Anxiety and Related Disorders

1. Anxiety and Related Disorders How do we identify and treat anxiety disorders?

2. Anxiety Disorders • Affects 2–5% of the child population. • Affects 20–30% of students referred to clinics for behavior problems. • Equal prevalence in boys and girls. • Have both social and biological causes. • Appear amenable to social learning approaches.

3. Interventions for School Phobia • Desensitize the child’s fear by role playing. • Reinforce school attendance, even for brief periods. • Include matter-of-fact parental statements that child will go back to school. • Remove reinforcers for staying home.

4. Obsessive Compulsive Disorder Dr. Aubrey H. Fine

5. Obsessive Compulsive Disorder • OCD may include: • Washing, checking, or other repetitive motor behavior • Cognitive compulsions consisting of words, phrases, prayers, or sequences of numbers • Obsessional slowness • Doubts and questions that elevate anxiety

6. Facts and Figures • Prevalence • Originally believed to be rare • >0.1% • Recent evidence suggests 1-3% Onset / Characteristics: • Males:, high prevalence of checking • Females:, high prevalence of washing

7. OCD Diagnosis (1): DSM IV • Obsessions defined by all of the following: • Recurrent and persistent thoughts, impulses or images experience at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress. • The thoughts/impulses/images are not simply excessive worries about real life problems. • The person attempts to ignore or suppress such thoughts/impulses/images, or neutralize them with some other thought or action. • The person recognizes that the obsessional thoughts/impulses/images are a product of their own mind (not imposed from without).

8. OCD Diagnosis (2): DSM IV • Compulsions defined by: • Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rules which must be applied rigidly • The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive • Not better accounted for by other diagnosis

9. What is an Obsession? • Involuntary intrusive cognition • Types • Doubts (74%) • Thinking (34%) • Fears (26%) • Impulses (17%) • Images (7%) • Other (2%)

10. Examples of Obsessions • Doubt “Did I lock the door” • Thought that he had cancer • Thought / Image that he had knocked someone down in his car • Impulse + thought to shout obscenities in church • Image of corpse rotting away • Impulse to drink from inkpot and to strangle son

11. Themes in Obsessions • Obsessions often have common themes • Contamination, dirt, disease, illness (46%) • Violence and aggression (29%) • Moral and religious topics (11%) • Symmetry and sequence (27%) • Sex (10%) • Other (22%) • The themes often reflect contemporary concerns (the devil, germs, AIDS)

12. Examples of Compulsions • Scanning text for “life” having read “death” • Touching the ground after swallowing saliva • Driving back to check he hadn’t knocked someone down in his car • Counting 6,5,8,3,7,4 in your head • Hand washing

13. Linking Obsessions and Compulsions OCD Cycle Obsessions Relief Anxiety Complusion

14. OCD and “Normal” Experience • Obsessional thoughts found in 90% of people • It is well replicated that 80%+ of normal people have intrusive thoughts • There thoughts are similar in content and form to OCD patients • Compulsions • Many people have compulsions such as stereotyped or superstitious behaviors • 66% of normal people report some form of checking behavior • Is OCD qualitatively distinct?

15. OCD Experiences

16. Cognitive Aspects of OCD • Responsibility for harm to self/others • Any influence over outcome = responsibility for outcome • Omission: “I will omit to do something that leads to myself/others being hurt” • Magical thinking • Thought Action Fusion • Thought = action “I will harm my child” • Obsessions = “going crazy” • Control: “Trying to hard” • Suppression: “white bears” • Pre-Occupation: “Looking for trouble”

17. OCD: Therapy • Exposure and Response Prevention (ERP) • Responsibility • Am I a murderer or just worried about being one? • Normalizing / Other explanations • Thought = action • Can I think myself to death? • Neutralizing • Experiment to show how thought suppression increases thought frequency • Exposure: Cued Intrusions

18. Key Issues • What are the strengths and limitations of behavioral models of OCD? • Think about the empirical findings of current psychological models such as Salkovskis’ • Have cognitive models of obsessions and compulsions helped us understand OCD and how it should be treated? • How are intrusive thoughts in OCD different from “normal” intrusive thoughts? • Are they different at all?

19. Posttraumatic Stress Disorder • Repeatedly perceived memories of the trauma. • Repetitive behaviors that may be similar to obsessions or compulsions. • Fears linked to the traumatic event. • Altered attitudes toward people, life, or the future, reflecting feelings of vulnerability.

20. Stereotyped Movement Disorders • Involuntary, repetitious, persistent, nonfunctional acts over which the individual can exert at least some voluntary control. • Self-stimulation • Self-injury • Tics • Tourette’s syndrome

21. Selective Mutism • Children who are reluctant to speak although they know how to converse normally. • May be a response to: • Trauma • Abuse • Social Anxiety • Most effective interventions incorporate social learning principles.

22. Eating Disorders • Anorexia • Bulimia • Pica • Rumination • Highly exclusive food preferences • Obesity

23. Elimination Disorders • Enuresis • Encopresis