Anxiety Disorders and Obsessive-Compulsive Disorders PDF

Anxiety Disorders and Obsessive– Compulsive Disorders Dr. Grace Azar  Anxiety: A complex emotional state of psychological distress that reflects e...

Anxiety Disorders and Obsessive– Compulsive Disorders Dr. Grace Azar  Anxiety: A complex emotional state of psychological distress that reflects emotional, Psychologists differ between 2 types behavioral, physiological, of Anxiety, fear and worry and cognitive reactions to threatening stimuli. Fear: A behavioral and physiological reaction to immediate threat, in which the person responds to imminent danger by Examples: confrontation or escape. 1. Experiencing fear when underprepared for an exam. 2.Manifested in increased pulse rate, shallow breathing, or even feeling dizzy. What Is the Difference Between 3.The person Normal Anxiety and an Anxiety experiencing fear may Disorder?: Adaptive vs. Maladaptive feel a sense of terror and the urge to run Anxiety away from the situation.  Worry: A cognitive response to threat in which the person considers and prepares for What Is the Difference Between future danger or Normal Anxiety and an Anxiety misfortune. Disorder?: Adaptive vs. Maladaptive Being worried can cause a Adaptive Anxiety chronic psychological state of distress, anxiety: manifested in: Uneasiness, apprehension, In most cases, anxiety and tension. helps in dealing with Ex: worry about an interview immediate threats to one’s integrity. Acts as a motivator to Maladaptive anxiety: prepare for potential danger. Anxiety characterized by intensity that is out of proportion to the Feeling apprehensive perceived threat, chronicity that lasts beyond removal of the can actually help study immediate threat, and impairment. better for an exam. Out of proportion anxiety causes intense distress and psychological discomforts. Example: A student going blank during a presentation. Chronic anxiety causes people to anticipate disasters in the long-run and may lead to enduring physical and emotional discomfort. Maladaptive anxiety impairs and interferes with the ability to perform daily tasks – not flying to best friend’s wedding  Socio-emotional task: A critical development task during infancy is to build trust in someone who will protect against danger or distress. It is a socio-emotional task that depends on: Natural emergence of object permanence at the age of 4 to 10 months. Stranger anxiety at the age of 6 to 12 months. Separation anxiety at the age of 12 to 18 months. Some children tend to exhibit anxiety of unusual proportion, chronicity or impairment such as screaming to stop being separated from caregivers at a daycare. Chronic anxiety may continue to be experienced beyond a developmentally normative age. It may inhibit a child’s ability to master other developmental tasks later in life, like avoiding sleepovers for fear of separation anxiety. Anxiety in the context of development  Social competence: The ability to establish meaningful friendships and other social roles at school, co-curricular activities or sports. Adolescents’ social interactions are enhanced by increased capacity to empathize and metacognition thinking about their own thinking. Social competence can also lead to self-doubts and insecurities. Some children's’ fears and doubts can assume intense proportions and extend beyond developmentally normative age, disrupting their overall functioning. Children’s anxiety about school may result in sleep Anxiety in the context of disorders, irritability, and avoidance of social situations development altogether  Continuum of fears, anxieties, and worries: Children’s fears anxieties, and worries tend to exist in continuum. One end is developmentally normative and expected. Reflected in adaptive anxiety which acts as a motivator to achieve developmental tasks and helps in social interactions. Another end of the continuum is occupied by fear, anxiety, and worry. The other end spills over developmentally normative periods and impairs capacities to face life’s challenges along the way. Many children lie somewhere in between the two extremes. It is difficult to draw a line between the end of normal anxiety and an anxiety disorder. Anxiety in the context of development A Continuum of Fears and Worries Across Childhood Developmentally Expected Fears/ Symptoms That Might Indicate a Corresponding DSM-5 Anxiety Age Worries Disorder Disorder Extreme panic when separated after age 2 years, sleep Fears of separation from caregivers Separation anxiety disorder Toddlerhood (2–3 years) disturbance, tantrums when Shyness, anxiety with strangers Selective mutism separated; failure to talk with others outside the home Fear of separating from parents to Clinging to parents, crying, Separation anxiety disorder/ go to preschool or day care tantrums, freezing, sneaking into selective mutism Preschool (4–5 years) Fear of thunderstorms, darkness, parents’ bed at night, avoiding Specific phobia (natural nightmares feared stimuli, sleep refusal, bed- environment) Fear of specific animals wetting Specific phobia (animals) Fear of specific objects (animals, Avoidance of feared stimuli, refusal monsters, ghosts) to attend school, extreme Specific phobia (animals, Elementary school (6–8 years) Fear of germs or illnesses anxiety/panic during tests, situations) Fear of natural disasters or injuries academic problems Anxiety about school Anxiety about school or tests, School refusal, academic problems, worry about completing procrastination, insomnia, tension assignments Social anxiety disorder Generalized Middle school (9–12 years) or restlessness, social withdrawal, Worries about making and keeping anxiety disorder timidity, extreme shyness in social friends, concerns about pleasing situations, persistent worry others Academic problems, persistent Concerns about acceptance and worry, sleep/appetite disturbance, Social anxiety disorder Generalized rejection by peers, teachers High school (13–18 years) depressed mood or irritability, anxiety disorder Panic disorder, Worries about grades, sports, substance abuse, recurrent panic agoraphobia relationships attacks, social withdrawal  1.DSM-5 enlists seven different anxiety disorders that can be diagnosed in children, adolescents, and adults. 2.Four of the seven disorders occur during middle childhood: Separation anxiety disorder (SAD); selective mutism; specific phobia; social anxiety disorder. Middle childhood anxiety disorders are characterized by repeated, unwanted fears of objects and situations. SAD, selective mutism, specific phobia, and social anxiety disorder are together considered fear disorders. 3.The fifth and sixth disorders are rare in children before puberty: Panic disorder and agoraphobia. Both are characterized by feelings of intense apprehension, dread or panic and can often occur together. Onset of 4.The seventh type of anxiety disorder is generalized anxiety disorder (GAD) that is Childhood underlined by persistent worry as against fear or panic. It usually sets in after later late childhood or adolescence since the ability to contemplate on future events, marked by worry, is more Anxiety: prevalent in older children.  1.Approximately 20% children and adolescents are known to develop some form of anxiety disorder before adulthood. 2.Amongst adults, the prevalence is roughly about 5%. 3.Prevalence is higher for adolescents than younger children and in girls than boys, the latter ratio being as high as 1:2 or even 1:3 during adolescence. 