Anxiety and Obsessive—Compulsive Disorders

1. 11 Anxiety and Obsessive—CompulsiveDisorders

2. Description of Anxiety Disorders • 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

3. Experiencing Anxiety • 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

4. Three Interrelated Anxiety Response Systems • 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

5. The Many Symptoms of Anxiety

6. Anxiety Versus Fear and Panic • 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

7. Normal Fears, Anxieties, Worries, and Rituals • 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

8. Common Fears and Anxieties

9. Common Fears and Anxieties (cont’d.)

10. Normal Anxieties • 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

11. Normal Anxieties (cont’d.) • 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

12. Normal Worries • 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

13. Normal Rituals and Repetitive Behavior • 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

14. Seven Categories of Anxiety Disorders • Separation Anxiety Disorder (SAD) • Generalized anxiety disorder (GAD) • Specific phobia • Social anxiety disorder • Panic disorder (PD) • Agoraphobia • Selective mutism

15. Separation Anxiety Disorder (SAD) • 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

16. Diagnostic Criteria for Separation Anxiety Disorder

17. Prevalence and Comorbidity • 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

18. Onset, Course, and Outcome • 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

19. Outcome as Adults • As adults, more likely to experience: • Relationship difficulties • Other anxiety disorders and mental health problems • Functional impairment in social and personal life

20. School Reluctance and Refusal • 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

21. Specific Phobia • 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

22. Diagnostic Criteria for Specific Phobia

23. Specific Phobia (cont’d.) • 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

24. Social Anxiety Disorder (Social Phobia) • 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

25. Diagnostic Criteria for Social Phobia

26. Prevalence, Comorbidity, and Course • 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

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

28. Selective Mutism • 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

29. Panic • 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

30. Panic Disorder • 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

31. Diagnostic Criteria for Panic Disorder

32. Prevalence and Comorbidity • 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

33. Onset, Course, and Outcome • 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

34. Generalized Anxiety Disorder • 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

35. Diagnostic Criteria for Generalized Anxiety Disorder

36. Generalized Anxiety Disorder (cont’d.) • 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

37. Obsessive-Compulsive Disorder • 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

38. Obsessive-Compulsive Disorder (cont’d.) • 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

39. Diagnostic Criteria for Obsessive-Compulsive Disorder

40. Prevalence and Comorbidity • 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

41. Onset, Course, and Outcome • 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

42. Associated Characteristics • Children with anxiety disorders display a number of associated characteristics • Cognitive disturbances • Physical symptoms • Social and emotional deficits • Anxiety and depression

43. Cognitive Disturbances • 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

44. Cognitive Disturbances (cont’d.) • Threat-related attentional biases • Selective attention is given to potentially threatening information • Anxious vigilance or hypervigilance permits the child to avoid potentially threatening events

45. 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

46. Physical Symptoms • 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

47. Social and Emotional Deficits • 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

48. Anxiety and Depression • 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

49. Anxiety and Depression (cont’d.) • Physiological hyperarousal (somatic tension, shortness of breath, dizziness, etc.) may be unique to anxious children • Predictors and environmental influences are different

50. Gender, Ethnicity, and Culture • 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