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. Aims and Learning Outcomes Describing OCD Classification Theories –Biological –Behavioral –Cognitive Treatment

7. 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

8. 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).

9. 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

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

11. 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

12. 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)

13. 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

14. Linking Obsessions and Compulsions

15. 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?

16. OCD Experiences OCDNot OCD A man who washes his hands 100 times a day until they are red and raw A woman who unfailingly washer her hands before every meal A women who locks and relocks her door before going to work every day – for half an hour A woman who double- checks that her apartment door and windows are locked each night before she goes to bed. A college student who must tap on the door frame of every classroom 14 times before entering A musician who practices a difficult passage over and over again until its perfect A man who stores 19 years of newspapers “just in case” – with no system for filling or retrieving A woman who dedicates all her spare time and money to building her record collection

17. Behavioral Explanation Mowrer’s 2-Factor Theory –Obsessions come to evoke anxiety through classical conditioning –Anxiety is reduced through compulsion, which are, therefore, reinforced (operant conditioning) Evidence: –Animals learn to avoid aversive stimuli in an “obsessive” way But: –Aren’t intrusive thoughts aversive to being with? –Why doesn’t everyone develop OCD?

18. 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”

19. 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

20. 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?

21. 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.

22. 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

23. 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.

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

25. Elimination Disorders Enuresis Encopresis

26. Sexual Problems Autoerotic activity Incest Masochism

27. Social Isolation Intervention using social skills training –Modeling –Rehearsal –Guided Practice –Feedback