4.Childhood anxiety disorders are a predictor for: Depressive disorder, substance use and suicide behaviors. 5.Anxiety and the development of depression have been found to be at a gap of 5 years, on average. Prevalence and course  Separation Anxiety Disorder (SAD): Emergence and decline of fear of separation Emerges in infants at 6 months of With a more firm trust established in should typically decline around the age of 3 to 5 years. age, and peaks between 13 to 18 caregivers, older infants and toddlers months. tend to display separation anxiety. Varied symptoms across ages Refusing to go to school (around 7 Around 12 yrs old they experience Older Falling ill, withdraw from social years old) diffuse fears of separation. situations, less concentration, Nightmares about parents being sense of feeling endangered when depression harmed separated from parents Sleeping with or out of parents Fear of parents getting sick room Onset of SAD is usually between 7 and 9 years of age.  SEPARATION ANXIETY DISORDER Concerned About Mom Valerie was a 14-year-old girl referred to our clinic because she persistently refused to go to school. According to her father, Valerie would feign sickness, lie, tantrum, and do “just about anything” to stay home. Her father explained, “Last week, she promised me that she would go. I watched her get on the bus, but she never made it to school. She was back home 25 minutes later saying that her stomach hurt.” Valerie’s mother added, “It’s getting to be a problem. All she wants to do is stay home. I ask her, ‘Don’t you want to go to Emily’s house or shopping with your friends?’ but she always prefers to be with us.” A psychologist at our clinic, Dr. Saunders, asked Valerie about her reluctance to go to school. “Did something bad happen at school? Are you having trouble there?” Valerie responded, “No. I get along fine with the other kids and I’m getting good grades. I just like being at home better, near my mom.” Dr. Saunders learned that Valerie’s school refusal began last autumn, after her mother recovered from respiratory problems associated with COVID-19. Valerie took care of her mother after she returned from the hospital, while her father was at work. Since that time, Valerie has shown especially strong attachment to her. After several sessions, Dr. Saunders asked, “Are you worried that something bad might happen to your mother, like maybe she’ll get sick again?” Valerie responded, “Of course not! The doctors say she’s fine.” After a long pause, Valerie added, “I just want to make sure.”  Diagnostic Criteria for Separation Anxiety Disorder A- Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following: 1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures. 2.Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injuries, disasters, or death. 3.Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure. 4.Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation. 5.Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. 6.Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. 7.Repeated nightmares involving the theme of separation. 8.Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated. B- The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults. C-The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. D- The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in Autism Spectrum Disorder; refusal to go outside without a trusted companion in Agoraphobia; or worries about ill health or other harm befalling significant others in Generalized Anxiety Disorder. Note: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association. All Rights Reserved.  Causes of separation anxiety disorder Genetics Attachment Parents’ anxiety and 1. Genetic factors have a smaller 1. Emotional bond between child- insecurities contribution to SAD, compared to other mother promotes safety and Children with SAD often have anxiety disorders. allows the child to explore the parents who are overly involved, 2.Genes probably predispose children environment. controlling, and protective of with SAD by increasing autonomic 2.Insecure attachment at infancy is their children’s behavior. arousal and overall anxiety in strange a predictor for childhood and 1. Controlling parents may model situations. adolescent anxiety problems. anxiety and fearfulness and 3.Increased autonomic arousal may lead 3.Infants who initially displayed encourage their children to be children to demand considerable insecure attachment relationships unnecessarily cautious. parental reassurance and comfort to with their mothers at age 12 2.Highly controlling and help them feel safe. months were more likely to overprotective parenting develop anxiety disorders during behaviors are consistent with their teenage years those who themselves have 4.Insecure-ambivalent attachment: histories of insecure Inconsistent parental care may attachments with their own cause children to experience parents. anxiety at times of stress, since they are unsure if their parents will turn up for support. 5.Sensitive and responsive parental care may prevent the emergence of SAD and other anxiety problems.  Selective Mutism: DSM-5 disorder characterized by consistent failure to speak in diagnosed only when the child’s not attributable exclusively to other psychiatric disorders like social situations in which there is inability to speak cannot be attributed communication disorder or autism an expectation for speaking (e.g., to a lack of knowledge or comfort of spectrum disorder (ASD), although children with selective mutism might at school); lasts for at least 1 speaking the language in a specific have communication difficulties. month and impairs functioning. situation Selective mutism as a rare condition: As a Long-term condition Affects less than 1% children in Usually goes undiagnosed before Can last to 8 years. An alarming 94% the general population. going to school when children with of children who do not receive twice the likelihood of occurrence selective mutism refuse to speak treatment go on to develop social in girls than boys. to classmates and teachers. anxiety disorder, resulting in anxiety onset between 2.7 to 4.2 years. and avoidance of social situations. Because of the failure to speak, children with selective mutism may also face academic difficulties and peer rejection.  Diagnostic Criteria for Selective mutism 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. B. The disturbance interferes with educational achievement or social communication. C. The duration of the disturbance is at least 1 month (not limited to the first month of school). D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social interaction. E. The disturbance is not better explained by a communication disorder (e.g., stuttering) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder. Note: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association. All Rights Reserved.  