Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5541_Библиотеки_им_академика_М_И_Перельмана.pdf
194 Chapter 11 Anxiety Disorders, Obsessive-Compulsive Disorder, and Somatic Symptom Disorders
Figure 11.1 The construct of distress tolerance and its
dimensions
Distress Tolerance
Construct
Tolerance of
Uncertainty
Source: Zvolensky et al., (2010). Distress tolerance: Theory, measurement, and relations to
psychopathology.
Tolerance of
Ambiguity
Tolerance of
Frustration
themselves in risky or unsafe situations. So, in line with
the fundamentally adaptive function of emotion, we are
looking for a healthy balance in the amounts of anxiety
experienced and in the situations in which anxiety is elicited
and supports adaptation.
With this background information, we can better
understand the fears and worries that are part of almost
every child’s life. Fears and worries range from the relatively
minor, such as getting poor grades, being sent to the
principal, and having parents argue; to the more troubling,
such as falling from high places or unease in public spaces;
to the truly awful and dangerous, such as being hit by a
car, getting burned in a fire, dying or seeing dead people,
and being bombed or attacked (Ollendick et al., 2014).
Although discussions of anxiety do not always differentiate
between fears and worries, the distinction provides clarity.
Fears are defined as anxieties elicited in the presence of a
specific stimulus. Worries are defined as anxieties about
possible future events.
Many children exhibit social fears (such as meeting
new people or speaking in class) and/or specific fears
(involving animals, the dark, or heights) as part of
typical development (Lieberman, 1993; Ollendick et
al., 2014). These types of fears may be relatively mild or
more extreme. Both age-related challenges and individual
differences influence the number and nature of children’s
fears. Cognitive development is perhaps the most relevant
age-related factor. Children’s increasing abilities to
make distinctions between fantasy and reality and to
recognize, understand, and control danger are noteworthy
achievements. Temperament, shyness, and behavioral
inhibition are individual factors influencing the number
and strength of fears. Sex/gender also plays a role, with
girls exhibiting more fears than boys (Husky et al., 2021;
Ollendick et al., 2014).
Tolerance of
Negative
Emotion
Tolerance of
Physical
Discomfort
In contrast to fears, worries involve somewhat more
vague concerns about possible threats, unwanted events,
or unacceptable outcomes. Across childhood and
adolescence, common worries are focused on health,
school, relationships, and possible harm (Gibbs &
Kenealey, 2022; Gonclaves & Byrnes, 2013). Worries
often go beyond personal concerns. Youth increasingly
report worrying about racism and discrimination,
economic concerns, climate change, and the COVID-19
pandemic (Mistry & Elenbaas, 2021; Nair et al., 2022;
Sáez-Clarke et al., 2022; Sciberras & Fernando, 2021).
As with fears, age-related challenges and individual
differences are important. Girls, again, worry more than
boys. Negative cognitive biases and executive function
difficulties are associated with increased worries (Caes et
al., 2016; Songco et al., 2020).
For most children and adolescents, fears and worries are
distressing. Now and then, they may make relationships,
activities, and routines more difficult. In general, most
fears and worries are short-lived or manageable. Although
there is significant variability in individual pathways, fears
and worries typically decline across development (Husky
et al., 2021; Kertz et al., 2019). Individual coping efforts,
support from others, and time itself eventually lead to good
adaptations. For some youth, however, fears and worries are
more problematic, signaling an anxiety disorder that is both
painful and disabling. These children and adolescents are
the focus of the rest of this chapter.
Anxiety Disorders
Anxiety disorders are among the most frequently diagnosed
psychopathologies in children, adolescents, and adults.
Along with high rates of anxiety and impairment are
relatively low rates of treatment (Creswell et al., 2020;
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Cohen/Ostrow/Getty Images
Occasional anxiety and distress are typical responses to
novelty and new situations for most children.
Georgiades et al., 2018; Vasey et al., 2014). Anxiety
disorders are internalizing disorders in which anxiety
has gone from typical or adaptive to pathological in
terms of its intensity, duration, and/or pervasiveness. All
of the anxiety disorders are characterized by inhibition
and withdrawal, exaggerated and unrealistic fears and
worries, overcontrolled behavior, and somatic symptoms.
