© cengage learning 2016 eric j. mash david a. wolfe anxiety and obsessive—compulsive disorders 11

© Cengage Learning 2016 © Cengage Learning 2016

Eric J. MashDavid A. Wolfe

Anxiety and Obsessive—CompulsiveDisorders

11

© Cengage Learning 2016

• Anxiety: a mood state characterized by strong negative emotion and bodily symptoms of tension in anticipation of future danger or misfortune

• Anxiety disorders involve experiencing excessive and debilitating anxieties; occur in many forms

• Many children with anxiety disorders suffer from more than one type

Description of Anxiety Disorders


• Moderate amounts of anxiety helps us think and act more effectively

• Excessive, uncontrollable anxiety can be debilitating

• The neurotic paradox is a self-defeating behavior pattern – fear with no threat

• Fight/flight response – Immediate reaction to perceived danger or

threat aimed at escaping potential harm

Experiencing Anxiety


• Physical system – The brain sends messages to the sympathetic

nervous system, fight/flight response

• Cognitive system – Activation leads to feelings of apprehension,

nervousness, difficulty concentrating, and panic

• Behavioral system – Aggression is coupled with a desire to escape

the threatening situation

Three Interrelated Anxiety Response Systems


The Many Symptoms of Anxiety


• Anxiety - future-oriented mood state– May occur in absence of realistic danger

• Fear - present-oriented emotional reaction – Occurs in the face of a current danger and

marked by a strong escape tendency

• Panic – A group of physical symptoms of fight/flight

response - unexpectedly occur in the absence of obvious danger or threat

Anxiety Versus Fear and Panic


• Moderate fear and anxiety are adaptive– Emotions and rituals that increase feelings of

control are common in children and teens

• Normal fears– Fears that are normal at one age can be

debilitating a few years later

– A fear defined as normal depends on its effect on the child and how long it lasts

– The number and types of fears change over time

Normal Fears, Anxieties, Worries, and Rituals


Common Fears and Anxieties


Common Fears and Anxieties (cont’d.)


• Anxieties are common during childhood and adolescence– Common examples

• Separation anxiety

• Test anxiety

• Excessive concern about competence

• Excessive need for reassurance

• Anxiety about harm to a parent

Normal Anxieties


• Girls display more anxiety than boys, but symptoms are similar

• Some specific anxieties decrease with age

• Nervous and anxious symptoms may remain stable over time

Normal Anxieties (cont’d.)


• Children of all ages worry

• Worry serves a function in normal development– Moderate worry can help children prepare for

the future

• Children with anxiety disorders do not necessarily worry more– They worry more intensely than other children

Normal Worries


• Normal routines help children gain control and mastery of their environment

• Many common childhood routines involve repetitive behaviors and doing things “just right” – Neuropsychological mechanisms underlying

compulsive, ritualistic behavior in normal development and those in OCD may be similar

Normal Rituals and Repetitive Behavior


• Separation Anxiety Disorder (SAD)

• Generalized anxiety disorder (GAD)

• Specific phobia

• Social anxiety disorder

• Panic disorder (PD)

• Agoraphobia

• Selective mutism

Seven Categories of Anxiety Disorders


• Separation anxiety is important for a young child’s survival – It is normal from about age 7 months through

preschool years

– Lack of separation anxiety at this age may suggest insecure attachment

• SAD is distinguished by:– Age-inappropriate, excessive, and disabling

anxiety about being apart from parents or away from home

Separation Anxiety Disorder (SAD)


Diagnostic Criteria for Separation Anxiety Disorder


• SAD is one of the two most common childhood anxiety disorders

• Occurs in 4-10% of children– It is more prevalent in girls than in boys

• More than 2/3 of children with SAD have another anxiety disorder and about half develop a depressive disorder

Prevalence and Comorbidity


• SAD has the earliest reported age of onset of anxiety disorders (7-8 years of age) and the youngest age at referral

