Anxiety and OCD - developmental psychopathology

1. CHILDHOOD ANXIETY
DISORDERS

2. ANXIETY
•Anxiety: mood state characterized by
strong, negative emotion and bodily
symptoms in which an individual
apprehensively anticipates future danger
or misfortune
•Fear: immediate alarm reaction to
current danger
•Anxiety disorder: excessiveand
debilitating anxiety with negative
emotion and fear

3. DEVELOPMENTAL
CONSIDERATIONS
•DSM-5 qualifiers for children
•Anxiety may be expressed by crying, tantrums,
freezing, or clinging
•Unlike adults, children are not required to
acknowledge that fears are unreasonable or
excessive
•Difficulties in recognizing symptoms
•Internalizing symptoms less observable
•Internalizing symptoms less aversive
•Children may lack verbal skills to communicate
concerns

4. ANXIETY: 3 INTERRELATED
SYSTEMS
•Cognitive
•Anxious thoughts develop in response to cognitive
distortions in the attention, interpretation, and
memory components of information processing
•Physical
•Brain sends messages to sympathetic nervous
system: fight or flight response
•Symptoms are excessive in intensity or duration
•Behavioral
•Action (or inaction) that individuals take to
prevent exposure to feared stimuli or to reduce
anxiety associated with exposure to the feared
stimuli

5. OBSESSIVE-COMPULSIVE DISORDER
DSM CRITERIA
DSM 5Criteria
A.Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
1.Recurrent and persistent thoughts, impulses, or
images that are experienced, at some time during
the disturbance, as intrusive and inappropriate
and that cause marked anxiety or distress
2.The thoughts, impulses, or images are not simply
excessive worries about real-life problems
3.The person attempts to ignore or suppress such
thoughts, impulses, or images, or to neutralize
them with some other thought or action
4.The person recognizes that the obsessional
thoughts, impulses, or images are a product of his
or her own mind (not imposed from without as in
thought insertion)

6. OBSESSIVE-COMPULSIVE
DISORDER
DSM CRITERIA
Compulsionsas 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 person 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 distress or
preventing some dreaded event or situation;
however, these behaviors or mental acts
either are not connected in a realistic way
with what they are designed to neutralize or
prevent or are clearly excessive

7. OBSESSIVE-COMPULSIVE
DISORDER
DSM CRITERIA
B.At some point during the course of the
disorder, the person has recognized that the
obsessions or compulsions are excessive or
unreasonable. Note: This does not apply to
children.
C.The obsessions or compulsions cause marked
distress, are time consuming (take more than 1
hour a day), or significantly interfere with
the person’s normal routine, occupational (or
academic) functioning, or usual social
activities or relationships.
D.If another Axis I disorder is present, the
content of the obsessions or compulsions is
not restricted to it.
E.The disturbance is not due to the direct
physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general
medical condition

8. COMMON OBSESSIONS AND
COMPULSIONS
•Obsessions
•Contamination
•Harm to self or others
•Need for symmetry/order
•Religious or moral
concerns
•Sexual or aggressive
•Lucky or unlucky
numbers
•Compulsions
•Cleaning
•Checking, counting,
repeating
•Ordering, straightening
•Praying, confessing,
reassurance seeking
•Touching, tapping, or
rubbing
•Hoarding

9. OCD: PREVALENCE AND
COURSE
•Prevalence
•1-4% of children and adolescents
•Ratio of boys to girls is 2:1 in
childhood; equalizes in adolescence
•80% of all cases have childhood onset
•Course
•Age of onset
•Males 6 -15 years (peak 10); Females 20 -29 years
•Onset typically gradual, some acute
•Chronic waxing and waning of symptoms
•Stress exacerbates symptoms
•Estimated that 15% display progressive
deterioration in social & occupational
functioning

10. ASSOCIATED
CHARACTERISTICS OF
ANXIETY DISORDERS
•Cognitive disturbances
•Interference with academic performance
•Attentional biases (toward threat)
•Cognitive biases (negative spin on ambiguous situations)
•Physical symptoms
•Sleep
•Aches/pains
•Social and emotional deficits
•Interference
•Low self-esteem
•Loneliness

11. ETIOLOGY
•Anxiety arises from a complex interaction of
specific characteristics related to the child
(e.g., biological, psychological, and genetic
factors) and his or her environment (e.g.,
conditioning, observational learning, family
relations, traumatic events)
•Focus on four most recognized models
•Biological
•Behavioral
•Cognitive
•Ecological

12. ETIOLOGY
•Biological
•Genetic Influences
•Biological vulnerability to inherit a fearful
disposition
•Genetic influences account for 1/3 of variance
•Neurobiological factors
•Within the limbic system, the behavioral
inhibition system is overactive
•Increased tendency to become over-reactive
and withdraw in response to novel stimulation
•Irritable, shy, cautious, and quiet
temperament

13. ETIOLOGY
•Biology, continued
•Neurochemical factors
•Abnormal function of serotonin,
norepinephrine, dopamine, and GABA

