstained would delay their commitment to abstinence and thus change Limitations of “all or nothing” approaches: • Deprives people who are not interested in cessation, but want to remain healthy • Deprives people who have problems controlling one addictive behaviour, but not other addictive behaviours • Limits the right to self-determination • Harm reduction policies, programs, and approaches deal with these limitations (e.g. safe injection sites and needle exchange programs) Relapsing Nature of Addictive Behaviours: • Although changing an addictive behaviour is difficult, maintaining change is even more challenging • Relapse means failure to maintain behavioural change • Relapse is common in the recovery process for addictive behaviours (during treatment and post-treatment) • Addiction has been conceptualized as a chronic relapsing disorder or chronic disease Psychological Treatment Approaches: (page 64) Five Principles of Motivational Interviewing: 1. Express empathy for the client 2. Develop discrepancy between the client’s goals and values and their current behaviour (behavioural addiction) 3. Avoid argumentation and direct confrontation 4. Roll with client resistance, instead of fighting it 5. Support the client’s self-efficacy, or their belief that they can change 12- Step Mutual Help Organizations: • Alcoholics Anonymous (AA) supports recovery through helping members cultivate spirituality and related practices as a new way of living • AA facilitates helpful social network changes (e.g. by having people drop heavy drinkers from their social networks and adapt abstainers and recovering people into their social network) • AA boosts people’s confidence in their ability to remain sober when faced with high risk social situations or when feeling down or angry • AA reduces craving and impulsivity, and provides a number of pro-recovery benefits Group Membership Matters: • Social Identity theory: part of people’s self-concept is derived from their membership in social groups • Double depression; people with persistent depressive disorder may also experience episodes of major depressive disorder Bipolar and Related Disorder: • Bipolar Disorder 1: historically called manic-depressive disorder, diagnosis requires presence of at least 1 manic episode o Manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes o Manic episode: A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal- directed activity or energy, lasting 1 week and present most of the day, nearly every day o Hypomanic episode: a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, every day o Major depressive episode: five or more symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood and (2) loss of interest or pleasure o Mixed episode: can occur during a depressive, manic, or hypomanic episode, symptoms occur during the majority of days of the episode ▪ Individual experiences rapidly alternating moods (sadness, irritability, euphoria) accompanied by symptoms of mania and depression ▪ Criteria are met for both a manic/hypomanic episode and a major depressive episode nearly every day • Bipolar Disorder 2: at least one hypomanic episode and at least one major depressive episode is required o The occurrence of the hypomanic episodes and major depressive episodes is not better explained by another disorder o The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning • Cyclothymic Disorder: for at least 2 years there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive disorder o Involves numerous periods of symptoms of depression and periods of symptoms of hypomania but the symptoms are not sufficient to be a major depressive episode or a hypomanic episode • Bipolar and Related Disorders: o Occurs less often than MDD o Lifetime prevalence rate for Bipolar Disorders 1 and 2 is 4.4% of population ▪ Cyclothymic disorder lifetime prevalence of 2.5% o Average age of onset is in the 20s o Bipolar disorders occur equally often in men and women, however, the kinds of episodes vary ▪ In women, episodes of depression are more common ▪ In men, episodes of mania are more common o Bipolar disorders tend to recur ▪ More than 50% have recurrence within 12 months ▪ More than 50% of cases have 4+ episodes Etiology of Mood Disorders and Suicide: • Psychoanalytic Theory of Depression: analogy to bereavement, according to Freud o Depression is seen to be like a mourner who identified with (introjects) lost love one o Anger turned inward (resents feeling abandoned) o Some individuals who show high dependency traits are more prone to depression following loss experiences • Psychological Theories: personality factors than increase vulnerability to depression o Sociotropy – over concern with pleasing others, avoiding disapproval, and avoiding separation o Autonomy ▪ Self-critical goal striving ▪ Preference for solitude ▪ Freedom from control (independence) o Perfectionism o Diathesis-stress • Biological Theories: Genetic Data o Bipolar: ▪ Concordance rate is as high as 85% ▪ Adoption studies provide support for a strong heritable component ▪ May be linked to a dominant gene on the 11th chromosome ▪ Brain-derived neurotrophic factor (BDNF) gene also implicated o MDD: ▪ Heritability estimate is 35% ▪ Relatives of unipolar probands are at increased risk for unipolar depression ▪ Serotonin transporter