• Progresses from mild to severe

• Associated with major stress– Examples: moving to new neighborhood or

entering a new school

• SAD persists into adulthood for more than 1/3 of affected children and adolescents

Onset, Course, and Outcome


• As adults, more likely to experience:– Relationship difficulties

– Other anxiety disorders and mental health problems

– Functional impairment in social and personal life

Outcome as Adults


• School refusal behavior– Refusal to attend classes or difficulty

remaining in school for an entire day

• Occurs most often in ages 5-11

• Fear of school may be fear of leaving parents (separation anxiety), but can occur for many other reasons

• Serious long-term consequences result if it remains untreated

School Reluctance and Refusal


• Age-inappropriate persistent, irrational, or exaggerated fear that leads to avoidance of the feared object or event and causes impairment in normal routine – Lasts at least 6 months

– Extreme and disabling fear of objects or situations that in reality pose little or no danger or threat

– Child goes to great lengths to avoid the object/situation

Specific Phobia


Diagnostic Criteria for Specific Phobia


• Prevalence and comorbidity– About 20% of children are affected at some

point in their lives, although few are referred for treatment

– More common in girls

• Onset, course, and outcome– Onset at 7-9 years - phobias involving

animals, darkness, insects, blood, and injury

– Clinical phobias are more likely than normal fears to persist over time

Specific Phobia (cont’d.)


• A marked, persistent fear of social or performance requirements that expose the child to scrutiny and possible embarrassment– Anxiety over mundane activities

– Most common fear is doing something in front of others

– More likely than other children to be highly emotional, socially fearful; and inhibited, sad, and lonely

Social Anxiety Disorder (Social Phobia)


Diagnostic Criteria for Social Phobia


• Lifetime prevalence of 6-12% of children

• Twice as common in girls

• Two-thirds also have another anxiety disorder

• 20% also suffer from major depression and may self-medicate with alcohol and other drugs

• Most common age of onset is early to mid-adolescence, and is rare under age 10

Prevalence, Comorbidity, and Course


Prevalence, Comorbidity, and Course (cont’d.)


• Failure to talk in specific social situations, even though they may speak loudly and frequently at home or other settings

• Estimated to occur in 0.7% of children

• Average age of onset is 3-4 years

• May be an extreme type of social phobia, but there are differences between the two disorders

Selective Mutism


• Panic attacks – Characteristics: sudden, overwhelming period

of intense fear or discomfort accompanied by four or more physical and cognitive symptoms characteristic of the fight/flight response

– Are rare in young children; common in adolescents

• Young children may lack cognitive ability to make catastrophic misinterpretations

– Are related to pubertal development

Panic


• In severe cases, high anticipatory anxiety and situation avoidance may lead to agoraphobia – Fear of being alone in and avoiding certain

places or situations

– Fear of having a panic attack in situations where escape would be difficult or help is unavailable

– Does not usually develop until age 18 or older

Panic Disorder


Diagnostic Criteria for Panic Disorder


• Panic attacks are common (16% of teens)

• Panic disorder is less common (about 2.5% of teens 13-17 years)

• Panic attacks are more common in adolescent females than adolescent males

• Comorbidity adolescents with PD – Most commonly have another anxiety disorder

or depression• At risk for suicidal behavior; alcohol or drug abuse



• Onset, course, and outcome– Age of onset for first panic attack 15-19 years;

95% of PD adolescents are post-pubertal

– Lowest remission rate for any of the anxiety disorders



• Generalized anxiety disorder (GAD)– Excessive, uncontrollable anxiety and worry

– Worrying can be episodic or almost continuous

– Worry excessively about minor everyday occurrences

• Accompanied by at least one somatic symptom, such as:– Headaches, stomach aches, muscle tension,

and trembling

Generalized Anxiety Disorder


Diagnostic Criteria for Generalized Anxiety Disorder


• Prevalence and comorbidity– Nat’l survey: lifetime prevalence rate - 2.2%

– Equally common in boys and girls

– Accompanied by high rates of other anxiety disorders and depression

• Onset, course, and outcome– Average age of onset is early adolescence

– Older children have more symptoms

– Symptoms persist over time

Generalized Anxiety Disorder (cont’d.)


