Chapter 11: Anxiety & Obsessive-Compulsive Disorders

Anxiety

defined by strong negative emotion and bodily symptoms of tension, usually in anticipation of future danger or misfortune

Fight-or-Flight Response

immediate reaction to perceived danger or threat aimed at escaping potential harm

3 Interrelated Anxiety Response Systems

1) Physical

2) Cognitive

3) Behavioral

Physical System

The brain sends messages to the sympathetic nervous system, fight/flight response (e.g., increased heart rate, upset stomach, sweating, tension).

Cognitive System

Activation leads to feelings of apprehension, nervousness, difficulty concentrating, and panic (e.g., thoughts of being scared).

Behavioral System Model

aggression is coupled with a desire to escape the threatening situation (e.g., avoidance, fidgeting, trembling voice, crying).

Anxiety vs. Fear vs. Panic

Anxiety: a future-oriented mood state, may occur in the absence of realistic danger

Fear: present-oriented emotional reaction to current danger, marked by strong escape tendency

Panic: a group of physical symptoms of fight/flight response that unexpectedly occur in the absence of obvious danger or threat

Normal Fears

-emotions and rituals that increase feelings of control are common in children and teens

-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

Normal Anxieties and Worries

-anxieties are common during childhood and adolescence (e.g., girls display more than boys)

-Children of all ages worry, it serves a function in normal development and can help children prepare for the future

-children with anxiety worry MORE INTENSELY than other children

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 may resemble early precursors of OCD

DSM-5-TR: Anxiety Disorders

1) Separation Anxiety Disorder (SAD)

2) Specific Phobia

3) Social Anxiety Disorder (SAD 2.0)

4) Selective Mutism

5) Generalized Anxiety Disorder (GAD)

6) Agoraphobia

7) Panic Disorder (PD)

Separation Anxiety Disorder (SAD)

-Age-inappropriate, excessive, and disabling anxiety about being apart from parents or away from home

-Children may become withdrawn, apathetic, or depressed over time

-ONE OF THE 2 MOST COMMON ANXIETY DISORDERS

Prevalence and Comorbidity of Separation Anxiety Disorder (SAD)

-occurs in 4-10% of children (more prevalent in girls than boys)

-more than 2/3s of children with SAD have another anxiety disorder, half develop a depressive disorder

Onset, Course, and Outcome of Separation Anxiety Disorder (SAD)

-earliest onset age of all anxiety disorders: ages 7-8

-persists into adulthood for more than 1/3rd of affected children

-as adults, more likely to experience relationship difficulties, other mental health problems, and functional impairment in social/personal life

School Reluctance and Refusal (SAD)

-refusal to attend classes or difficulty remaining in school for entire day

-common ages: 5-11

-may be fear of leaving parents (separation anxiety)

-serious long-term consequences if remains untreated

Specific Phobia

-age-inappropriate, persistent, irrational fear that leads to avoidance of the feared object or situation

-lasts at least 6 months

-symptoms: crying, tantrums, freezing, clinging

Prevalence and Comorbidity of Specific Phobia

-About 20% of children are affected

-More common in girls

-co-occurring disorders: other anxiety disorders and depressive disorders

Onset, Course, and Outcome of Specific Phobia

-Onset at 7-9 years: phobias involving animals, darkness, insects, blood, and injury

-Clinical phobias persist more than normal fears

Social Anxiety Disorder

a marked, persistent fear of social/performance situations where embarrassment is possible

Characteristics of Social Anxiety Disorder

-anxiety over mundane activities

-the 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

Prevalence and Comorbidity of Social Anxiety Disorder

-6-12% lifetime prevalence (2x as common in girls)

-2/3s also have another anxiety disorder

-20% develop depression

Onset, Course, and Outcome of Social Anxiety Disorder

-onset: early to mid-adolescence, rare before age 10

-duration: 20-25 years, the lowest remission rate of all anxiety disorders

-adolescent females may have higher biological sensitivity to being judged by peers than males

Selective Mutism

-Failure to talk in specific social situations, even though they may speak loudly and frequently at home or other settings

Prevalence, Comorbidity, Onset, and Course of Selective Mutism

-occurs in 0.7% of children

-onset ages 3-4 years old

-likely an early childhood variant of social anxiety disorder

-may be an extreme type of social phobia

Panic Disorder

recurrent unexpected panic attacks

-at least 1 month of concern/worry about having another attack and its consequences

Panic Attack

short period of intense fear or discomfort, accompanied by symptoms characteristic of the fight/flight response

Agoraphobia

marked fear or anxiety in certain places or situations

Prevalence and Comorbidity of Panic Disorder (PD) and Agoraphobia

-panic attacks: 16% of teens

-PD/Agoraphobia: about 2.5% of teens (13-17 years)