gene-linked promoter region (5-HTTLPR) is being considered o Early theories postulated that decreased levels of norepinephrine and dopamine lead to depression and increased levels of norepinephrine and dopamine lead to mania o Serotonin Theory: serotonin which regulates norepinephrine produces both depression and mania o Clues for theories based on drug effectiveness: ▪ tricyclic drugs prevent some of the reuptake of norepinephrine, serotonin, and/ or dopamine by the presynaptic neuron after it has fired ▪ Monoamine oxidase (MAO) inhibitors keep the enzyme monoamine oxidase from deactivating neurotransmitters therefore increasing the levels of serotonin, norepinephrine, and/or dopamine in the synapse ▪ SSRIs inhibit the reuptake of serotonin o Neuroimaging studies: decreased hippocampal volume and neurocognitive impairment ▪ Functional imagining of cingulated area 25 ▪ Induction of dysphoria in healthy people cause increased glucose metabolism in cingulated area 25 ▪ Treatment with paroxetine showed decreased hypermetabolism in cingulated area 25 ▪ MAO-A levels in the brain are elevated during untreated depression o Neuroendocrine System: HPA axis may play a role in depression ▪ Limbic area of brain (closely linked to emotion) affects the hypothalamus which in turn controls endocrine glands (release of hormones) ▪ Increased levels of cortisol in depressed patients ▪ Disorders of thyroid function are often seen in bipolar patients ▪ Thyroid hormones can induce mania, right hemisphere dysfunction – sense of indifference or flatness Summary of Main Biological Hypotheses About Major Depression and Bipolar Disorder: • Major Depression: genetic diathesis, low serotonin or serotonin-receptor dysfunction, high levels of cortisol • Bipolar Disorder: genetic diathesis, low serotonin or low norepinephrine in depressed phase, high norepinephrine in manic phase • Other Theories: o Interpersonal Theory of Depression: sparse social networks that provide little support, they decrease an individual’s ability to handle negative life events, and increase vulnerability to depression ▪ Depressed people are elicit negative reactions from others and are low in social skills ▪ They also constantly seek the reassurance of others o Psychological Theories of Bipolar Disorder: largely neglected by scholars and clinicians o To form stable, integrated and coherent representations of self and others (to see yourself and others as they are) o To develop capacity for intimacy (to have positive inter-relationships) o To engage in pro-social and cooperative behaviours (to function adaptively in society) • Personality disorders occur when there is a failure to manage these life tasks Millon’s Perspective: Normal Personality and Personality Disorders • Criteria that distinguish normal vs disordered personality o Rigid and inflexible o Self-defeating, vicious cycle that perpetuate troubled ways of thinking and behaving o Structural instability, fragility, cracking under stress Personality Traits: • Enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts • Only when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute PDs Personality Disorders: • Eliminated Axis || (DSM-IV-TR) • Maintained same categories as DSM-IV-TR • Considered dimensional approach, which is described as an alternative model (AMPD) in DSM-5 Section ||| o Dimensional perspective: disordered personality reflects extreme levels of tendencies (traits) o Not fully adopted in DSM-5, remains a proposal General Criteria for Personality Disorder: • Moderate or greater impairment in personality (self/interpersonal) functioning • One or more pathological personality traits • Impairments in personality functioning are relatively inflexible and pervasive across a broad range of personal and social situations and stable across time • Impairments in personality functioning are not better explained by another mental disorder and are not solely attributable to the physiological effects of a substance or another mental condition (severe head trauma) • Impairments in personality functioning are not better understood as normal for an individual’s developmental stage or sociocultural environment Alternative Model of Personality Disorder (AMPD): Criterion A: Level of Personality Functioning • Self: o Identity: experience of oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of self-appraisal; capacity for and ability to regulate, a range of emotional experience o Self-direction: pursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behaviour; ability to self-reflect productively • Interpersonal: o Empathy: comprehensive and appreciation of others experiences and motivations; tolerance of differing perspectives; understanding the effects of one’s own behaviour on others o Intimacy: depth and duration of connection with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behaviour Negative Affectivity vs Emotional Stability: (emotional lability, anxiousness, separation insecurity, submissiveness, hostility, and preservation) (page 14) Detachment vs Extraversion: (withdrawal, intimacy avoidance, anhedonia, depressivity, restricted affectivity, suspiciousness) (page 15) Antagonism vs Agreeableness: (manipulativeness, deceitfulness, grandiosity, attention seeking, and callousness) (page 16) Disinhibition vs