• An unusual disorder of ritual and doubt– Characterized by recurrent, time-consuming

and disturbing obsessions and compulsions• Obsessions: persistent and intrusive thoughts,

urges, or images - experienced as intrusive and unwanted

• Compulsions: repetitive, purposeful, and intentional behaviors or mental acts performed to relieve anxiety

Obsessive-Compulsive Disorder


• OCD is extremely resistant to reason

• OCD children often involve family members in rituals

• Normal activities of children with OCD are reduced, and health, social and family relations, and school functioning can be severely disrupted

Obsessive-Compulsive Disorder (cont’d.)


Diagnostic Criteria for Obsessive-Compulsive Disorder


• Prevalence and comorbidity– Lifetime prevalence in children and

adolescents is 1-2.5%

– Clinic-based studies find it twice as common in boys

– Comorbidities most common are other anxiety disorders, depressive disorders, disruptive behavior disorders

• Substance-use; learning and eating disorders; vocal and motor tics are also overrepresented



• Onset, course, and outcome– Average age of onset 9-12 years with peaks

in early childhood and early adolescence

– Chronic disorder - as many as two-thirds continue to have OCD 2-14 years after initial diagnosis



• Children with anxiety disorders display a number of associated characteristics– Cognitive disturbances

– Physical symptoms

– Social and emotional deficits

– Anxiety and depression

Associated Characteristics


• Disturbance in how information is perceived and processed

• Intelligence and academic achievement – Despite normal intelligence, deficits are seen

in memory, attention, and speech or language

– High levels of anxiety can interfere with academic performance

– Those with generalized social anxiety may drop out of school prematurely

Cognitive Disturbances


• Threat-related attentional biases– Selective attention is given to potentially

threatening information

– Anxious vigilance or hypervigilance permits the child to avoid potentially threatening events

Cognitive Disturbances (cont’d.)


• Cognitive errors and biases– Perceptions of threats activate danger-

confirming thoughts

– Children with conduct problems select aggressive solutions in response to a perceived threat

– Children with anxiety disorders see themselves as having less control over anxiety-related events than other children

Cognitive Disturbances (cont’d.)


• Somatic complaints, such as stomachaches or headaches, are more common in children with GAD, PD and SAD than in those with a specific phobia

• 90% with anxiety disorders have sleep-related problems, e.g., nocturnal panic

• High rates of anxiety in adolescence are related to reduced accidents and accidental deaths in early adulthood

Physical Symptoms


• Anxious children – Display low social performance and high

social anxiety

– See themselves as shy and socially withdrawn, and report low self-esteem, loneliness, and difficulty initiating and maintaining friendships

– Have deficits in understanding emotion and in differentiating between thoughts and feelings

Social and Emotional Deficits


• A child’s risk for accompanying disorders will vary with the type of anxiety disorder– Depression is diagnosed more often in

children with multiple anxiety disorders

– Negative affectivity: persistent negative mood,

– Positive affectivity: persistent positive mood• Negatively correlated with depression, but is

independent of anxiety symptoms and diagnoses

Anxiety and Depression


• Physiological hyperarousal (somatic tension, shortness of breath, dizziness, etc.) may be unique to anxious children

• Predictors and environmental influences are different

Anxiety and Depression (cont’d.)


• Higher incidence of anxiety disorders in girls suggests genetic influences and related neurobiological differences

• The experience of anxiety is pervasive across cultures

• Ethnicity and culture may affect the expression, developmental course, and interpretation of anxiety symptoms

Gender, Ethnicity, and Culture


Cumulative Incidence of Anxiety Disorders in Females and Males


• Classical psychoanalytic theory– Anxieties and phobias seen as defenses

against unconscious conflicts rooted in the child’s early upbringing

• Behavioral and learning theories– Fears and anxieties learned through classical

conditioning and maintained through operant conditioning (two-factor theory)

Theories and Causes – Early Theories


• Bowlby’s theory of attachment – 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 behaviors

• No single theory is sufficient

Early Theories (cont'd.)