Selective mutism Reticent Russell Russell was a 3-year-old boy referred by his teacher for suspected language problems and possible developmental delays. Although Russell had attended preschool for 4 weeks, he had yet to say a word to his teacher or classmates. “Russell is a shy but friendly child,” his teacher reported. “He smiles and makes good eye contact but refuses to say anything.” Instead of speaking, Russell communicated largely through gestures and nods. Russell’s mother reported that Russell met early develop- mental milestones on time. “Then,” she added, “approximately 1 year ago—about the time his father and I separated—Russell stopped talking to other people. He speaks to me when we’re alone. He’ll also whisper or ‘mouth’ things to his brother. But Russell won’t speak to his teacher, other people outside the house, or even his father.” His teacher commented, “Russell is such a sweet boy, but I’m worried about him. I can’t help him develop good speech and language skills if he never talks in class. I also worry that he won’t develop the social skills he needs for kindergarten. I hope there’s something we can do.”  Causes of selective mutism Genetics Behavioral inhibition Mowrer’s two-factor 1. interplay of genetics, temperament, and Children with selective mutism are theory of anxiety: early social learning. known to display high behavioral A general theory of anxiety that 2.Family studies indicate heredity as a inhibition and social anxiety, in posits that disorders emerge cause with 9% of fathers, 18% of mothers, general. through classical conditioning and 18% of siblings of children with àThe capacity to inhibit play and and are maintained through selective mutism having displayed the vocalization, to withdraw, and to negative reinforcement. disorder themselves. seek a parent when encountering Children with selective mutism unfamiliar people or situations. learn, over time, that remaining 3.Approximately 50% of parents of 1. According to Jerome Kagan, silent can help lower their children with selective mutism are children with high behavioral arousal and avoid distress. known to display extreme shyness in inhibition experienced arousal and The habitual silence may social situations. distress when presented with novel eventually inhibit speaking and stimuli. social skills. 4.Geneticists have identified an allele for 2.Example: Flailing of arms and legs, Reduces likelihood of breaking a certain gene, CNTNAP2, that accompanied with crying by an the cycle of negative predisposes children toward social infant with high behavioral reinforcement and speaking out. anxiety and greatly increases their inhibition, on being presented with chance of developing selective mutism, a mobile. social anxiety disorder, and similar 3.15% of all infants with heightened problems. behavioral inhibition would withdraw from novel stimuli to cope with such arousal.  Specific Phobias: DSM-5 disorder characterized by: Classification: 1-Animals: snakes, spiders, dogs, or birds. 4- Specific situations: fear of marked fear or anxiety about a specific object or situation; 2-Natural environment: thunderstorms, airplanes, elevators or enclosed height or water. spaces. persists for at least 6 months and causes distress or 3- Blood, injections, and injuries or seeing 5-Other stimuli: fear of choking or impairment. blood. costumed characters.. Diagnostic criteria Prevalence Symptoms: 1.racing heartbeat, shallow breathing, 1. 2% to 9% of children and sweaty palms, dizziness, and other 1.The anticipatory fear or anxiety adolescents suffer from specific phobia, the most common being bodily symptoms. disrupts their daily functioning. from animals. 2. Girls are more likely to experience 2.Younger might cry, throw tantrums, 2.Symptoms cause significant specific phobia than boys. 3. Phobias can last for up to 2 years, freeze or cling to their parents distress in children. causing distress and impairment, if not treated in time. excessively.  Phobias Mary and Man’s Best Friend Mary Valenta was a 6-year-old girl who was referred to our clinic because of her intense fear of dogs. Whenever Mary saw a dog, regardless of its size, Mary’s body would tense, and she would immediately try to run away or cling to her parents. If she was forced to remain near a dog, she would cry, tantrum, and even hyperventilate! Mary’s fear of dogs began 2 years ago when she saw a cocker spaniel bite her older brother. Mrs. Valenta commented, “It seems silly, but Mary’s fear of dogs really has had a negative effect on our family. She can’t play with friends who have dogs as pets; Mary would have a fit. When we visit her grandmother’s house, we have to be extra careful because she has a large black lab. Mary was constantly looking over her shoulder during the entire visit. She can’t relax.” Mary’s phobia became even more salient because her family recently moved next door to a family that owns a Great Dane. Mrs. Valenta reported, “Now, Mary doesn’t even want to go outside to play. We need to do something.”  Diagnostic Criteria for specific Phobia A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging. B. The phobic object or situation almost always provokes immediate fear or anxiety. C. The phobic object or situation is actively avoided or endured with intense fear or anxiety. D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in Agoraphobia); objects or situations related to obsessions (as in Obsessive-Compulsive Disorder); reminders of traumatic events (as in Posttraumatic Stress Disorder); separation from home or attachment figures (as in Separation Anxiety Disorder); or social situations (as in Social Anxiety Disorder). Note: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association. All Rights Reserved.  Causes of specific Phobias Genetics Classical conditioning: Informational transmission and 1. Genes play an insignificant role in the 1. Fear could be acquired by pairing Mowrer’s two-factor theory of development of specific phobia. two stimuli together in time. anxiety: 2.Children may inherit a genetic tendency 2.Little Albert Study 1. Overhearing conversations can also toward anxiety, which may later lead to instill fear in children about objects or a specific phobia. Observational learning: situations. 3.Phobia of blood, injection, and injury 1. Children can also learn to fear Example: Hearing about a dog bite from a may still be attributed to genes. something by observing others friend can instill fear of dogs. respond with fear or avoidance to Phobias develop through classical certain objects, events, or conditioning and are sustained through situations. negative reinforcements. 2.Example: Parents refusing to visit Example: A child bitten by a dog may the doctor to get their flu shot can develop dog phobia and may discover transfer this anxiety to their that avoiding dogs can significantly children. reduce anxiety, thus negatively reinforcing avoiding of dogs to manage anxiety. Example: A child with dog phobia may eventually stop visiting friends who have dogs at home.. Avoidance can also inhibit the development of coping strategies to deal with anxiety.  Social anxiety disorder DSM-5 disorder characterized by: Symptoms of social anxiety disorder: marked fear or anxiety about one or feared situationà immediate anxiety Examples of social anxiety disorder more social situations in which the or panic symptoms. include fear of public speaking, a individual is exposed to possible àany social setting where they might party or social gathering, a scrutiny by others; lasts at least 6 be judged, criticized, or negatively performance in front of other people. months and causes distress or evaluated. impairment. Diagnosis Prevalence and course of the disorder: 1.feeling of distress, embarrassment, or 1.Usually emerges in late About 60% of children with this fear of being called crazy or stupid by childhood or early adolescence. disorder report problems at school. others. 