-more common in females

-comorbidity with PD, most commonly have another anxiety disorder or depression

Onset, Course, and Outcome of Panic Disorder (PD) and Agoraphobia

-onset: 15-19 years old

-95% of PD adolescents are post-pubertal

-one of the lowest remission rates for any of the anxiety disorders

Generalized Anxiety Disorder (GAD)

excessive, uncontrollable worry about multiple issues, accompanied by at least one somatic symptom: headaches, stomach aches, muscle tension, and trembling

Prevalence and Comorbidity of Generalized Anxiety Disorder (GAD)

-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 of Generalized Anxiety Disorder (GAD)

-onset age: early adolescence

-older children have more symptoms

-chronic with low remission rates

Obsessive-Compulsive Disorder (OCD)

a disorder characterized by recurrent, time-consuming (more than 1 hour per day), and disturbing obsessions and compulsions

-resistant to reason; children often involve family members in rituals

Obsessions (OCD)

persistent and intrusive thoughts, urges, or images

Compulsions

repetitive, purposeful, and intentional behaviors or mental acts performed to relieve anxiety

Prevalence and Comorbidity of OCD

-lifetime prevalence: 1-2.5%

-2x as common in boys (clinic-based)

-comorbidities: anxiety disorders, ADHD, ODD, and vocal/motor tics

-as child gets older, depressive/substance-use/learning/eating disorders are more common

Onset, Course, and Outcome of OCD

-onset age: 9-12 years old, peaks in early childhood and early adolescence

-chronic disorder: as many as 2/3s still have OCD 2-14 years after initial diagnosis

Associated Characteristics of Anxiety Disorders

- cognitive disturbances

- physical symptoms

- social and emotional deficits

- anxiety and depression

Cognitive Disturbances

-disturbances in how information is perceived and processed

-deficits in attention, executive functioning, working memory, speech/language

-cognitive errors: viewing events as threatening; danger-confirmation biases

Physical Symptoms

-Somatic complaints: 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.

-Anxiety takes its toll over time by increasing the long-term risk of serious health problems

Social and Emotional Deficits

-Social withdrawal, loneliness, low self-esteem, difficulty making and maintaining friends

-younger children show lower levels of theory of mind

Anxiety and Depression

-Risk for accompanying disorders varies with the type of anxiety.

-Depression is diagnosed more often in children with multiple anxiety disorders.

-Physiological hyperarousal may be unique to anxious children.

Negative Affectivity

persistent negative mood is related to both anxiety and depression

Positive Affectivity

persistent positive mood is negatively correlated with depression, but is independent of anxiety

Gender

-by age 6, girls show 2x greater anxiety symptoms

-boys are less likely to report anxiety

-genetic and neurobiological factors may contribute

-masculinity = lower overall levels of fearfulness

-femininity = no relation to fearfulness

Ethnicity

-more prevalent in underrepresented groups

-black children report more anxiety symptoms

-white children more likely to present with school refusal

-native Hawaiian adolescents show 2x OCD rates

Culture

-the experience of anxiety is pervasive across cultures

-influences the expression, interpretation, and expectations of anxiety

Behavior Lens Principle

a principle that states that child psychopathology reflects a mix of actual child behavior and the lens through which it is viewed by others in a child's culture.

Early Theories

1) Psychoanalytic: anxiety = defense against unconscious conflicts rooted in child's early upbringing

2) Behavioral: classical conditioning + operant reinforcement (2-factor theory)

3) Bowlby's Theory of Attachment: fearfulness is biologically rooted in the emotional attachment needed for survival

-no single theory is sufficient

Temperament

-Behavioral Inhibition (BI): a low threshold for novel and unexpected stimuli; 15-20% of children

-BI -> higher risk for anxiety depending on parental response, gender, and stress exposure

Family and Genetic Risk

-Parents of children with anxiety disorders have increased rates of current and past anxiety disorders.

-heritability: 30-40%

-no strong, direct link between specific genetic markers and specific types of anxiety disorders

Neurobiological Factors

-overactive behavioral inhibition system

-brain networks involving GABA, amygdala, and limbic structures.

- y-aminobutyric acidergic (GABA-ergic) system

Family Factors

-parents are seen as overinvolved, intrusive, or limiting the child's independence

-high family dysfunction, low SES, insecure early attachment

Treatment & Prevention

main goal: expose children to anxiety triggers while teaching coping skills to reduce avoidance and distorted thinking

Behavior Therapy

-main technique: exposure to feared stimulus

-systematic desensitization, flooding (prolonged repeated exposure), response prevention (prevents the child from engaging in escaping or avoiding stimuli)

Cognitive-Behavioral Therapy (CBT)

-most effective treatment for most anxiety disorders

-usually combined with exposure

-programs like Coping Cat

Coping Cat

decrease negative thinking, increase active problem solving, and a functional coping outlook

Medication

-can reduce symptoms, especially for OCD

-most common and effective are SSRI's

-most effective when combined with CBT

-CBT is first line of treatment

Prevention

-early preventions with at-risk preschoolers reduce later anxiety disorders

-prevention programs are highly cost-effective