• Variations in behavioral reactions to novelty result in part from inherited differences in the neurochemistry of brain structures– Amygdala - primary function is to react to

unfamiliar or unexpected events

– Projections of amygdala to the motor system, anterior cingulate and frontal cortex, hypothalamus, and sympathetic nervous system

Temperament


• Behavioral inhibition (BI): a low threshold for novel and unexpected stimuli – Place an individual at greater risk for anxiety

disorders

• Development of anxiety disorders in BI children depends on:– Gender, exposure to early maternal stress,

and parental response

Temperament (cont'd.)


• Family and twin studies suggest – About 1/3 of the variance in childhood anxiety

symptoms is genetic

– Serotonin and dopamine systems are related to anxiety

– Genes are linked to broad anxiety-related traits (e.g., behavioral inhibition)

• No strong direct link between specific genetic markers and specific types of anxiety disorders

Family and Genetic Risk


• The entire anxiety response system is controlled by several interrelated to produce anxiety– Hypothalamic-pituitary-adrenal (HPA) axis

– Limbic system

– Ventrolateral prefrontal cortex

– Other cortical and subcortical structures

– Primitive brain stem

Neurobiological Factors


• An overactive behavioral inhibition system (BIS) implicated– BIS may be shaped by early life stressors

• Brain abnormalities have been implicated in children who are anxious and/or behaviorally inhibited

• Primary neurotransmitter system implicated in anxiety disorders– γ-aminobutyric acidergic (GABA-ergic)

system

Neurobiological Factors (cont'd.)


• Parenting practices– Parents of anxious children are seen as

overinvolved, intrusive, or limiting child’s independence

• Prolonged exposure to high doses of family dysfunction associated with extreme trajectories of anxious behavior

• Low SES

• Insecure early attachments

Family Factors


A Possible Developmental Pathway For Anxiety Disorders


• Overview – Main line of attack for treating anxiety

disorders is exposing children to anxiety producing situations, objects, and occasions

• Treatments are directed at modifying:– Distorted information processing

– Physiological reactions to perceived threat

– Sense of a lack of control

– Excessive escape and avoidance behaviors

Treatment and Prevention


• Main technique is exposure to feared stimulus – While providing children with ways of coping

other than escape and avoidance

• Systematic desensitization

• Flooding: prolonged repeated exposure

• Response prevention prevents child from engaging in escaping or avoidance stimuli

• Modeling and reinforced practice

Behavior Therapy


• The most effective procedure for treating most anxiety disorders

• Almost always used with exposure-based treatments

• Coping Cat

• Skills training and exposure combat problematic thinking

• Computer-based CBT has also been shown to be effective

Cognitive-Behavior Therapy (CBT)


• Child-focused treatments may have spillover effects into the family

• Addressing children’s anxiety disorders in a family context may result in more dramatic and lasting effects

• Family treatment for OCD:– Provides education about the disorder

– Helps families cope with their feelings

Family Interventions


• Medications can reduce symptoms, especially for OCD– The most common and effective medications

are selective serotonin reuptake inhibitors (SSRIs), especially for OCD

– Medications are most effective when combined with CBT

• CBT is the first line of treatment

Medications


• Prevention study – Researchers identified children with a mean

age of less than 4 years who were at-risk for later anxiety disorders

• Brief intervention (six 90-min group sessions) was carried out

– Intervention group (compared with a control group) showed fewer anxiety disorders and lower symptoms severity

• Untreated children may be on a worsening developmental trajectory

Prevention


Prevention (cont’d.)

© cengage learning 2016 eric j. mash david a. wolfe anxiety and obsessive—compulsive disorders 11

Documents