Anxiety and Obsessive-
Compulsive Disorders
WEEK 4
CHAPTER 11
Defining and Classifying
•Anxiety and fear – Complex pattern of three types of reactions to
perceived threat
• Behavioral responses
• Cognitive responses
• Physiological responses
•Fear – Immediate reaction to current threat
•Anxiety – Alarm reaction to future-oriented concerns
• Worry
• Thoughts about possible negative outcomes
• Cognitive component of anxiety.
Normal Fears
•Parents may underestimate fears, especially in adolescents
•Girls exhibit more fears than boys
•Girls exhibit more intensity than boys
•Fears commonly reported to decline with age
•Worry becomes more prominent and complex with age
•Certain fears coincide with different stages of development
•Few cultural differences
Anxiety disorders in DSM-5
o Separation Anxiety Disorder
o Specific Phobia
o Social Anxiety Disorder (Social Phobia)
o Selective Mutism
o Panic Disorder and Agoraphobia
o Agoraphobia
o Generalized Anxiety Disorder
o Obsessive-Compulsive and Related Disorders
Empirical Approach
Estimates of prevalence among
children vary
◦ Usually 2.5–5%, but some report 12–25%
Slightly higher prevalence among
girls
Limited information on ethnic
differences, but differences may
exist
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Specific Phobias
Persistent fear in response to object or situation
Diagnosis also requires certain conditions
◦ An immediate anxiety response occurs almost every time
◦ Person realizes that fear is unreasonable/excessive
◦ Person must either avoid the anxiety situation(s) or endure any exposure with
anxiety or distress
◦ Fears interfere significantly with child’s routine, academic functioning, or
social relationships
◦ Duration – at least 6 months
Prevalence – 3 to 4%
◦ Higher in girls than boys
Social Anxiety Disorder (Social Phobia)
Marked, persistent fear of acting in an embarrassing or humiliating way in social or
performance situations
◦ Speaking
◦ Reading
◦ Writing
◦ Public performances
◦ Initiating or maintaining conversations
◦ Speaking to authority figures
◦ Interacting in informal social situations
Focus on perceived negative attributes
May develop somatic symptoms
Miss school and other activities
Report lesser self-worth, sadness, loneliness
Social Anxiety Disorder
Most with social anxiety
disorder also meet criteria
for one or more other
disorders
Selective Mutism (SM)
Children with SM do not talk in specific situations (usually when
peers do talk)
◦ 90% talk at home, do not talk at school
◦ Whatever she says, she will be guilty – «What if I blurt it out!»
Usual onset – 2.5 to 4 years of age
Large percentage of SM children (perhaps 90–100%) also meet
criteria for social phobia
Selective Mutism (SM)
What does this symptom serve?
Becomes a part of personality – the school knows me like that
◦ We want to bring her to a point where she does not need that part
Very resistant. Some may be a stranger for their own voice, and may not regulate their tone of voice
Play is a good way to feed their emotional hunger
◦ E.g., a child with autism in the family, sm did not get any attention
They know that this illness scores points, but the other child has autism and gets all the attention. The one
with SM even may get beat up
Characteristics: quiet, submissive, passive-aggresive; anal character traits, symptoms of OCD
Never insist on talking! She is accepted here, and she has to experience it – they talk once they trust you
They need healthy and trusting relationships
They are very stubborn, CBT does not work because they do not cooperate
Separation Anxiety Disorder
Developmentally inappropriate and excessive anxiety about separation from home
or a major attachment figure
Symptoms include the following:
◦ Distress when separation from home or major attachment figure occurs or is anticipated
◦ Worry about losing or harm befalling attachment figures
◦ Persistent reluctance or refusal to go to school
◦ Persistent refusal to be alone or to go to sleep
◦ Physical symptoms when separation occurs or is anticipated
May follow a stress or trauma
Prevalent in 3 to 12%, decreases with age
Comorbid with other diagnoses, most commonly GAD
School Refusal
Often associated with separation anxiety, but other causes possible
Functional analysis may help in identifying cause
Prevalence – 1 to 2% of general population
No gender differences
Majority of clinicians emphasize importance of getting the child back
to school
Generalized Anxiety Disorder
Excessive anxiety and worry about multiple, general life circumstances
(not confined to a specific stress or situation)
Nervous habits, sleep disturbances
Prevalence – 2 to 14% (all ages)
Sometimes reported as more common in girls
Median age of onset – 10
Commonly comorbid with depression, separation anxiety, and phobias
May be overdiagnosed
Does not appear to be transitory
Panic Attacks & Panic Disorder
Attacks
◦ Discrete period of intense fear, terror that has a sudden onset and
reaches a peak quickly (10 minutes or less)
◦ Unexpected (uncued) – spontaneous, no trigger
◦ Recurring panic attacks make up Panic Disorder
Panic Attacks & Panic Disorder
A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes,
and during which time four (or more) of the following symptoms occur:
Note: The abrupt surge can occur from a calm state or an anxious state
1. Palpitations
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed, or faint
9. Chills or heat sensations
10. Paresthesias (numbness or tingling sensations)
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
12. Fear of losing control or “going crazy”
13. Fear of dying
From American Psychiatric Association, 2000
Panic Attacks & Panic Disorder
Panic disorder
◦ Recurrent, unexpected attacks
◦ For diagnosis, an attack must me followed by a month or more of
the following:
◦ Persistent concern about having other attacks
◦ Worry about the implications of the attack (“going
◦ crazy,” having a heart attack)
◦ Significant change in behavior related to attacks.
