Chapter 11 - Anxiety and Obessesive-Compulsive Disorders

Characterize the prevalence of anxiety.

Anxiety disorders are among the most common mental health problems in children and adolescents, but they often go unnoticed and untreated.

List the three aspects of anxiety.

Anxiety is an adaptive emotion that prepares youths to cope with potentially threatening people, objects, or events. Strong negative emotions, physical tension, and apprehensive anticipation of future danger or misfortune characterize it.

Identify the three interrelated response systems of anxiety.

The symptoms of anxiety are expressed through three interrelated response systems: physical, cognitive, and behavioral.

Describe whether anxiety is a present-focused or future-focused emotion.

Fear is a present-oriented emotional reaction to current danger. In contrast, anxiety is a future-oriented emotion characterized by feelings of apprehension and a lack of control over upcoming events that might be threatening.

Anxiety

A mood state characterized by strong negative affect, bodily symptoms of tension, and apprehensive anticipation of future danger or misfortune.

anxiety disorders

A disorder in which the child experiences excessive and debilitating anxiety.

fight/flight response

The immediate reaction to perceived danger or threat whereby efforts are directed toward protecting against potential harm, either by confronting the source of danger (fight), or by escaping from the situation (flight).

Physical symptoms of Anxiety

Increased heart rate, Fatigue, Increased respiration, Nausea, Stomach upset, Dizziness, Blurred vision, Dry mouth, Muscle tension, Heart palpitation, Blushing, Vomiting, Numbness, Sweating

Cognitive Symptoms of Anxiety

Thoughts of being scared or hurt, Thoughts or images of monsters or wild animals, Self-deprecatory or self-critical thoughts, Thoughts of incompetence or inadequacy, Difficulty concentrating, Blanking out or forgetfulness, Thoughts of appearing foolish, Thoughts of bodily injury, Images of harm to loved ones, Thoughts of going crazy, Thoughts of contamination

Behavioural Symptoms of Anxiety

Avoidance

Crying or screaming

Nail biting

Trembling voice

Stuttering

Trembling lip

Swallowing

Immobility

Twitching

Thumb sucking

Avoidance of eye contact

Physical proximity

Clenched jaw

Fidgeting

Anxiety is a precursor to

Depression

Fear

An alarm reaction to current danger or life-threatening emergencies; marked by strong escape-oriented tendencies and a surge in the sympathetic nervous system.

Panic

A group of unexpected physical symptoms of the fight/flight response that occur in the absence of any obvious threat or danger.

Seven DSM-5-TR Anxiety Disorders

Separation Anxiety Disorder (SAD), Specific phobia, Social anxiety disorder, Selective mutism, Panic Disorder, Agoraphobia, Generalized Anxiety Disorder

Separation Anxiety Disorder (SAD)

Characterized by excessive worry regarding separation from home or parents. Youths may show signs of distress and physical symptoms on separation, experience unrealistic worries about harm to self or others when separated, and display an unwillingness to be alone. Children with SAD display age-inappropriate, excessive, and disabling distress related to separation from and fear of being alone without their parents or other major attachment figures.

Specific Phobia

Characterized by severe and unreasonable fears and avoidance of a specific object or situation, for example, dogs, spiders, darkness, or riding on a bus. specific phobia

An extreme and disabling fear about objects or situations that in reality pose little or no danger or threat; those with a specific phobia go to great lengths to avoid these objects or situations. They experience extreme fear or dread, physiological arousal to the feared stimulus, and fearful anticipation and avoidance when confronted with the object of their fear.

Social Anxiety Disorder

Characterized by a severe and unreasonable fear of being embarrassed or humiliated when doing something in front of peers or adults. A marked and persistent fear of social or performance requirements that expose the individual to scrutiny and possible embarrassment. These individuals go to great lengths to avoid these situations, or they may face the challenge with great effort, wearing a mask of fearlessness.

Selective Mutism

Characterized by a consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., school), even though the child may speak loudly and frequently at home or in other settings. An anxiety disorder involving a consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations.