Conscientiousness: (irresponsibility, impulsivity, distractibility, risk taking, and rigid perfectionism (lack of)) (page 17) Psychoticism vs Lucidity: (unusual beliefs and experiences, eccentricity, and cognitive and perceptual dysregulation) (page 18) DSM-V Personality Disorder Clusters: • Cluster A: paranoid, schizoid, and schizotypal • Cluster B: anti-social, borderline, histrionic, and narcissistic • Cluster C: avoidant, dependent, and obsessive-compulsive Paranoid Personality Disorder: • A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts Schizoid Personality Disorder: • A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning in early adulthood and present in a variety of contexts Schizotypal Personality Disorder: • A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behaviour beginning by early adulthood and present in a variety of contexts Etiology of Schizotypal Personality Disorder: • Psychosocial Risk Factors (Raine, 2006): o Compared to controls, individuals with SPD experienced higher rates of child abuse and early trauma o Multiple forms of abuse, child maltreatment, and child neglect, are each associated with higher rates of symptoms o Disturbances in early parental bonding is also associated with SPD ▪ With both anxious attachment and avoidant attachment being associated with SPD symptoms • Behavioural Genetics: o Evidence that SPD is genetically transmitted o Also linked to schizophrenia • Molecular Genetics: SPD has been linked to variations in 22q11 (a gene on chromosome 22) and to FMR-1 (a gene that codes for a protein involved in synaptic connections) • Neurodevelopmental Processes: evidence that SPD is related to prenatal and postnatal environmental influences (prenatal stress, exposure to influenza, birth complications, early nutrition) • Neurochemistry: o Dopamine dysregulation has been associated with SPD o Increased dopamine activity associated with positive symptoms and decreased dopamine activity associated with negative symptoms Borderline Personality Disorder: • A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts Etiology of BPD: • Characterized by a pervasive pattern of instability in regulation of emotion, interpersonal relationships, self-image, and impulse control • High rate of mortality – up to 10% of patients commit suicide • Currently believed to be a complex interaction between genetic factors and adverse childhood experiences Biological Factors in BPD: • Affective dysregulation has been suggested to represent the core of borderline symptomology o Manipulates others for personal gain o Exploits people o Thrill seeking • All psychopaths are diagnosed with APD but many with APD do not meet the criteria for psychopathy o Example from Hare (1996): killers who were not simply persistently antisocial; they were remorseless predators, used charm, intimidation and cold-blooded violence to achieve their ends o 20% of people with APD score higher on the Hare Psychopathy Checklist ▪ 75 to 80% of convicted felons meet criteria for APD but only 15 to 25% of convicted felons meet criteria for psychopathy Etiology of APD and Psychopathy: • Role of the Family: o Lack of affection o Severe parental rejection o Physical abuse o Inconsistencies in disciplining o Failure to teach child responsibility toward others • Limitations to research findings on family role in APD and psychopathy: o Harsh or inconsistent disciplinary practices could be reactions to the child’s antisocial behaviour o Many individuals who come from disturbed backgrounds do not become psychopaths • Genetic Correlates of APD: o Criminality and APD have heritable components o Higher concordance of MZ compared to DZ twin pairs o Adoption studies also provide research evidence o Environmental influences: ▪ Higher parental conflict and higher negativity ▪ Lower parental warmth predicts antisocial behaviours ▪ Families without antisocial tendencies may become harsh in their disciplining in reaction to the child with antisocial tendencies • Emotion and Psychopathy: o Unresponsive to punishments/ no conditioned fear responses o Lower skin conductance in resting situations o Lower skin conductance is less reactive when confronted or anticipate intense or aversive stimuli o Normal heart rate under resting conditions but higher heart rate when anticipating intense or aversive stimuli • Response Modulation, Impulsivity, and Psychopathy: o Slow brain waves and spikes in the temporal area o Less activity in the amygdala/ hippocampal formation o Decreased prefrontal activity The Evil Personality: • The dark triad consists of the combination of narcissism, psychopathy, and Machiavellianism • The dark tetrad includes sadism • Evil = higher narcissism + higher psychopathy + higher Machiavellianism + higher sadism Avoidant Personality Disorder: • A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts o Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection o Preoccupied with being criticized or rejected in social situations Dependent Personality Disorder: • A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviours and fears of separation, beginning by early adulthood and present in a variety of contexts o Has difficulty making everyday decisions without an excessive amount of advice or reassurance from others o Needs others to assume responsibility