1. Anxiety and Obsessive—Compulsive Disorders11
Anxiety and Obsessive—Compulsive Disorders

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
Table 11.1 The many symptoms of anxiety
Source Adapted from Fears and Anxieties, by B. A. Barrios and D. P. Hartmann, 1997, p In E. J. Mash and L. G. Terdal (Eds.), Assessment of Childhood Disorders, 3rd ed. Copyright © 1997 by Guilford Publications. Reprinted by permission.

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
Table 11.2 Common fears and anxieties of infancy, childhood and adolescence; possible symptoms; and corresponding DSM-5 diagnoses
Source Based on Beesdo, Knappe, & Pine, 2009

9. Common Fears and Anxieties (cont’d.)
Table 11.2 Common fears and anxieties of infancy, childhood and adolescence; possible symptoms; and corresponding DSM-5 diagnoses
Source Based on Beesdo, Knappe, & Pine, 2009

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
Table 11.3 Diagnostic criteria for Separation Anxiety Disorder (SAD)
Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association.

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
Table 11.4 Diagnostic criteria for Specific Phobia
Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association.

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
Table 11.5 Diagnostic criteria for Social Phobia
Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (Copyright © 2000). American Psychiatric Association.

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.)
Figure 11.1 The figure (a) shows increased neural activity as detected in the hippocampus while participants appraised how they thought preferred peers would evaluate them. (b) As age increased, neural activity in the hippocampus increased in females but did not change in males
Source (a) © 2009, Amanda E. Guyer, Erin B. McClure-Tone, Nina D. Shiffrin, Daniel S. Pine, Eric E. Nelson; “Probing the Neural Correlates of Anticipated Peer Evaluation in Adolescence” Child Development, © 2009, Society for Research in Child Development, Inc. (b) From Probing the neural correlates of anticipated peer evaluation in adolescence by Guyer et al. Child Development, 80, 1000–1015. Journal Compilation © 2009, Society for Research in Child Development, Inc. John Wiley and Sons.

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
Table 11.6 Diagnostic criteria for Panic Disorder
Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association.

32. Prevalence and Comorbidity
Panic attacks are common (16% of teens)
Panic disorder is less common (about 2.5% of teens 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
Age of onset for first panic attack 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
Table 11.8 Diagnostic criteria for Generalized Anxiety Disorder
Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association.

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
Table Diagnostic criteria for Obsessive-Compulsive Disorder
Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association.

40. 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
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

51. Cumulative Incidence of Anxiety Disorders in Females and Males
Figure 11.2 Cumulative incidence of anxiety disorders in females and males
Source Figure 1 from Stable Prediction of Mood and Anxiety Disorders Based on Behavioral and Emotional Problems in Childhood A 14-Year Follow-Up During Childhood, Adolescence, and Young Adulthood Sabine J. Roza, M.Sc.; Marijke B. Hofstra, M.D.; Jan van der Ende, M.S.; Frank C. Verhulst, M.D. Am J Psychiatry 2003; –2121. Adapted with permission from the American Journal of Psychiatry, (Copyright © 2003). American Psychiatric Association.

52. 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)

53. 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

54. 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

55. 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

56. 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

57. 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

58. 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

59. 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

60. A Possible Developmental Pathway For Anxiety Disorders
Figure 11.3 A possible developmental pathway for anxiety disorders
Source Cengage Learning, 2016

61. 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

62. 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

63. 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

64. 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

65. 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

66. 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

67. Prevention (cont’d.)
Figure 11.4 Number and severity of diagnosed anxiety disorders over 3 years in children whose parents received an intervention or who received only monitoring
Source Reprinted with permission from the American Journal of Psychiatry, (Copyright © 2010). American Psychiatric Association.