2.Usually not diagnosed before 53% of such children lack friends, 2.Social and emotional functioning are age 10. while 27% experience difficulty in severely impaired. sports and other leisure activities. 3.Social avoidance, less peers interaction can also lead to depression, social isolation, and loneliness and substance use  Diagnostic Criteria for social anxiety disorder A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others). C. The social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. D. The social situations are avoided or endured with intense fear or anxiety. E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. F. The fear, anxiety, or avoidance is persistent, typically lasting 6 months or more. G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as Panic Disorder or Autism Spectrum Disorder. J. If another medical condition (e.g., obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive. Specify if: Performance only: If the fear is restricted to speaking or performing in public. Note: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association. All Rights Reserved.  Selective mutism Social anxiety disorder Erin’s Social Anxiety I’ve been dealing with social anxiety disorder since I was 10 or 11. I struggled all through middle school, crying every day, feeling like I had no friends, wondering why I couldn’t just be normal! Meeting new people without other friends around to make me feel “normal” was extremely difficult. I hated parties, dances, interviews, class presentations, and get-to-know-you type of games. I dreaded any type of social setting. I didn’t ever want to share my writing in my composition class, even though I was friends with just about everyone in the class. I found that I had trouble being creative.... I edited all my ideas as being too “weird” or “stupid.” I worried all the time about how I looked. I also worried about calling my friends or asking them to do things with me. I thought that I might be bothering them. I kept a lot of things to myself and never told anyone what I felt. When they asked me what was wrong, I was sure that they would think that I was ridiculous. Note: Used with permission of the author.  Causes of social anxiety disorder Genetics Behavioral inhibition: Parents-child interaction 1. Twin studies have proved that about 1. High levels of behavioral inhibition 1-Parents of children with social anxiety 50% variance n children’s symptoms of in infants and toddlers can disorder are likely to be suffering from the social anxiety disorder can be attributed contribute to social anxiety disorder themselves (model) to genetics. disorder. 2-Controlling and imposing behaviors 2.The tendency to experience anxiety n 2.Habitual avoidance, sustained 3- Overprotective behaviors social situations and social anxiety through negative reinforcement, 4- Hostile and critical behaviors disorder in particular, can be inherited. and interferes with children’s 5- Avoiding emotionally charged activities at school, after school discussions: and with peers, hinting at social Parents of children with social anxiety tend anxiety disorder. to avoid discussing children’s feelings, contributing to their social anxiety..  Panic Disorder DSM-5 disorder characterized by: Panic attack Symptoms of Panic attack Recurrent, unexpected panic A surge of intense fear or discomfort that 1. Thoughts of losing control or going crazy. 2. Feelings of unreality or detachment. reaches a peak within 10 minutes and is attacks and 1 month of worry 3. 3. Heart palpitations, chest pain or dizziness.. characterized by heightened negative about future attacks or a change affect and physiological arousal; can in behavior because of the occur by itself or in the context of an attacks. anxiety disorder. Diagnosis of panic disorder Young adults and adolescents report Least common symptoms include: Recurrent and unexpected attacks followed by: two most common symptoms: Numbness or tingling sensations and A persistent concern over having another attack. Palpitations or a pounding heart Choking Worrying about the implications of the attack. Dizziness A significant change in daily routines owing to the attacks. A person is only diagnosed with panic disorder if it causes significant distress or impairment. The duration of panic attacks is variable. The median duration is approximately 12.6 minutes. However, average durations range from 23.6 minutes to 45 minutes, depending on the age and gender of the child or adolescent  Diagnostic Criteria for Panic Disorder 1.Recurrent unexpected panic attack. Diagnostic A panic attack is an Criteria abrupt during which time four (or more) of the following symptoms occur: surge of for Separation intense fear or intense Anxiety discomfort that Disorder reaches a peak within ten minutes, and 1.Palpitations, pounding heart, or accelerated heart rate. 2.Sweating. 3.Trembling or shaking. 4.Sensations of shortness of breath or smothering. 5.Feelings of choking. 6.Chest pain or discomfort. 7.Nausea or abdominal distress. 8.Feeling dizzy, unsteady, light-headed, or faint. 9.Chills or heat sensations. 10.Paresthesias (numbness or tingling sensations). 11.Derealization (feelings of unreality) or depersonalization (being detached from oneself). 12.Fear of losing control or “going crazy.” 13.Fear of dying. 2.At least one of the attacks has been followed by one month (or more) of one or both of the following: 1.Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, going crazy”). 2.A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid panic attacks, such as avoidance of exercise or unfamiliar situations). 3.The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders). 4.The disturbance is not better explained by another mental disorder (e.g., panic disorders do not only occur in response to separation from attachment figures as in Separation Anxiety Disorder; in response to circumscribed phobic objects or situations as in Specific Phobia; in response to feared social situations as in Social Anxiety Disorder; or in response to reminders of traumatic events as in Posttraumatic Stress Disorder). Note: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association. All Rights Reserved.  Panic disorder Heart Attack at Age 16 Paul was a 16-year-old boy who was sent to the emergency department of the hospital after two episodes of “heart problems” in 1 week. Paul’s mother told the physician that Paul had experienced symptoms of a heart attack after dinner at home. Specifically, Paul’s heart raced, his breathing became shallow, he experienced dizziness, and his skin became clammy to the touch. “It came out of nowhere,” Paul explained. “I felt like my heart was going to explode in my chest. Then, I got a terrible urge to run away, but I couldn’t. I just froze. I was scared and shaking all over.” The physician at the hospital determined that Paul was medically healthy and showed no signs of heart problems. Dr. Dresser, a pediatric psychologist at the hospital, suggested that Paul had a panic attack. “Do anxiety problems run in your family?” Dr. Dresser asked. Paul’s father admitted to taking medication for both anxiety and depression. Paul worried, “Do you mean that I’m going to have more of these attacks?” Dr. Dresser replied, “That is a possibility. The important thing is that you learn to cope with them if they recur. Do you want to learn some techniques that can help?”  