Lesson 9: Anxiety and Obsessive-Compulsive Disorders PDF

LESSON 9: Anxiety and Obsessive— Compulsive Disorders Psychology of Exceptional Children Rhalf Jayson F. Guanco, Ph.D, RPsy, RPm, CSDP Description of Anxiety Disorders Anxiety: a mood state characterized by strong negative emotion and bodily symptoms of tension in anticipation of future...

LESSON 9: Anxiety and Obsessive— Compulsive Disorders Psychology of Exceptional Children Rhalf Jayson F. Guanco, Ph.D, RPsy, RPm, CSDP 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 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 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 The Many Symptoms of Anxiety 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 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 Common Fears and Anxieties Common Fears and Anxieties (cont’d.) 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 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 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 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 Seven Categories of Anxiety Disorders Separation Anxiety Disorder (SAD) Generalized anxiety disorder (GAD) Specific phobia Social anxiety disorder Panic disorder (PD) Agoraphobia Selective mutism 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 Diagnostic Criteria for Separation Anxiety Disorder 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 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 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 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 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 Diagnostic Criteria for Specific Phobia 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 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 Diagnostic Criteria for Social Phobia 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 Prevalence, Comorbidity, and Course (cont’d.) 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 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 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 Diagnostic Criteria for Panic Disorder 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 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 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 Diagnostic Criteria for Generalized Anxiety Disorder 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 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 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 Diagnostic Criteria for Obsessive-Compulsive Disorder 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 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 Associated Characteristics Children with anxiety disorders display a number of associated characteristics – Cognitive disturbances – Physical symptoms – Social and emotional deficits – Anxiety and depression 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 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 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 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 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 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 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 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 Cumulative Incidence of Anxiety Disorders in Females and Males 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) 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 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 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 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 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 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 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 A Possible Developmental Pathway For Anxiety Disorders 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 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 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 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 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 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 Prevention (cont’d.)