Avoidant behavior, generally viewed as a maladaptive
response to fear and anxiety, is also a key component of
these disorders (Hofmann et al., 2018). Although there is
underlying similarity across many of the anxiety disorders,
there are distinctive perceptions, thoughts, emotions,
levels of arousal, behaviors, somatic symptoms, and social
difficulties that are associated with particular types of
anxiety disorders (refer to Table 11.1).
In addition to the primary symptoms of anxiety, many
children and adolescents exhibit anxiety sensitivity,
involving hypervigilance and attention to bodily sensations,
a tendency to focus on weak or infrequent sensations, and a
predisposition to react to somatic sensations with distorted
cognitions (Weems et al., 2010). Anxiety sensitivity interacts
with distress tolerance. High levels of anxiety sensitivity
may decrease individuals’ capacities to tolerate distressing
experiences. Developmental and sociocultural factors are
important influences on individual differences in anxiety
sensitivity (Weems, 2011; Weems et al., 2021).
Epidemiological studies of anxiety disorders in children
and adolescents estimate overall prevalence rates between
6%–12% (Collishaw, 2015; Polanczyk et al., 2015; Sequeira
et al., 2020). In both childhood and adolescence (and into
adulthood), girls are diagnosed with anxiety disorders more
frequently than boys. Prevalence and clinical presentation
appear to be mostly similar for youth from varied racial and
ethnic backgrounds (Gordon-Hollingsworth et al., 2015;
Sequeira et al., 2020). Higher prevalence rates are observed
in LGBTQ+ and nonbinary youth (Childs et al., 2021;
Connolly et al., 2016).
Anxiety Disorders 195
Between 40% and 60% of children and adolescents
with one anxiety disorder also meet the diagnostic criteria
for another anxiety disorder (Collishaw, 2015; Vasey
et al., 2014). Comorbidity with other types of disorders
is also common. Children and adolescents with multiple
disorders (e.g., anxiety + depression, anxiety + conduct
disorder) experience more severe symptoms and have more
psychosocial risk factors (Creswell et al., 2020; Vasey
et al., 2014).
The Case of Lakshmi: Separation Anxiety
Disorder
Lakshmi is a six-year-old girl starting first grade. She
enjoyed kindergarten and was in the same class as her
best friend. Early in the summer, her mother had surgery
and was hospitalized for several days. Although she made
a good recovery, the event was stressful for Lakshmi. As
the summer progressed, Lakshmi became increasingly
concerned about her mother’s well-being, despite frequent
reassurances. Lakshmi also began to have difficulty
staying with her babysitter and needed her mother to call
frequently if she was away from home.
The first several days of first grade were uneventful for
Lakshmi, but she was unhappy about the fact that her close
friend was in a different classroom. Late in the first week
of school, Lakshmi refused to get on the school bus, and
her mother drove her to school. The following morning,
Lakshmi said that she felt too sick to go to school. By the
following week, Lakshmi was upset about going to school
every morning, often crying and pleading to stay home.
On days that she was allowed to stay home, she seemed
quite happy and content. If forced to go to school, she was
quite agitated, though she tended to calm down over the
course of the day. The daily struggle has continued for
months, and Lakshmi, her mother, and her teacher are all
upset, exhausted, and hoping for some relief.
Lakshmi’s symptoms are consistent with a DSM-5-TR
diagnosis of separation anxiety disorder (SAD) (refer
to Table 11.2). The symptoms include significant distress
when separated from the home or attachment figures. The
key developmental criterion is that the anxiety must be ageinappropriate. In younger children like Lakshmi, anxiety
is often focused on the caregiver’s well-being or possible
harm to the caregiver. In older children and adolescents,
anxiety is also frequently related to difficulties being away
from home and is expressed in a reluctance or refusal to go
to school.