Prevalence and course of panic disorder: 1.Panic disorder is relatively common in adolescents with at least 18% teens having experience a full-blown panic attack. 2.Almost equal prevalence in boys and girls, but may be more severe in girls. 3.Panic disorder, as against panic attacks, is pretty uncommon in adolescents, and almost rare in children. 4.Although panic disorder usually occurs between the ages of 15 to 19, there are also isolated incidents of it occurring before puberty. 5.Adults with panic disorder also increase the risk of their children developing SAD. 6.On the other hand, children with SAD are 3.5 times more likely to develop panic disorder in late childhood or adolescence. 7.Furthermore, children with SAD, and adults with panic disorder may exhibit subtly abnormal respiration that make them more susceptible to panic symptoms. Metacognition: The ability to think about one’s own thoughts and feelings. Younger children who have experienced a panic attack are This might be due to the less at risk to develop panic cognitive immaturity that disorders. It is also known to prevents them from worrying worry less about another one or about recurrent panic. its implications.  Causes of panic disorder Complex causes: Expectancy theory of panic Anxiety sensitivity 1. Cognitive and behavioral models have An explanation for the emergence of panic received the maximum empirical 1. The tendency to perceive anxiety disorder; posits that people are prone to anxiety support from studies involving symptoms as upsetting and about panic attacks because of their heightened sensitivity to anxiety. adolescents. aversive; may explain a person’s Individual with high anxiety sensitivity pay extra 2.These models posit the interaction of likelihood of developing panic attention to symptoms like increased heart rate, biological, cognitive, and behavioral disorder. and shallow breathing, hinting at early signs of factors to produce recurrent panic 2.Most people would feel moderate anxiety. attacks. anxiety before an exam. Personalize negative events: Low anxiety sensitivity helps a They blame themselves when negative things person acknowledge and cope with happenà worsens the anxiety and impairs ability anxiety symptoms, like taking deep to cope. Catastrophic thinking: breaths to calm down. Individuals with heightened anxiety sensitivity High anxiety sensitivity will generate anticipate the worst when in distress. pre-exam anxiety, causing severe It is self-fulfilling and escalates psychological distress and fear response, leading distress. to panic. Anxiety sensitivity, combined with personalizing negative events, and catastrophic thinking can trigger a panic attack.  Agoraphobia 1.A DSM-5 disorder characterized by marked anxiety about places or situations from which escape or help is not possible without considerable effort or embarrassment. 2.For example, a woman might avoid traveling on an airplane because she knows she cannot easily exit the plane in the event of a panic attack. The woman does not have specific phobia (i.e., a fear of flying); instead, she has a fear of places or situations in which escape might be impossible or extremely difficult. Symptoms and effects of agoraphobia: 1.People with agoraphobia tend to avoid public places like shopping malls, movie theatre, stadiums, or any other place where exit is difficult, like airplane or subways. 2.Signs and symptoms include panic attacks, or panic-like symptoms. 3.Agoraphobia leads to avoidance of feared situations. 4.Agoraphobia restricts social and educational functioning in adolescents by limiting their ability to attend school, participate in after-school activities or spend time with friends. 5.Adolescents may also be forced into agoraphobia: An adolescent who is afraid to step out of home, will eventually have to go to school. In such situations, adolescents experience extreme emotional distress and discomfort. In some cases, a parent or a close friend can provide them with reassurance and safety.  Diagnostic Criteria for Agoraphobia A. Marked fear or anxiety about two (or more) of the following five situations: B. Using public transportation (e.g., buses, trains, ships, planes). C. Being in open spaces (e.g., parking lots, marketplaces, bridges). D. Being in enclosed places (e.g., shops, theaters, cinemas). E. Standing in line or being in a crowd. F. Being outside of the home alone. G. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in H. the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms. I. The agoraphobic situations almost always provoke fear or anxiety. J. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. K. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context. L. The fear, anxiety, or avoidance is persistent, typically lasting 6 months or more. M. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. N. If another medical condition is present, the fear, anxiety, or avoidance is clearly excessive. O. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example, the symptoms are not confined to fear of separation (as in Separation Anxiety Disorder); fear of specific objects or situations (as in Specific Phobia); fear of social situations (as in Social Anxiety Disorder); or reminders of traumatic events (as in Posttraumatic Stress Disorder). Note: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association. All Rights Reserved.  Causes of Agoraphobia Genetic and environmental Classical conditioning: factors: 1. An alarming 61% of an individual’s risk of 1. 50% to 75% adolescents with a agoraphobia can be attributed to history of panic disorder can genetic factors. develop agoraphobia. 2.Agoraphobia is also associated with 2.This happens because these families characterized by low warmth, adolescents associate certain high demandingness, and places or situations with a panic overprotection. attack, through classical 3.Parents have high expectations of conditioning. children, but are unable to provide Example: A girl who experiences a necessary support to meet those panic attack at school might want expectations. to avoid going to school altogether. 4.Parents might also compel children to 1. Negative reinforcement sustains believe that the world is full of threats. agoraphobia. 5.Authoritarian parenting style, coupled with genetic risks, increases the probability of agoraphobia in adolescents.  AGORAPHOBIA (WITH PANIC DISORDER) Planning for an Emergency Ryder was a 15-year-old boy who was referred to an anxiety disorders clinic in a large metropolitan area near his home. Several months ago, Ryder experienced a panic attack in the elevator of his apartment building. “My throat started to tighten and I couldn’t breathe. It was terrible,” he recalled. His mother added, “We were both very upset. I immediately took him to the hospital, but all of the tests came up negative.” Ryder experienced his second, unexpected panic attack 1 week later while sitting alone in his bedroom. He reported, “I had the same symptoms, but this time I also felt dizzy and nauseous.” Since then, Ryder has experienced 12 more attacks. “I constantly worry about having more of them,” he said. Recently, Ryder has begun to limit his activities because of the attacks. He refuses to ride in elevators, walking six flights of stairs to his apartment. He also refuses to ride the subway or buses, or go to the movies with friends. “His phone recently broke,” his mother reported. “He’s saved his money to buy a new one in case he needs to call 911. He’s afraid to leave home without it.”  