Prevalence in clinical samples – about 10–15%
Panic Attacks & Panic Disorder
Panic attacks more common than panic disorder
Panic disorder rare in childhood
More common in females
Few seek treatment
Appears to run in families
Commonly comorbid with other diagnoses
Obsessive-Compulsive Disorder
Own category in DSM-5, Obsessive-Compulsive and Related Disorders
Obsessions – unwanted, repetitive, intrusive thoughts
Compulsions – repetitive, stereotyped behaviors
◦ Disorder (OCD) may involve either or both
Highly time-consuming, interfere with normal routines, academic functioning, social relationships
In children, compulsions reported more often
Broad themes – preoccupation with cleanliness/averting danger and pervasive doubting
Parents may not see problem
Prevalence – about 1%
Boys more than girls in childhood, evens out by teens
Mean age of onset 10 years of age
Commonly comorbid with at least one other disorder
Etiology of Anxiety
Biological Influences
◦ Genetics may contribute
◦ Aggregation of anxiety disorders in families
◦ Risk for developing anxiety disorders likely inherited
◦ Possibly different patterns inherited, or tendency is inherited rather than specific disorder
◦ Serotonin, GABA, CRH
◦ Limbic system, particularly the amygdala
◦ Biological influences for OCD
◦ Higher heritability
◦ Studies link OCD to problems in basal ganglia, frontal lobes
◦ PANDAS
Etiology of Anxiety
Temperament
◦ Behavioral inhibition
◦ Negative affectivity
◦ Effortful control
Etiology of Anxiety
Psychosocial influences
◦ Three pathway theory (Rachman)
◦ Fear begins with exposure to trauma or threat
◦ Fear modeled by parents, who also reinforce it
◦ Fear acquired through transmission of information
◦ Parenting styles and practices
◦ Avoidant solutions
◦ Overprotective, intrusive
◦ Insecure attachments
Assessment
Interviews & self-report instruments
◦ State Trait Inventory for Children
◦ Revised Children’s Manifest Anxiety Scale
◦ Multidimensional Anxiety Scale
◦ Negative Affect Self-Statement Questionnaire
Direct observations
Physiological recordings
Interventions
Psychological treatments - exposure to anxiety-provoking
situation central to treatment
◦ Relaxation
◦ Desensitization/systematic desensitization
◦ Relaxation training paired with exposure
◦ Modeling
◦ Participant modeling
◦ Contingency Management
◦ Stop reinforcing for avoidance
◦ Reinforce improvement
Interventions
Psychological treatments (continued)
◦ Cognitive-behavioral treatments (CBTs) – goals:
◦ Recognize signs of anxious arousal
◦ Identify cognitive processes associated with anxious arousal
◦ Employ strategies, skills for managing anxiety
◦ For OCD - CBTs first treatments of choice
◦ Central aspect to these approaches: exposure with response prevention
Pharmacological
◦ Strongest evidence for efficacy is for SSRIs, but because of side effects
these may not be first choice for treatment of anxiety in youth
◦ For OCD – medications also are an option, but CBTs still preferred
Prevention
Content for prevention programs highly similar to CBTs
◦ Offered interventions include FRIENDS and similar programs
◦ Programs targeting at-risk children
◦ Parent-education programs
◦ School-based programs
Kenny
10 year-old-boy
Living with parents & 2 half-siblings from mother’s previous marriage
Referred by parents: extremely fearful, school refusal in the past several months
Cannot stay in other situations when separated from his parents – playing in the backyard, at
football practice, staying with sister
Behavioral symptoms: crying, tantrums, threats to hurt himself (e.g., jump from the school
window)
Emotions: high anxiety, a number of specific fears, depressive symptoms (sad mood, guilt about
his problems, occasional wishes to be dead, sleep disturbance)
Began a year ago, when his father was having drinking problems, away from home for long time
Adapted from Last, 1988, pp. 12-13
John
Like his mother, John had a very low opinion of himself and his abilities, and found
it difficult to cope with the scary things inside himself. His main problem had to do
with the numerous fears that he had and the panic attacks that overtook him from
time to time. He was afraid of the dark, of ghosts, of monsters, of being abandoned,
of being alone, of strangers, of war, of guns, of knives, of loud noises, and f-of
snakes.