Lakshmi’s struggles with somatic problems are also
common. Headaches and stomachaches are frequent
complications of SAD. Nightmares and panic symptoms
may also occur with the disorder. Higher levels of
anxiety sensitivity are also observed in youth with SAD
(Hannesdottir et al., 2018). Estimates of SAD range from
about 4% in 6- to 12-year-old children to 2%–3% in
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
196 Chapter 11 Anxiety Disorders, Obsessive-Compulsive Disorder, and Somatic Symptom Disorders
Table 11.1 Clinical Comparison of Anxiety Disorders
Perception
Cognition
Affect
Separation Anxiety Phobias
●
Separation is
perceived as
threatening.
●
Specific objects,
events, or
situations are
perceived as
threatening.
●
The child believes
that harm to
the parent or
the self will
occur following
separation.
●
The child believes
that contact with
the phobic object
or entry into the
phobic situation
will lead to
catastrophe.
●
Intense fear or
anger occurs
when separation
is anticipated,
during separation,
or following
separation.
●
Intense fear
or anger is
experienced if
contact with the
feared object
or situation is
anticipated or
occurs.
Generalized
Anxiety Disorder Panic Disorder
●
The whole
environment
is perceived as
threatening.
●
The child is
hypervigilant,
scanning the
environment for
threats to wellbeing.
●
The child
catastrophizes
about many minor
daily events.
●
The recurrence of a
panic attack is seen
as threatening.
●
Attention is
directed inward,
and benign somatic
sensations are
perceived, but
misinterpreted as
threatening.
●
The child believes
that the panic
attacks may lead
to death or serious
injury.
●
A continual,
moderately high
level of fear is
experienced,
often called free-
floating anxiety.
●
During panic
attacks, intense
fear occurs, and
between attacks, a
moderate level of
fear of recurrence
is experienced.
Arousal
Behavior
Additional
difficulties
●
Episodes of
hyperarousal
●
Sleep problems
●
Separation
is avoided or
resisted.
●
The child refuses
to go to school.
●
The child refuses
to sleep alone.
●
Peer relationships
may deteriorate.
●
Academic
performance may
deteriorate.
●
Episodes of
hyperarousal
●
Sleep problems
●
The phobic object
or situation is
avoided.
●
With simple
phobias,
interpersonal
problems are
confined to
phobic situations.
●
Agoraphobia may
lead to social
isolation.
●
Continual
hyperarousal
●
Sleep problems
●
As worrying
intensifies, social
activities become
restricted.
●
Peer relationships
may deteriorate.
●
Academic
performance may
deteriorate.
●
Episodes
of extreme
hyperarousal
against a
background
of moderate
hyperarousal
●
Sleep problems
●
The child may
avoid public places
in case the panic
attacks occur away
from the safety
of home. This
phenomenon is
called
secondary
agoraphobia.
●
If agoraphobia
develops
secondary to the
panic attacks,
social isolation
may result.
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Anxiety Disorders 197
Table 11.2 Separation Anxiety Disorder:
Summary of DSM-5-TR Diagnostic Criteria
A. Developmentally inappropriate and excessive
anxiety concerning separation from those to
whom the individual is attached, as evidenced by
at least three of the following:
1. Distress when anticipating or experiencing
separation from home or major attachment
figures.
2. Persistent and excessive worry about losing a
major attachment figure.
3. Persistent and excessive worry about
experiencing an untoward event (e.g., getting
lost, kidnapped, illness) causing separation
from a major attachment figure.
4. Persistent reluctance to leave home without
major attachment figure.
5. Excessive fear of being alone without major
attachment figure.
6. Persistent reluctance to sleep away from
home.
7. Repeated nightmares involving the theme of
separation.
8. Repeated complaints of physical symptoms
when separated from major attachment
figure.
winds. Jack has missed several birthday parties, and
his family canceled plans for a day with friends at a
children’s museum after Jack became upset and refused
to get in the car during a rainstorm. Jack’s parents are
increasingly frustrated by Jack’s fears and worries but
are not sure how to help their child.