for most major areas of his or her life Obsessive-Compulsive Personality Disorder: • A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning in early adulthood and present in a variety of contexts o Is preoccupied with details, rules, order, lists, to the point that the major point of the activity is lost o Shows perfectionism that interferes with task completion Etiology of Cluster C: • Not much is known about cases for personality in this cluster • Speculation about causes has focused on parent-child attachment relationships • Psychoanalytic theories: OCPD traits due to fixation at anal stage of psychosexual development Therapies for Personal Disorders: • Schema therapy for PD uses CBT approach to examine logical errors and dysfunctional attitudes o Therapies for borderline personality disorder (BPD) ▪ Individuals with borderline personality disorder have troubles establishing trust ▪ Alternatively idealize then vilify therapist • Two main therapy approaches are used for BPD: o Object-relations therapy for BPD: ▪ Strengthening client’s weak ego ▪ Reducing splitting ▪ Combines client-centred acceptance with cognitive-behavioural o Dialectical behaviour therapy (DBT) for BPD: ▪ Challenge dichotomous (black and white) thinking ▪ Teach assertiveness and emotion regulation PSYC 3604 – Chapter 14 - Disorders of Uncontrolled Behaviour: Externalizing Problems Oppositional Defiant Disorder: • A pattern of angry/irritable mood, argumentative/ defiant behaviour, or vindictiveness lasting at least 6 months and exhibited during interaction with at least one individual who is not a sibling o Angry/ Irritable Mood: ▪ Often loses temper ▪ Is often touchy or easily annoyed ▪ Is often angry and resentful o Argumentative/ Defiant Behaviour ▪ Often argues with authority figures or for children and adolescents, with adults ▪ Often actively defies or refuses to comply with requests from authority figures or with rules Psychological Theories of ADHD: • Diathesis-stress theory of ADHD: o Hyperactivity develops when predisposition to disorder is coupled with an authoritarian upbringing (Bettelheim) o Attention-seeking and hyperactivity o Reinforced by getting attention, thus increasing (mis)behaviours in frequency or intensity • These psychological theories are not supported by research Treatment of ADHD: • Behavioural therapies have shown some promise • Stimulants (i.e. methylphenidate (MPH) = Ritalin) • 80% of doctors have at some point seen a patient with ADHD • 84% of these had prescribed MPH (67% of all) • MPH use is on the rise Pervasive Developmental Disorder: (based on DSM-IV-TR – now eliminated) • Rett’s Disorder: o Very rare; found only in girls o Poor speech o Walks in an uncoordinated manner o Loses ability to use hands purposefully o Head growth decelerates o Loses ability to use hands purposefully o Stereotyped movements such as handwringing or hand washing o Development normal until 1st-2nd year of life • Childhood Disintegrative Disorder: o Very rare o Normal development in the first 2 years of life then significant loss of ▪ Social, play, language and motor skills’ • Asperger’s Syndrome: o Persistent deficits in social communication and social interaction across multiple contexts o Now regarded as a mild form of autism spectrum disorder o Poor social relationships o Stereotyped behaviour o Language and intelligence are intact Etiology of ASD: • Psychological bases: o Psychoanalytic and behavioural perspectives believed that parents play a crucial role in ASD • Biological bases: o Genetic factors o Risk of autism in siblings of people with the disorder is about 75x greater ▪ Fragile X syndrome; Chromosomal abnormalities o Linked genetically to broader spectrum of deficits in communicative and social areas o Autism reflects exceeding complex genetic variation with potentially more 1’000 genes being involved (Du Rubeis and Buxbaum, 2015) Treatment of ASD: • Early intervention is critical to providing a better chance of success in school and in living independently • Most effective treatments use modelling and operant conditioning techniques o Early intensive behavioural intervention (EIBI) o Most effective if delivered early (start before 5), intensively (20 hours or more per week for more than two years) o Children with higher initial cognitive levels and fewer early social interaction deficits show best response to EIBI • Most commonly used medications for treating problem behaviours in autistic children are anti-psychotics Disorders of Overcontrolled Behaviour: Internalizing Problems • Separation Anxiety (now included among anxiety disorders) • Social phobia • Selective mutism • Specific phobia • GAD • OCD • PSTD • Panic disorder • Depression Separation Anxiety Disorder: • Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached Reactive Attachment Disorder: • A consistent pattern of inhibited, emotionally withdrawn behaviour toward adult caregivers and a persistent social and emotional disturbance Disinhibited Social Engagement Disorder: • A pattern of behaviour in which a child actively approaches and interacts with unfamiliar adults Treatment of Fears and Phobias: • Similar to that employed with adults • Exposure to feared object while performing some action to inhibit their anxiety • CBT shows great promise in treating childhood anxiety