14. ETIOLOGY
•Behavioral
•Mowrer’s Two Stage Model of Conditioning
•Acquisition of fear through classical conditioning
•An individual associates a threatening stimulus with
a nonthreatening stimulus, so that the latter by
itself triggers anxiety
•Maintenance of fear through operant conditioning
•Negative reinforcement is manifested by avoidance
and/or escape learning
•Consequently, without opportunities for new learning
provided by exposure, the fear/anxiety does not
extinguish

15. ETIOLOGY
•Behavioral, continued
•Observational learning
•Children learn about anxiety-provoking
situations by
•observing others experience such
situations or
•by acquiring information through
activities like reading or watching the
news on television

16. ETIOLOGY
•Cognitive
•Attentional biases toward threat-related information
•Selectively attend to information that may be potentially
threatening
•Distorted judgments of risk
•Negative spin on ambiguous/non-threatening situations
•Lead them to select avoidant solutions
•Selective memory processing
•Tendency to remember anxiety-provoking cues/experiences
•Perfectionistic beliefs
•Inflated sense of responsibility

17. ETIOLOGY
•Ecological
•Bidirectional relationships among child,
family, and other environmental
contributions to anxiety
•Child temperamental characteristics
(i.e., behavioral inhibition) X insecure
parent-child attachment X anxious and
controlling parenting styles
•Parental modeling of fear responses
•Community violence

18. ASSESSMENT
•Diagnostic Interviews
•Anxiety Disorders Interview Schedule for
DSM-5
•Schedule for Affective Disorders and
Schizophrenia for School-Age Children
•Clinician-administered
•Comprehensive
•Time-consuming and labor-intensive

19. ASSESSMENT
•Rating Scales
•Screen for Child Anxiety Related Emotional
Disorders -Revised (SCARED)
•Multidimensional Anxiety Scale for Children
•Fear Survey Schedule for Children –Revised
•Also, disorder-specific measures
•Quick and easy to administer
•Standardized with good psychometric properties
•Can be used as screening devices *not to
diagnose

20. ASSESSMENT
•Observation
•Social-evaluative tasks (e.g., classroom
presentation)
•Behavioral avoidance to phobic stimulus
•Parent-child interaction
•Self-monitoring procedures
•Quantify and describe symptoms

21. TREATMENT
•Behavioral and Cognitive-Behavioral
Treatments have received most empirical
support
•Pharmacotherapy has recently received
promising support
•Selective Serotonin Reuptake Inhibitors
(SSRIs)
•Psychodynamic and Family therapies have
not received much empirical support

22. TREATMENT
•Treatments should target the 3 interrelated
symptoms
•Physical symptoms
•Rapid heart beat
•Muscle tension
•Insomnia
•Cognitive symptoms
•Distorted perceptions of threat
•Behavioral symptoms
•Avoidance
•Escape

23. BEHAVIORAL THERAPY
•Exposure Therapy
•Systematic Desensitization
•Relaxation Exercises
•Contingency Management Strategies
•Modeling

24. EXPOSURE WITH RESPONSE
PREVENTION
•Obsessive-compulsive disorder
•In addition to exposures, the child is asked
to refrain from engaging in compulsive rituals
•Example
•Touches floor of public bathroom (exposure)
•Does not engage in handwashing (response
prevention)
•Proposed therapeutic mechanism of exposure
•Break the conditioned fear response
•Consequently, acquire new, less threatening
(and more adaptive), fear representations

25. SYSTEMATIC
DESENSITIZATION
•3 Steps
•Teach child to relax
•Construct fear hierarchy
•Present anxiety-provoking stimuli
sequentially as child remains relaxed
•Proposed therapeutic mechanism
•Break the conditioned fear response,
because relaxation is incompatible with
fear response

26. RELAXATION
•Deep breathing
•Imagery
•Progressive Muscle Relaxation
•Proposed therapeutic mechanism
•Increased control over sympathetic nervous
system
•Decreased physiological symptoms

27. MODELING
•Filmed modeling
•Live modeling
•Participant modeling

28. COGNITIVE-BEHAVIORAL
THERAPY
•In addition to behavioral strategies…
•Teaches children to understand how
thoughts contribute to anxiety
•And how to modify distorted thoughts to
decrease symptoms
THOUGHTSBEHAVIOR
FEELINGS

29. COPING CAT: CBT FOR
ANXIETY
•Developed by Phil Kendall at Temple
University
•It is based on basic Cognitive Behavioral
Principles
•Treatment typically takes place across 16
sessions where the child is taught:
•how to recognize their physical reactions and
anxious feelings when confronted with anxiety
related stimuli
•to become aware of anxiety-related cognitions
•to develop a coping plan for dealing with anxiety
that involves positive self statements and problem
solving skills

30. COPING CAT
•The child is also taught to evaluate
their coping responses and apply self-
reinforcement for adaptive coping
behaviors
•Children are encouraged to engage in
both imaginal and in vivo exposure to
anxiety related stimuli, while using
the skills they have been taught
•In-session and out-of-session
activities are used to give children
opportunities to use skills
•Therapists also reinforce the
successful use of coping skills