Phobic disorders involve excessive and exaggerated
fears of particular objects or situations, intense anxiety in
the presence of such objects or situations, and avoidant
behaviors. The fears and anxieties are associated with
significant impairment (Vasey et al., 2014). DSM-5-TR
distinguishes a variety of specific phobias, including
animals (e.g., dogs, spiders, birds), situations (e.g., fear
of flying), injury or blood, and natural phenomena (e.g.,
thunderstorms). Related to specific phobias are social
anxiety disorder (previously social phobia, a fear of
scrutiny or evaluation by others) and agoraphobia (intense
anxiety in places where individuals feel insecure, trapped,
or not in control). Prevalence estimates are about 5%
to 7% for specific phobias in children and adolescents,
with more girls diagnosed than boys. Children are often
diagnosed by six or seven years of age (Vasey et al., 2014).
Many youth experience multiple phobias (Burstein et al.,
2012; refer to Figure 11.2). The cumulative effect of fears
is important to note. The greater the number of distinct
fears, the greater the risk of anxiety symptoms (Husky
et al., 2021).
B. The fear, anxiety, or avoidance is persistent,
lasting at least four weeks in children and
adolescents.
C. Symptoms cause clinically significant
impairment in current functioning.
adolescents (Spence et al., 2018; Vasey et al., 2014). SAD
is often diagnosed with other anxiety disorders such as
social anxiety and general anxiety disorder (Spence et al.,
2018).
The Case of Jack: Phobic Disorder
Jack is a seven-year-old boy who has developed a
pervasive fear of bad weather. Jack has always been
somewhat wary of loud noises and dark places, but
these concerns became focused on bad weather after
he and his parents drove home in the early evening
during a severe rainstorm accompanied by thunder
and lightning. His home lost electricity for several
hours, and Jack’s parents were unable to calm him or
reassure him that they would all be okay. Following
this experience, Jack began to pay close attention
to any signs of bad weather and now cries if he has
to go outside if there are dark clouds, rain, or heavy
The Case of Rory: Social Anxiety Disorder
Rory is an 11-year-old non-binary child in sixth grade
at a large suburban middle school. Rory has always had
some difficulty adjusting to new situations and has
been described as “slow to warm up” when meeting new
people. But neither Rory’s parents nor Rory’s teachers
had expressed significant concerns until this year—
their first in middle school. Rory’s parents note that
at home, they are generally energetic and fun loving.
And although Rory was seen as quiet and reserved at
their elementary school, Rory enjoyed close friendships
with several other children and never resisted going to
school.
Rory has struggled in several noteworthy ways since
starting middle school. From the start of the year, they
seemed to be anxious and distressed from the time they
woke up in the morning until their return home at the
end of the day. Rory complained that not only were they
not making new friends at middle school, but their best
friends from elementary school were also developing
new groups of friends that Rory believed were excluding
them. Rory’s schoolwork suffered, and they seemed
to lose confidence in their abilities as a student. Rory
struggled, in particular, with the increasing focus on
group projects, where they were reluctant to offer ideas
for fear that the other students would “think they were
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
198 Chapter 11 Anxiety Disorders, Obsessive-Compulsive Disorder, and Somatic Symptom Disorders
6
Age in Years
Cumulative Percent
Four or More
Figure 11.2 Prevalence of multiple phobias, ages 4 to 17
One
5
4
3
2
1
0
3
4 5 6 7 8 9 10
Source: Burstein et al. (2010). Specific phobia among U.S. adolescents: Phenomenology and typology.Used
with permission of John Wiley & Sons©2012 permission conveyed through Copyright Clearance Center, Inc.
11 12 13 14 15 16 17 18
Two
Three
stupid.” On those occasions where groups were required
to meet outside of school, Rory would often neglect
to tell their parents to avoid having to go to another
student’s home.
Rory was also beginning to miss a considerable
amount of school because of frequent stomachaches and
occasional headaches. In elementary school, Rory enjoyed
participating in music concerts and having small parts in
class plays. Thinking it might help Rory’s adjustment to
middle school, their parents encouraged them to try out
for the all-school musical production. Reluctantly, Rory
signed up. But when the day came to audition, Rory called
their mother, crying, and told her that they didn’t feel
well and couldn’t perform in front of other students and
teachers.