…Like his mother again, he had many psychosomatic complaints involving his
bladder, his bowels, his kidneys, his intestines, and his blood… He also suffered from
insomnia and would not or could not go to sleep until his mother did. He was also
afraid to sleep alone or to sleep without a light, and regularly wet and soiled
himself. He was often afraid but could not say why and was also fearful of contact
with others.
Anthony, 1981, pp. 163-164
Frank
Discrete episodes of quick heart beats, shortness of breath, tingling in hands,
extreme fearfulness while falling asleep
Lasting 15-20 minutes
Began sleeping on the livingroom couch – cannot sleep in his room
Once he was asleep, his father brings him back to his bed
Tired during the day, deterioration in school work
Adapted from Rapoport & Ismond, 1996, pp. 240-241
Sam
Sam is a 17-year-old, former high school student. Only a year ago, Sam seemed
to be a normal adolescent with many talents and interests. Then, almost
overnight he was transformed into a lonely outsider, excluded from social life by
his psychological disabilities. Specifically, he was unable to stop washing.
Hounted by the Notion that he was dirty – in spite of the contrary evidence of
his senses – he began to spend more and more of his time cleansing himself of
imaginary dirt. At first, his ritual ablutions were confined to weekends and
evenings and he was able to stay in school while keeping them up, but soon they
began to consume all his time, forcing him to drop out of school, a victim of his
inability to feel clean enough.
Rapoport, 1989, p.83
The Role of Social Skills in Predicting Treatment-Recovery in
Children with a Social Anxiety Disorder
Klein et al., 2021
General aim: To investigate the role of parent-reported social skills performance on treatment
outcome and the possible interaction with social anxiety
3 main goals:
1) whether parents of children with SoAD reported different levels of social skills in their
children prior to treatment than parents of children with an anxiety disorder without SoAD
2) whether levels of social skills predicted treatment outcome
3) whether there was an interaction between parent-reported social skills and social anxiety
The Role of Social Skills in Predicting Treatment-Recovery in
Children with a Social Anxiety Disorder
Klein et al., 2021
1) parents of children with SoAD reported significantly lower levels of assertive and
responsible social behavior prior to treatment in their children compared to parents of
children with an anxiety disorder without SoAD.
2) No significant effect of social skills on reliable change
◦ Higher levels of assertion, self-control and responsibility predicted a higher likelihood of Treatment-Recovery
3) Parental-reported responsibility was only a valid predictor for Treatment-Recovery in
children without a SoAD, but not for children with SoAD.
◦ Children with no SoAD who had higher levels of responsibility had a more favorable outcome as measured
with the ADIS-TR than children with lower social skills, but this effect did not show for children with SoAD.
More generally,
◦ Higher social skills in general predicted Treatment-Recovery, and that SoAD only played a minor role in this
relation.
◦ The children with anxiety, with and without social anxiety, profited equally regardless of their pretreatment
level of parent-reported social skills.
Think about the article…
(Klein et al., 2021)
Your thoughts?
When you relate the lecture knowledge with the article?
After reading this article, any change in your thoughts about people with social
anxiety, or with any other type of anxiety?
What is the most important point of this article for you?
Is there something that you want to engage in your own practice?
