Chapter 7

Anxiety, Posttraumatic Stress, and Obsessive-Compulsive Disorders

Defining Fear and Anxiety

• Problems of anxious children much less obvious, more difficult to assess– Fear – strong emotional alarm reaction to real

or perceived danger. Sympathetic nervous system stimulates flight or fight response

– Panic – sudden overwhelming state of extreme terror or fear

– Anxiety – persistent concern about danger in the future

Children’s Common Fears

• 0-12 months – loss of support, loud unexpected, looming objects, strangers

• 12-24 months – separation from parent, strangers, injury

• 24-36 months – separation from parents, animals, darkness

• 3-6 years separation from parents, strangers, animals, darkness, injury

• 6-10 years – darkness, injury, being alone, imaginary beings

• 10-12 years – injury, social evaluations, school failure, ridicule, thunderstorms, death

• 12-18 years – school failure, peer rejection, family problems, wars, future plans

Sources of fears

• Physical and cognitive limitations

• Observing other people’s fearful reactions

• Adult’s warnings about potential threats

Phobias

• DSM-IV-TR recognizes that children’s phobic symptoms differ from those of adults

• Criteria for assessment includes age, duration, intensity, and type of fear

Separation Anxiety Disorder

• When a child grows less rather than more tolerant of separations from one or both parents

• One of most common childhood problems– Show excessive age-inappropriate worries

about separation– School refusal can be a form (DSM-IV)

although some classify as separate

Generalized Anxiety Disorder

• Uncontrollable, excessive anxiety and worry, occurring consistently for 6 months, extending to many events and activities

• Child shows one of following in extreme form:– Irritability

– Restlessness

– Fatigue

– Difficulty in concentrating

– Muscle tension or sleep disturbance

• Child may be insecure, perfectionist (resembles OCD)

• Accompanied by depression

• Widespread anxiety in many different situations

Posttraumatic Stress Disorder

• Experienced by people who have experienced an extremely devastating event

• Persistent and unwilling re-experiencing of traumatic event, persistent attempts to avoid all thoughts and acts related to the event, and a high state of arousal

• Children can develop PTSD even if not directly physically threatened

• Children who lose a parent at particular risk

• Important gender and developmental differences in how people react to catastrophic events– Girls 5 times more likely than boys

Symptoms

• May develop immediately or months/years after event

• Disorganized, agitated behavior• Persistent mental experiencing of event followed

by long periods of avoidance and emotional numbing

• Avoidance of anything associated with event• Exaggerated startle responses, hyper alertness

Treatment

• Limited research suggests immediate relief comes from support of teachers and classmates

• Parents and teachers need to convey sense of calm and control

• Cognitive-behavioral therapy

• Family/group treatment

Diagnosis

• Difficult to diagnose– Overlap of symptoms of anxiety, mood and

other internalizing disorders– Depends heavily on self-reported anxiety, fear

or depression, difficult for young children

Social Anxiety Disorder, or Social Phobia

• Average onset is 15 years

• Marked by extreme self-consciousness and incapacitating anxiety in social situations

• Occurs twice as often in women as men, but men are more likely to seek help

• Complaining about pervasive fear of being observed, judged negatively

• Constant concern about inadvertently doing things that are humiliating

• Worry far in advance of social situations• Peaks at informal gatherings rather than at

formal situations or presentations, which are highly scripted

Vicious Cycle

• Social phobic children are less socially skillful

• Draw negative reactions from peers

• Undermines self-confidence, leading to further social failures

School-Related Avoidance Disorders

• Not in DSM-IV as separate disorder, but as symptom of separation anxiety

• Persistent avoidance of school motivated by intense fear and anxiety

• Can stem from specific phobia

• Can indicate generalized anxiety or separation anxiety

• Perfectionists displaying excessive concerns about academic performance

• Can arise from modeling of anxious, overprotective parents, anxiety disorder or specific phobia

Two Types of Refusal

• Mild acute school refusal– Affects younger children, little or no family

discord, sudden onset– Rapid return to school is most used treatment

• Severe chronic school refusal– Typical in children over 11 from unstable

families– Parents may be overcontrolling

Management of School Refusal

• Mild form best treated by parents’ firm, supportive insistence that the child gradually return to school