Confused and distressed, Rory’s parents talked with
them about their increasing avoidance of activities that
they had previously enjoyed. Rory, with tears welling up
in their eyes, insisted that they were no longer interested
in the same things as when they were younger, argued
that the kids and teachers at the middle school were mean
and did not like them, and said that they would be fine
if they could simply come home after school and do their
homework on their own.
Social phobia is not just shyness or inhibition.
Shyness is a complex psychological construct, and it is
sometimes difficult to distinguish between typical and
atypical social anxieties. It may be useful to think of it
as a continuum, with groups of shy children followed by
groups of somewhat socially anxious children followed by
groups of children with social anxiety disorder. Children
who are shy are those who may be slow to warm up at
a friend’s birthday party but who eventually join in the
fun. Children who are somewhat socially anxious are
those who stay close to a parent for the party’s duration.
Children with social anxiety disorder cannot attend the
party at all.
avoidance in social situations and/or situations that may
involve negative evaluations. One compelling example
of social anxiety disorder is displayed by children and
adolescents with performance anxiety. Studies of talented
young musicians suggest that distress and impairment
related to performance anxiety are quite common and
are accompanied by a range of coping strategies (Fehm &
Schmidt, 2006; Osborne et al., 2005). Other forms of social
anxiety are observed in adolescents who cannot complete
school projects that require oral presentations or those
who cannot eat with their friends in restaurants. Social
anxiety disorder is sometimes observed in combination with
selective mutism, with selective mutism understood as part
of a larger pattern of avoidant behavior (Muris & Ollendick,
2021; Vasey et al., 2014).
increasing with age. Somewhat higher rates for girls have
been observed. The median age of onset for social anxiety
disorder ranges between 7 and 13 years of age. Social
anxiety disorder is often comorbid with generalized anxiety
disorder (Sequeira et al., 2020; Spence et al., 2018; Vasey
et al., 2014). Compared to Black and White adolescents,
rates of social anxiety appear to be somewhat higher in
Asian American adolescents (similar to Asian American
adults) (Brice et al., 2015).
Social anxiety disorder is characterized by fear and
Prevalence rates for social phobia range from 1% to 6%,
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
For children experiencing social phobia, anxiety
symptoms often prevent them from enjoying
developmentally important group activities.
The Case of Charlotte: Generalized
Anxiety Disorder
Charlotte is a nine-year-old girl presenting with a high
level of general distress. She was originally referred for
evaluation because of concerns raised at school about
some learning difficulties and problems related to
extreme avoidance behavior. These problems included
not talking in class, not turning things in, not going
to her locker, and not interacting with other kids on
the playground. For several months, Charlotte has
refused to ride the school bus, so one of her parents
has driven her to school. Although Charlotte has always
liked sports, she will only play soccer and softball with
her parents or her older brother, and only in their yard.
Both Charlotte’s father and stepfather have tried several
times to encourage her participation on a team, but
Charlotte became so anxious and upset before games
that she often refused to get out of the car at the playing
field.
Recently, Charlotte has been unable to use public
restrooms because she says that they scare her. After
witnessing a classmate vomit in class on a hot spring day,
she has become preoccupied with a fear that she will
also vomit if she becomes too warm. Consequently, she
has come to associate being hot with being nauseated
and insists on always being in air-conditioned buildings
during the summer.
Charlotte has difficulty sleeping because of her
tendency to ruminate. She describes this as being “unable
to shut my brain off.” She also worries at night that she
will be kidnapped. Charlotte is interested in theater and
would like to participate in school plays and summer
community theater programs, but she says that she is too
nervous to try out. When asked if she could change one
thing about her life, Charlotte says that she would most
want to be able to be in a play.
Anxiety Disorders 199
The Case of Asher: Generalized Anxiety
Disorder with Autism Spectrum Disorder
Asher is a 12-year-old boy in the 6th grade at a large
suburban middle school. Shortly after beginning
kindergarten, Asher’s teacher met with his parents
to discuss her concerns about his social isolation, his
difficulty adjusting to the classroom routine, and a range
of repetitive actions and perseverative interests. Following
a comprehensive evaluation, Asher was diagnosed with
autism spectrum disorder (ASD). Fortunately, Asher’s
elementary school offered considerable support for
iStock.com/LumiNola
students like Asher. School services included a dedicated
special education classroom and individual support, along
with participation in mainstream classes for much of the
day. This school programming continued as Asher entered
middle school in the 5th grade.