Panic Disorder (PD)

Characterized by recurrent, unexpected, and severe panic attacks. These attacks may consist of an accelerated heart rate, shortness of breath, sweating, upset stomach, dizziness, fear of dying, and others. The individual also experiences a persistent concern or worry about additional panic attacks or their consequences, or displays a significant maladaptive change in behavior to avoid having panic attacks (e.g., avoidance of exercise or new situations).

Agoraphobia

Characterized by fear or anxiety about two or more situations such as using public transportation, being in open spaces (e.g., parking lots, marketplaces), being in enclosed spaces (e.g., theaters), being in a crowd, or being outside of the home alone. The fear or anxiety about these situations occurs because the individual thinks that escape might be difficult or help not available if they were to develop panic-like or other incapacitating symptoms.

Generalized Anxiety Disorder (GAD)

Characterized by ongoing and excessive worry about many events and activities. Youths may worry about their grades in school, their relations with peers, and their own or others’ safety. They may constantly seek comfort or approval from others to help reduce their worry.

State whether SAD is a common youth disorder.

SAD is one of the most common anxiety disorders of childhood, with the earliest reported age at onset and the youngest age at referral.

School refusal behavior

A form of anxious behavior in which the child refuses to attend classes or has difficulty remaining in school for an entire day.

Identify the most common specific phobia in children.

Evolutionary theory contends that human infants are biologically predisposed to learn certain fears that alert them to possible sources of danger. This may explain why the most common specific phobia in children is a fear of animals, such as dogs, snakes, and insects.

Name the five subtypes of DSM-5-TR that categorize specific phobias.

Five subtypes based on the focus of the phobic reaction and avoidance: animal; natural environment; blood-injection-injury; situational; and other (which includes fears of vomiting and choking).

State the age range that specific phobias peak in youth.

Many youths experience specific phobias, but only a very few are referred for treatment. Specific phobias can occur at any age, but seem to peak between 10 and 13 years of age.

State the greatest fear for a child with social anxiety disorder.

Children with social anxiety disorder fear being the focus of attention or scrutiny or of doing something in public that will be intensely humiliating.

Identify the lifetime prevalence of social anxiety disorder.

Social anxiety disorder is common, with a lifetime prevalence of 6% to 12%, and affecting nearly twice as many girls as boys.

Describe when social anxiety disorder generally develops.

Social anxiety disorder generally develops after puberty, at a time when most teens experience heightened self-consciousness and worries about what others think of them.

Describe prevalence for selective mutism.

Selective mutism is a rare disorder occurring in about 0.7% of all children. Its prevalence does not seem to vary by sex or race/ethnicity.

State common co-occurring disorders with selective mutism.

The most common co-occurring disorders are other anxiety disorders, particularly social anxiety disorder and specific phobia.

Define panic attack.

An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time is accompanied by four (or more) physical and cognitive symptoms (e.g., palpitations, sweating, trembling, shortness of breath, chest pain, dizziness, chills, numbness, fear of losing control, fear of dying).

Specific Phobias last

Longer than 6 months

Many postpubertal adolescents experience panic attacks, but PD and agoraphobia are much less common, affecting about:

2.5% of teens, and females about twice as often as males. Average age at onset for a first panic. attack in adolescents with PD is 15 to 19 years.

PD and agoraphobia are associated with many other disorders, most commonly:

other anxiety disorders

PD and agoraphobia are

stable and over time and have one of the lowest rates of complete remission for any of the anxiety disorders

Youths with a GAD experience:

chronic or exaggerated worry and tension, often accompanied by physical symptoms

GAD occurs in about 2% of children in community samples, but it is one of the:

most common anxiety disorders in children who are referred to specialty clinics for treatment of anxiety

Define OCD.

A disorder in which the individual experiences recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and that in most individuals cause marked anxiety or distress; the individual attempts to ignore or suppress such thoughts, urges, or images or to neutralize them with some other thought or action (i.e., by performing a compulsion).

Describe the most common obsessions in children with OCD.

contamination and fears of harm to self and others. Among the most common compulsions are washing and bathing, and repeating, checking, and arranging.

Compulsions

Repetitive, purposeful, and intentional behaviors or mental acts that are performed in response to an obsession.