Generalized Anxiety disorder (GAD) DSM-5 disorder characterized by Apprehensive expectation persistent worry, that is difficult Excessive worry about the future. Children and adolescents with GAD to control, and associated with Adults with GAD worry too much worry about things like exams, school restlessness, poor about aspects of daily life, like assignments, and co-curricular concentration, fatigue, completing tasks at work, managing activities. irritability, tension, and/or finances or performing household GAD also causes worry about sleep problems. chores. relationships with friends, family well- being, and daily hassles. Worry as a cognitive activity: 1. Marked by repeated and increasingly elaborated thoughts about negative events in the future and their possible consequences. 2. First signs of worry usually surface between the ages of 4 or 5 3. GAD usually develops with the development of cognitive capacity to dwell on future events between the ages of 8 and 10. 4. With increasing capacity, the frequency and severity of GAD also goes up. 5.Children with or without GAD usually dwell on the same topics of school, sports, relationships, and future goals. 6.Number intensity, and duration of worries differentiate between children with and without GAD: 1. Individuals with GAD report a greater number of worries, 2. GAD-related worries are more intense and distressing, and can cause impairments through 3. daytime restlessness, sleep disorders, fatigue, muscle tension, irritability, and difficulty in concentrating.  Diagnostic Criteria for Generalized Anxiety Disorder A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events and activities (such as work or school performance). B. The individual finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item is required in children. 1. Restlessness or feeling keyed up or on edge. 2. Being easily fatigued. 3. Difficulty concentrating or mind going blank. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance (difficulty falling asleep or staying asleep, or restless unsatisfying sleep). D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The disturbance is not better explained by another mental disorder (e.g., worry about separation from attachment figures as in Separation Anxiety Disorder; worry about negative evaluation as in Social Anxiety Disorder; or worry about having panic attacks as in Panic Disorder). Note: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association. All Rights Reserved.  GAD’s Interference with children’s daily lives: mood problems The distress takes up time and energy. contributor to physical problems headache, irritability insomnia WORRY Fatigue disrupts children’s inhibits the frustration development of more ability to pay attention to parents adaptive coping or completing their strategies. homework. DSM-5 requires the display of at least one symptom of worry in children, and at least 3 in adults.  G GENERALIZED ANXIETY DISORDER Tammie’s Sleepless Nights Tammie was an 11-year-old girl who was referred to the hospital by her parents because of insomnia. Her mother explained, “A few months ago, Tammie started complaining about having problems falling asleep. We’d put her to bed, but she’d lie awake for several hours. Then, she’d wander out of her room and ask for a drink of water. Sometimes, she’s not asleep until 11:30 or midnight, and then she’s exhausted the next day.” Dr. Baldwin reviewed Tammie’s developmental and medical history, her diet, and her habits before bed. However, he couldn’t find any explanation for her sleep problems. Tammie’s father said, “Tammie’s never been a problem. She’s very smart and does extremely well in school. She has a lot of friends. She’s very mature for her age and almost always listens to her mother and me.” Dr. Baldwin interviewed Tammie: “When you’re in bed at night, how do you feel?” Tammie replied, “At first I feel good, because I’m so tired. Then, I sort of tense up and feel nervous. I get tingly in my stomach.” Dr. Baldwin asked, “When you’re in bed, what goes through your mind?” Tammie responded, “I start to think about all the things I need to do the next day for school. I worry about my homework, tests, volleyball... stuff like that. Then, I get more and more nervous and tingly. I just can’t stop. I start to bite my lip or pick at my fingernails until they bleed. When I’ve had enough, I get out of bed.” Dr. Baldwin continued, “Is there anything you can do to make yourself relax and go to sleep?” Tammie responded  Causes of GAD Risk Factors of anxiety disorders Cognitive avoidance theory: Cognitive distortions in children with GAD: Most risk factors of anxiety disorder apply Posits that worry (and GAD) is Catastrophizing cognitive distortions: to GAD as well: maintained through negative Children with GAD expect disastrous Difficult temperament. reinforcement; results from mildly aversive situations. Behavioral inhibition. worrying helps people avoid A girl with GAD might worry about her Less than optimal parent–child emotionally and physically upcoming dance recital, and might interactions. distressing mental images forget her shoes, trip on stage, and end of imminent danger with more up humiliating her family. abstract, analytical thoughts about Overgeneralizing cognitive distortions: future misfortune. Children with GAD may assume that See next slide for example one sole setback is reflective of future misfortunes. A girl who has not fared well in her first. dance recital, might anticipate mistakes in all her upcoming recitals. Personalizing cognitive distortions: Children with GAD often blame themselves for their misfortunes. A girl who trips during her dance recital may attribute it to her own clumsiness rather than a slippery floor. Cognitive avoidance theory- Example To understand how worry can be negatively reinforcing, consider Elsa, a perfectionistic 12-year-old with GAD. Elsa’s teacher has assigned her to work with three classmates on a science project. As a group, the students must complete the project, create a poster, and present their findings at the school science fair. Most children would experience some apprehension when faced with this assignment; however, Elsa shows great distress. She imagines the group failing miserably in their experiment, making countless mistakes on their poster, and humiliating themselves during the presentation. Furthermore, she foresees chastisement and disapproval from her teacher and parents. To cope with these mental images, Elsa thinks about the situation in more abstract, verbal terms—she worries. She thinks to herself, “What if my classmates don’t follow through with their part of the project?” or “I had better double-check our spelling on the poster” or “Maybe I’m not prepared enough for the presentation—I should rehearse one more time.” These worries occupy Elsa’s time and energy, but they also serve an important function: They allow Elsa to avoid imagining the terrible consequences of failing the project. To the extent that worry allows children like Elsa to avoid or escape distressing images, worry can be negatively reinforcing.  Please download and install the Slido app on all computers you use What do we know about OCD? ⓘ Start presenting to display the poll results on this slide.  