Now in 6th grade, Asher has the same classmates and
teacher as the previous year. Understanding that anxiety
is commonly experienced by individuals on the autism
spectrum, Asher’s teachers were skilled at anticipating
and minimizing anxiety triggers during the school day.
Asher’s main teacher, however, grew concerned when
he became increasingly withdrawn from classmates
he had known for years. Asher also displayed more
worry and irritability throughout the day, although
these moods did not seem particularly connected to
any one situation. He also became resistant to leaving
his special ed classroom for mainstream activities like
lunch, physical education, and band. Attempts to
encourage Asher to return to previous school routines
led to emotional outbursts, and Asher remained upset
for long periods following these outbursts. When
asked if he could describe how he felt or what had
changed, Asher appeared confused and unsettled by
the questions. Asher’s parents and teachers agreed that
a new evaluation would be helpful.
Both Charlotte’s and Asher’s presentations are consistent
with the DSM-5-TR criteria for generalized anxiety
disorder (GAD), with excessive and unrealistic worries and
fears about a variety of stimuli and situations (refer to Table
11.3). Prevalence is estimated at about 2%, with similar rates
for girls and boys, and with an average onset at about eight
years of age (Spence et al., 2018; Vasey et al., 2014). GAD
is observed throughout the childhood years, although it is
more commonly diagnosed in older children, adolescents,
and adults. With age, fears and worries become more
complex and increases in somatic symptoms are observed
(In-Albon et al., 2020). Children with GAD receive
comorbid diagnoses of obsessive-compulsive disorder, mood
disorders, and ADHD more frequently than children with
other anxiety disorders (Spence et al., 2018). The case of
Asher illustrates another frequent comorbid combination:
autism spectrum disorder with GAD.
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
200 Chapter 11 Anxiety Disorders, Obsessive-Compulsive Disorder, and Somatic Symptom Disorders
Table 11.3 Generalized Anxiety Disorder:
Summary of DSM-5-TR Diagnostic Criteria
A. Excessive anxiety and worry, occurring more
days than not, lasting at least 6 months, about a
number of events or activities.
B. The individual finds it difficult to control the
worry.
C. The anxiety and worry are associated with at
least three of the following symptoms (only one
required for children):
1. Restlessness
2. Easily fatigued
3. Difficulty concentrating
4. Irritability
5. Muscle tension
6. Sleep disturbance
D. The anxiety, worry, or physical symptoms cause
clinically significant impairment in important
areas of functioning.
The Case of Brynn: Panic Disorder
Brynn is 15 years old and in ninth grade. Brynn’s parents
have accompanied her for a consultation following
several panic attacks that happened during the school
day. Brynn’s two mothers describe her during her
early years as bright, friendly, and somewhat reserved.
Although she has always been somewhat anxious in new
situations, she has a number of close friends and is a
talented musician. At home, Brynn is talkative and even
mildly argumentative at times. At school, she is seen as
quiet and serious.
Brynn’s parents first became concerned about her
in sixth grade, when she transitioned from elementary
school to junior high. At the start of that school year,
Brynn began to complain of stomachaches and to miss
school frequently. Her symptoms gradually receded as
she became more comfortable with her new environment.
Brynn acknowledges that the start of each school year has
been a struggle for her, although never quite as severe as
in sixth grade.
Brynn was nervous about high school but also looked
forward to the new school and new experiences. Overall,
Brynn’s parents were pleased with her adjustment. She
found her classes challenging but engaging, and she was
enjoying new opportunities provided by an expanded
music program. Socially, she stayed close to junior high
friends and said that she found it difficult to venture out
and make new friends.
One day, while eating lunch alone in the cafeteria,
Brynn began to feel ill. She felt her pulse racing and became
short of breath. She was light-headed and nauseated. She
made it to the first class after lunch, where her teacher
immediately asked her if she was all right. Brynn said she
felt as if she might pass out and was sent to the nurse’s
office. Once there, she began to cry and told the nurse
that she was afraid she would die. After lying down for
a short time, Brynn began to feel better and had largely
recovered by the time one of her mothers came to pick
her up.
