11
Anxiety and Obsessive—Compulsive
Disorders
Eric J. Mash
A. Wolfe
©David
Cengage Learning
2016
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
The Many Symptoms of Anxiety
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Common Fears and Anxieties
© Cengage Learning 2016
Common Fears and Anxieties (cont’d.)
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Seven Categories of Anxiety Disorders
•
•
•
•
•
•
•
Separation Anxiety Disorder (SAD)
Generalized anxiety disorder (GAD)
Specific phobia
Social anxiety disorder
Panic disorder (PD)
Agoraphobia
Selective mutism
© Cengage Learning 2016
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
© Cengage Learning 2016
Diagnostic Criteria for Separation Anxiety
Disorder
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Diagnostic Criteria for Specific Phobia
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Diagnostic Criteria for Social Phobia
© Cengage Learning 2016
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 midadolescence, and is rare under age 10
© Cengage Learning 2016
Prevalence, Comorbidity, and Course
(cont’d.)
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Diagnostic Criteria for Panic Disorder
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Diagnostic Criteria for Generalized Anxiety
Disorder
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Diagnostic Criteria for ObsessiveCompulsive Disorder
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Associated Characteristics
• Children with anxiety disorders display a
number of associated characteristics
– Cognitive disturbances
– Physical symptoms
– Social and emotional deficits
– Anxiety and depression
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Cognitive Disturbances (cont’d.)
• Cognitive errors and biases
– Perceptions of threats activate dangerconfirming 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
© Cengage Learning 2016
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 sleeprelated problems, e.g., nocturnal panic
• High rates of anxiety in adolescence are
related to reduced accidents and
accidental deaths in early adulthood
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
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
© Cengage Learning 2016
Cumulative Incidence of Anxiety Disorders
in Females and Males
© Cengage Learning 2016
Theories and Causes – Early Theories
• 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)
© Cengage Learning 2016
Early Theories (cont'd.)
• 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
© Cengage Learning 2016
Temperament
• 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
© Cengage Learning 2016
Temperament (cont'd.)
• 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
© Cengage Learning 2016
Family and Genetic Risk
• 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
© Cengage Learning 2016
Neurobiological Factors
• 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
© Cengage Learning 2016
Neurobiological Factors (cont'd.)
• 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
© Cengage Learning 2016
Family Factors
• 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
© Cengage Learning 2016
A Possible Developmental Pathway For
Anxiety Disorders
© Cengage Learning 2016
Treatment and Prevention
• 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
© Cengage Learning 2016
Behavior Therapy
• 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
© Cengage Learning 2016
Cognitive-Behavior Therapy (CBT)
• 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
© Cengage Learning 2016
Family Interventions
• 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
© Cengage Learning 2016
Medications
• 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
© Cengage Learning 2016
Prevention
• 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
© Cengage Learning 2016
Prevention (cont’d.)
© Cengage Learning 2016