Obsessive-Compulsive Disorder - OCD DSM-5 disorder characterized by: Obsessions and/or Recurrent and persistent thoughts, Thoughts about contamination like compulsions that are time urges, or images that are touching dirty objects, fear of germs consuming and cause experienced as intrusive and Recurrent doubts like wondering if unwanted. significant distress or someone left the door open. impairment. Need for order or symmetry like Fear of losing control over one's behavior. arranging clothes by color. Most people with OCD tend to Fear of forgetting, losing, or misplacing Aggressive or horrific impulses like ignore or suppress their something. hitting, stabbing family members. obsessions, leading to anxiety, tension, or distress. Sexual imagery.  Obsessive-Compulsive Disorder - OCD Compulsions: Common compulsions can Checking doors over and over Repetitive behaviors or mental include washing, cleaning, again to make sure they're acts that an individual feel counting, checking, repeating, locked. driven to perform in response arranging, and ordering. Checking the stove over and to an obsession or according Performed in rigid manners over again to make sure it's off. to specific, inflexible rules. Symptoms of OCD 1.Many adults and adolescents 3.DSM-5 requires specification with OCD might deem the of an individual’s insights into Counting in certain patterns. unwanted thoughts or urges her OC symptoms. to be just products of their 4.People with good insight Silently repeating a prayer, own minds and unlikely to may be more motivated and word or phrase. come true. inclined to participate in 2.Younger children with OCD treatment. are almost convinced of their obsessions coming true.  Diagnostic Criteria for Obsessive–Compulsive Disorder A- The presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2): Diagnostic Criteria for Separation Anxiety Disorder 1-Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. 2- 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). Compulsions are defined by (1) and (2): 1- Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2-The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts. B- The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C- The obsessive–compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. D- The disturbance is not better explained by the symptoms of another mental disorder (e.g., repetitive patterns of behavior as in Autism Spectrum Disorder; impulses as in Conduct Disorder; preoccupation with substances as in Substance Use Disorders; excessive worries as in Generalized Anxiety Disorder; hair pulling as in Trichotillomania; skin picking as in Excoriation Disorder1; or guilty ruminations as in Major Depressive Disorder). Specify if: With good or fair insight: The individual recognizes that obsessive–compulsive disorder beliefs are definitely or probably not true or that they may or may not be true. With poor insight: The individual thinks that obsessive–compulsive disorder beliefs are probably true. With absent insight: The individual is completely convinced that obsessive–compulsive disorder beliefs are true. Specify if: Tic-related: The individual has a current or past history of a Tic Disorder. Note: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association. All Rights Reserved.  OCD Prevalence of OCD: 1.About 1% to 2% of children and adolescents suffer from OCD. 2.According to epidemiological studies, at any given time, almost 90% of children with OCD do not undergo treatment. 3.OCD is more common in boys than girls in childhood, with a gender ratio of 2:1. 4.By adolescence this ratio almost becomes equal. OCD in children and adults: 1.Obsessions and compulsion vary between children and adults. 2.Children may change obsessions or compulsions over time. 3.Children’s obsessions and compulsions are often vague, magical or even superstitious 4.Children may have difficulty describing their obsession  Kids Obsessions-examples Imagining loved ones getting hurt Worrying about dirt, germs or infection – for example, feeling scared about getting sick from touching dirty surfaces Feeling that something terrible will happen if things aren’t done a certain way – for example, if books aren’t in the right order. Kids compulsions and rituals - examples Touch, tap, or step in unusual ways Arrange things over and over Repeat words, phrases, or questions Have many doubts, and trouble making choices Wash or clean more than needed Take a long time to do things — like get dressed, shower, eat, do homework https://www.youtube.com/watch?v=3lvbcShuz14 Until 1min.13  OCD Diagnosis of OCD: 1.Individuals can be diagnosed with OCD if they show either obsession or compulsion. 2.Most children demonstrate both features of OCD. 3.Some children only display obsessions while their compulsions involve mental rituals like counting or praying to prevent harm befalling a loved one. 4.Mental rituals may easily be overlooked and lead to the conclusion that no compulsions exist. Effects of OCD: 1.Childhood OCD is a serious disorder than can persist over time. 2.40% youth also show a marked reduction in symptoms in late adolescence or early adulthood. 3.Youths that are most likely to show persistent OCD symptoms include: 1.Youths with early symptom onset. 2.Youths with longer duration of symptoms. 3.Youths with symptoms that require hospitalization. 4.Youth OCD increases the risk of relationship, employment, and emotional problems in young adults.  OCD- case study Doing Things “Just Right” Tony Jeffries was a 12-year-old boy who was referred to our clinic by his mother after she noticed him repeatedly engaging in “strange rituals” around the house. Mrs. Jeffries first became aware of Tony’s behavior when she noticed his persistent habit of turning lights on and off multiple times before entering or leaving a room. When she asked about this habit, Tony seemed embarrassed and dismissed it as “nothing.” Mrs. Jeffries subsequently noticed other rituals. Tony avoided cracks in sidewalks, opened and closed doors several times, and entered and exited rooms multiple times before finally leaving. When Mrs. Jeffries confronted Tony, he admitted to performing these compulsions. Later, Tony’s therapist tried to gather information about possible obsessions. She asked, “Do any thoughts pop into your mind before you perform these acts?” Tony replied hesitantly, “Yeah, but they’re hard to describe. I feel tense. I feel like something bad is going to happen to me or to my mom... like maybe I’ll get an F in school or my mom will lose her job. Then, I just feel like I need to do something in a certain way, like turn the lights on and off three times, or open and close a door three times, or enter and exit a room three times.” His therapist asked, “Always in threes?” Tony explained, “Yeah, it has to be in threes and just right so that I don’t feel bad.”  