The next morning, Brynn complained of a headache
and expressed anxiety about returning to school. Both of
her mothers encouraged her to go, though, reassuring her
that one of them would come and get her if she became ill.
After several days without incident, Brynn had a second
attack, during which she felt dizzy and nauseated, felt her
heart pounding, and had trouble breathing. This occurred
at a football game, just after Brynn performed in the band’s
halftime program. Again, she reported feeling a sense of
panic that she might be dying. Brynn has not been able to
return to school since the second panic attack.
Brynn meets the DSM-5-TR criteria for panic disorder.
Recurrent, somewhat unpredictable panic attacks are
the primary component of panic disorder. Panic attacks
are extremely intense and uncomfortable episodes of
anxiety. Sometimes, panic occurs in typically developing
children without other symptoms and with few negative
consequences. Although certainly distressing, these isolated
attacks are not necessarily a cause for alarm. However, when
panic attacks are associated with one of the other anxiety
disorders, such as separation anxiety disorder, phobias, or
generalized anxiety disorder, they are more likely to be a
complication of that specific disorder rather than a separate
disorder. Panic disorder is usually diagnosed in adults but
may be observed in adolescents. Girls are more frequently
diagnosed than boys, but the gender difference in rates
increases further over the course of adolescence and young
adulthood (Vasey et al., 2014).
Obsessive-Compulsive Disorder
The Case of Daniel
Daniel is a 13-year-old boy referred because of concerns
noted by both his parents and teachers about some of his
increasingly unusual behaviors. He has been an excellent
student throughout his school years until this term, in
eighth grade, when he began to fall behind in his classes.
His parents also reported that he has dropped several
favorite activities a nd become increasingly socia lly isolated.
During the initial assessment, Daniel took an unusually
long time to complete some simple questionnaires.
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Obsessive-Compulsive Disorder 201
When asked about this, he admitted that he felt compelled
to count the words in each sentence before reading it.
He said that this has become a real problem because he
can no longer complete his homework on time. Daniel
also described counting steps and feeling that he always
needed to finish climbing stairs with his right foot. In
fact, he has memorized the number of steps throughout
his school, church, and home so he always knows which
foot to start with. If he does finish climbing stairs with
his left foot, he feels compelled to go back down the stairs
and start over.
Although he has never worried about germs before,
he is now very concerned about them and has begun
carrying a cloth with him so he does not have to touch
things like doorknobs or staircase rails. He also finds
himself washing and rewashing his hands as often as
he can throughout the day. He also said that after he
showers, he often still feels dirty and so immediately
takes another shower. This has recently caused him to be
late getting to school on many mornings.
This description of Daniel reflects the acute distress
and level of impairment associated with obsessive-
compulsive disorder (OCD) (refer to Table 11.4). Daniel’s
intrusive concerns about germs and contamination and
his repetitive counting behaviors are among the most
common symptoms. Other characteristic obsessions
involve a fear of harming others, death, or sex. Prevalent
rituals include handwashing, checking, counting and
ordering, and avoidant behaviors. In previous editions
of the DSM, obsessive-compulsive disorder was included
with the anxiety disorders. In DSM-5 and DSM-5-TR,
obsessive-compulsive disorder is in its own section with
related disorders including hoarding disorder, body
dysmorphic disorder, hair-pulling disorder, and skinpicking disorder.
It is important to evaluate children’s obsessions (i.e.,
persistent and intense intrusions of unwanted thoughts
or images) and compulsions (i.e., persistent and intense
impulses to perform a specific behavior) within a
developmental framework because many children display
specific preferences and rituals that are not pathological
(Kraper et al., 2014). For instance, prescribed sequences of
separation behaviors at day care centers or bedtime routines
are common, but most of these kinds of rituals fade by later
childhood.