Obsessions

Persistent, intrusive, and irrational thoughts, ideas, impulses, or images that focus on improbable or unrealistic events or on real-life events that are greatly exaggerated

Body Dysmorphic Disorder

Disorder characterized by a preoccupation with defects or flaws in physical appearance that are not observable by or appear slight to others.

Hoarding Disorder

Disorder characterized by persistent difficulty discarding or parting with possessions, regardless of their actual value.

Trichotillomania (Hair-Pulling Disorder)

is characterized by recurrent pulling out of one’s hair, resulting in hair loss (not attributable to another medical condition), repeated attempts to decrease or stop hair pulling, and significant distress or impairment in important areas of life functioning.

Excoriation Disorder (Skin-Picking Disorder)

is characterized by recurrent skin picking resulting in skin lesions, repeated attempts to stop skin picking, and significant distress or impairment in important areas of life functioning.

OCD has a mean age of onset of

9 to 12 years and affects about 1% to 2.5% of all children. Children with an early onset are more likely to be boys and are more likely to have a family history of the disorder than are those with a later onset.

List the specific areas of cognitive functioning deficits for children with an anxiety disorder.

deficits in specific areas of cognitive functioning, such as attention, memory, and speech and language.

“anxious vigilance.”

They selectively attend to information that may be potentially threatening, a tendency referred to as

Negative affectivity

A persistent negative mood evidenced by nervousness, sadness, anger, and guilt.

positive affectivity

A persistent positive mood as reflected in states such as joy, enthusiasm, and energy.

State gender difference in anxiety and youth.

About twice as many girls as boys experience symptoms of anxiety, and this difference is present in children as young as 6 years of age.

Describe how ethnicity and culture affect anxiety in youth.

Children’s ethnicity and culture may affect the expression and developmental course of fear and anxiety, how anxiety is perceived by others, and expectations for treatment.

behavior lens principle

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

Describe at least one early theory on anxiety.

Early theories viewed anxiety as a defense against unconscious conflicts, a learned response, or an adaptive mechanism needed for survival.

State the overall conclusion of family and twin studies and biological vulnerability of anxiety disorders.

suggest a moderate biological vulnerability to anxiety disorders.

List at least three family factors associated with anxiety in youth.

specific parenting practices, family functioning, the parent–child attachment, and parents’ beliefs about their children’s anxious behavior

two-factor theory

Theory used to explain the learning and maintenance of fears through a combination of classical and operant conditioning.

behavioral inhibition (BI)

The ability to delay one’s initial reactions to events or to stop behavior once it has begun.

State the primary treatment intervention for anxiety in youth.

Exposing youths to the situations, objects, and occasions that produce their anxiety is the main line of attack in treating fears and anxieties.

The most effective procedures for treating specific phobias involve participant modeling and reinforced practice.

CBT

Medications

Family interventions

age of onset for a panic attack

15-19 years old, 95% PD adolescents are post-pubertal

Describe cognitive–behavioral therapy (CBT) for anxiety.

Cognitive–behavioral therapy (CBT) teaches children to understand how their thinking contributes to anxiety, how to change maladaptive thoughts to decrease their symptoms, and how to cope with their fears and anxieties other than by escape and avoidance.

Identify the role of medications such as SSRIs in treating anxiety in youth.

Medications such as SSRIs are effective in treating children with anxiety disorders. CBT is generally considered the first line of treatment, with medication reserved for those with severe symptoms or comorbid disorders or when CBT is not available or proves unsuccessful.

exposure

A behavioral therapy technique for treating anxiety disorders that exposes the subject to the source of his or her fear while providing appropriate and effective ways of coping with the fear (other than through escape and avoidance).

graded exposure

Gradual exposure of a subject to a feared situation.

systematic desensitization

A three-step behavior therapy technique for treating anxiety whereby: (1) the child is taught to relax, (2) an anxiety hierarchy is constructed, and (3) the anxiety-provoking stimuli are presented sequentially while the child remains relaxed.

response prevention

A procedure used in the treatment of anxiety that prevents the child from engaging in escape or avoidance behaviors. This procedure is usually used in conjunction with flooding.

flooding

A procedure for treating anxiety that involves prolonged and repeated exposure to the anxiety-provoking situation until the subject’s level of anxiety has diminished.