Causes of OCD Heredity: Cortico-basal-ganglionic Learning: circuit: 1. Individuals with first-degree relatives A neural pathway that underlies OCD; 1. OCD is probably sustained through with OCD are at a higher risk of consisting of (1) orbitofrontal cortex, (2) learning. developing OCD themselves. cingulate gyrus, and (3) caudate: a 2.People might develop obsessions feedback loop. when they start associating specific 2.10% to 25% youths with OCD have at When a person notice dirt on her hands environmental stimuli with distressing the cortex is activated that sends signal least one parent affected by the thoughts and beliefs. to the cingulate gyrus: OBSESSIONS BEGIN disorder. àA portion of the limbic system associated with cognitive An individual who believes that 3.Other shared environmental factors like contemplation, and feelings of anxiety, touching door knobs can cause parenting style or socio-economic apprehension, or tension –”the dirt is contamination, will associate washing status contribute very little to OCD. bothering me” with reduction of contamination Normally the caudate would regulate worries. most of the distress by inhibiting Compulsions are negatively reinforced information from the orbitofrontal cortex by the reduction of distress. and cingulate gyrus àa behavioral response to reduce these negative thoughts and feelings “wash your hands” In people with OCD, there is over activity in the cingulate and lack of inhibition from the caudate, resulting in high levels of distress on noticing abnormalities in the surrounding.  Causes of OCD Cognitive distortions: Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus 1-Individuals with OCD experience inflated responsibility (PANDAS) theory for misfortune. If a parent loses her job, the adolescent might blame posits that streptococcus infection leads to an herself for this bad luck. autoimmune reaction that causes OCD-like àcan also lead to feelings of guilt and self-doubt. symptoms, tics, and irritability. These children may also exhibit other symptoms like 2-Individuals with OCD can also display thought-action irritability, anxiety, and low fine motor skills like fusion. handwriting. This makes them wrongly believe that simply thinking of a misfortune will increase its probability of occurrence. Caused by an autoimmune reaction that disrupts A child with OCD might believe that thinking about her brain functioning. grandfather’s death might lead him to fall sick. A teenage girl may worry that if she has a thought of a home invasion happening to her family, then the break-in will undoubtedly occur. Because of these thoughts, the child might attempt to control negative thoughts to prevent future misfortunes. Case Study: Sibling Rivalry Isabella Hague was an 11-year-old girl referred to an outpatient mental health clinic by her mother because of “a curious preoccupation about harming her infant brother.” Isabella’s immediate family consisted of herself, her father and mother, and her 12-month-old baby brother, Manuel. Isabella’s mother, a sales executive, and her father, were thrilled when Isabella was born. The couple had difficulty conceiving a child. Although they thought Isabella would be their only child, Mrs. Hague was surprised to learn that she was pregnant with Manuel last year. Mrs. Hague reduced her work hours to stay at home with Manuel and the family soon adjusted to being a group of four. Or so it seemed. Approximately 3 months after Manuel’s birth, Mrs. Hague noticed Isabella’s mood change. The formerly cheerful girl who loved to spend time with her parents became irritable and reclusive. “Isabella would often snap at us for no reason,” described her mother. “She’d seldom smile and was often crabby or disrespectful. We knew something was different about her. She’d also spend a lot of time by herself, usually in her room or in her tree house in the backyard.” Mr. Hague added, “We figured that Isabella was having a bad case of sibling rivalry. For 11 years, she was our only child—our baby. Now she has to share attention with Manny. And, to be honest, Manny demands a lot of attention. We tried to make sure that Isabella didn’t feel neglected, so we’d take her on special outings, like to the movies or to dinner—you know, one-on-one.” On one such outing, Mrs. Hague discovered the source of Isabella’s change in mood. While they were eating frozen custard, Mrs. Hague raised the possibility that Isabella might be jealous of Manny. Isabella burst into tears. After a long while, Isabella admitted that she often had “strange thoughts” about hurting Manny. Once, while watching Manny in his crib, Isabella thought about how easy it would be to smother him with a blanket or pillow. Another time, when her mother was bathing Manny, Isabella imagined drowning him in the tub. Such thoughts began shortly after his birth and gradually increased in frequency and severity. The psychologist at the clinic questioned Isabella about her strange thoughts. Isabella explained, “I love Manny so much. I’ve always wanted a baby brother or sister. I’d never do anything to hurt him. I feel so guilty!” “Guilty?” the psychologist asked. “Like maybe I might actually do something that could hurt him,” Isabella explained. “I know I never will but I still think about it.” She paused and then added, “Like maybe if I think about it, it might actually come true.” The psychologist asked, “So if you don’t act upon these thoughts, how do you get rid of them?” Isabella responded hesitantly, “I pray. I ask God to get rid of these bad thoughts and to help me love my brother. I know I shouldn’t have these thoughts, but I do, so I pray to get rid of them.” “Do you say specific prayers?” asked the psychologist. “At first I would say three Our Fathers,” said Isabella. “That helped a lot. Then I started adding other prayers to get the thoughts out of my mind and to make me feel better. This all took a lot of time and if I messed up, I’d think, ‘I need to start over and get it right’ otherwise it wouldn’t work.” “You mean, if you didn’t say the prayers right, it wouldn’t help you get rid of the bad thoughts?” asked the psychologist. “Yes,” responded Isabella. “Or it wouldn’t stop bad things from happening to Manny. Sometimes, I would spend a lot of time praying, getting it right until I felt like everything was okay. I wish there was some way I could stop.” Describe how Isabella meets diagnostic criteria for OCD How might you characterize Isabella’s insight regarding her problem? What might be causing her OCD? Describe how Isabella meets diagnostic criteria for OCD A.Isabella experiences obsessions and compulsions, although only one is required for the DSM-5 diagnosis of OCD. Obsessions: Recurrent thoughts about harming Manuel which are unwanted and cause distress. These thoughts are suppressed and neutralized by compulsions Compulsions: Repetitive mental acts (i.e., praying) that Isabella feels driven to perform according to certain rules in response to her unwanted thoughts about harming Manuel. The mental acts reduce guilt and appear excessive. A.The obsessions cause clinically significant distress and impair Isabella’s emotional functioning and interactions with her parents (e.g., increased irritability and reclusive behavior). B.Symptoms are not attributable to a substance. C.Symptoms are not better explained by another psychiatric disorder. How might you characterize Isabella’s insight regarding her problem? Isabella’s insight would likely be described as “good or fair” according to the DSM-5 classification system. She reports that she loves her brother and does not wish him harm. She also feels guilty about having thoughts about killing him. On the other hand, Isabella worries that simply having ill thoughts about her brother might somehow magically cause harm to him. This belief is called “thought-action fusion” and is sometimes reported by people with OCD.