• Severe form often accompanied by other disorders and requires professional intervention– Complexity requires assessment and therapy

tailored to individual child

Etiology of Anxiety Disorders

Psychodymanic Theory

• Freud – psychologically created tension, anxiety, guilt, sexual jealousy

• Present day theory loosely based on psychoanalysis, but emphasizes importance of social rather than sexual interactions– Phobic person wants to be center of attention– Child develops specific phobia or anxiety as a

way of expressing an unacceptable desire

Social Learning and Cognitive Approaches

• Research based and emphasizes role of modeling in development of fears

• Bandura’s Self-efficacy theory: – People don’t develop fears so much from fright

paired with sight of feared object as from anxiety that they cannot successfully avoid feared object and protect themselves

– Lack of self-confidence leads to dwelling on possibility of losing control

• Children don’t necessarily fear things that can harm them (automobiles, drowning)

• Parents need to teach children realistic fears and help them overcome unrealistic ones

Biological Contributors

• Hints in recent research suggests that there may be complex multiple gene contributions to anxiety and panic disorders

• Children of mothers, but not fathers, who have a lifetime history of anxiety disorder are doubly at risk

• Research suggests that stable differences in brain activity may characterize certain children as susceptible to anxiety disorders

Prognosis for Children with Phobias and Anxiety Disorders

• Most early phobias are quickly and effectively treated by

• Prognosis is worse for those with severe anxiety disorders – When they persist only 20% are eventually

overcome– Fear of physical illness and social anxiety

disorder tend to persist throughout life

Psychological Interventions

• Psychodynamic Therapies– Child encouraged to act out fears and fantasies

in therapy sessions– Analyst interprets meaning of fantasies– Childs troubling unconscious feelings

transferred from parent to analyst– Phobic reactions disappear without specific

intervention when psychological conflicts have been resolved

• Critique:– Expensive and time consuming – Some aspects have become incorporated into

mainstream of child psychotherapy

Desensitization Therapy

• Takes place in gradual steps• Focus on child’s learning to relax in stress-

inducing circumstances by going through fear hierarchies from mild to most severe

• Relaxation used to counteract the muscular tension of anxiety

• Drawback: doesn’t teach child to deal with what they fear, so needs to be coupled with other treatments

Modeling and Guided Participation

• Effective in treating children's specific phobias especially when limited to a particular situation– Modeling: Child’s confidence built by watching

someone else deal with feared stimulus– Guided Participation: Carefully supervised

confrontations with feared stimulus in natural environment

Cognitive-Behavioral Treatments

• Multifaceted cognitive-behavioral treatment very effective, and rigorously tested. Techniques include– Modifying anxious self-talk– Teaching problem solving and behavioral

strategies

Obsessive-Compulsive Disorder

• Common rituals or routines reassure young children and provide sense of security

• Pathological obsessive-compulsive behavior consists of attempts to reduce severe anxiety and involves unusual activities – Hand washing– Bathing– Scrubbing already spotless surroundings

Compulsive Children

• Compulsions can develop without obsessions

• Rituals involving washing, repeatedly arranging objects, or checking on location of certain objects over and over

• Compulsive children may develop phobias, depression, and neurological conditions

Obsession

• Obsessions usually accompany other problems (phobias, depression)

• Likely to persist through life

DSM-IV-TR diagnostic criteria

• Obsessions and compulsions are senseless repeated thoughts, images, or impulses (obsessions) or repetitive acts (compulsions) that are:– Unrealistic and dysfunctional– Experienced as unwelcome but irresistible– Experienced as products of one’s own mind rather than

external threats– Ritualistic and stereotyped– Time-consuming – Disruptive of everyday activities

Typical features for youngsters

• Obsessive themes – contamination, aggression, maintaining ultra strict order, fear that family members might be killed

• Compulsions – checking under bed constantly, wipe possessions repeatedly, tapping. Most engage in rituals at home and try to hide them

Treatment of Obsessive-Compulsive Disorder

• Cognitive-Behavioral therapy – most recommended treatment, alone or combined with an SSRI – Contact with anxiety-provoking event followed

by guided, prolonged exposure to feared stimulus, or

– Sudden exposure to feared stimulus. To demonstrate that compulsive behavior is not necessary

Drug Treatment

• Fluvoxamine – well tolerated and acts rapidly in short term

• Long-term effects unknown