Four distinct symptom dimensions of OCD in children,
adolescents, and adults have been identified: (1) obsessions
about harm/responsibility and checking compulsions;
(2) symmetry obsessions and arranging/ordering
compulsions; (3) contamination obsessions and cleaning
compulsions; and (4) hoarding obsessions and compulsions
(Bloch et al., 2008; Højgaard et al., 2017). Other research
has outlined additional dimensions, including body-focused
symptoms, superstitions, and concerns about loss and
Table 11.4 Obsessive-Compulsive Disorder:
Summary of DSM-5-TR Diagnostic Criteria
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by:
1. Recurrent and persistent thoughts, urges, or
images that are experienced as intrusive and
unwanted.
2. Individual attempts to ignore or suppress such
thoughts, urges, or images, or to neutralize
them with some other thought or action.
Compulsions are defined by:
1. Repetitive behaviors (e.g., hand washing,
ordering, checking) or mental acts (e.g.,
counting, repeating words silently) that the
individual feels driven to perform in response
to an obsession or according to rigidly applied
rules rigidly.
B. The behaviors or mental acts are aimed at
preventing or reducing anxiety or preventing
some dreaded event; however, these behaviors
or mental acts are not connected in a realistic
way with what they are designed to neutralize or
prevent, or they are clearly excessive.
Note: Young children may not be able to
articulate the aims of these behaviors or mental
acts.
C. The obsessions or compulsions are time-
consuming or cause clinically significant
impairment in important areas of functioning.
separation (Cervin et al., 2021). The symptom dimension
related to harm, responsibility, and checking is associated
with fear and anxiety in children and adolescents. The
symptom dimensions related to contamination and
iStock.com/Bearmoney
Excessive handwashing is often observed in children and
adolescents with contamination obsessions.
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
202 Chapter 11 Anxiety Disorders, Obsessive-Compulsive Disorder, and Somatic Symptom Disorders
symmetry/ordering, in contrast, are associated with disgust
and feelings that things are “not just right” (Cervin et al.,
2022).
Childhood prevalence rates for OCD range between 2%
and 4% (Kraper et al., 2014). There are data that suggest that
boys are at higher risk than girls, but more research remains
to be done on both sex/gender and sociodemographic
variables. The timing of onset reflects two peak periods,
an early onset around age 11 and a later onset in early
adulthood. More boys are diagnosed in childhood, but from
adolescence forward, gender rates are similar (Kraper et al.,
2014). OCD is frequently diagnosed in combination with
other disorders, including anxiety disorders, tic disorders,
autism spectrum disorder, depression, and externalizing
disorders (Kraper et al., 2014). Sleep-related problems are
also frequently observed (Reynolds et al., 2015).
Somatic Symptom Disorders
The Case of Isabella
Isabella is a 14-year-old girl, a good student who is well
liked by her teachers. Although not rejected by peers,
she is rather shy and spends most of her time with just
a few friends. Isabella reports feeling ill frequently, and
each year, she has missed many school days, including
field trips and special events. Isabella’s older sister had an
emergency appendectomy several years ago. Ever since
this event, Isabella’s grandparents, with whom she lives,
have been especially vigilant about Isabella’s health.
Isabella’s grandparents have extremely high expectations
for their grandchildren’s academic achievement. Any
problems with academic performance are viewed with great
concern, and doing well is highly reinforced. Isabella’s older
sister is a top student at her high school, where Isabella
is currently enrolled as a 9th grader. In the spring of 8th
grade, Isabella began to show a pattern of frequent headaches
and stomachaches in the morning that sometimes led to
her being late to, and occasionally missing, school.
Beginning the second week of 9th grade, Isabella
began complaining of severe, debilitating abdominal
pain. After being called on several occasions to bring
Isabella home from school because of pain, Isabella’s
grandparents became alarmed and brought her first to her
pediatrician and then, after a particularly severe episode,
to the emergency room. Preliminary assessments in each
case could find no obvious cause for Isabella’s symptoms.
Finally, the specialist the family consulted recommended
hospitalization for more extensive and intrusive diagnostic
procedures. The findings from these tests were negative
and a psychology consult was requested.
Although initially skeptical of the involvement of
the psychologist, Isabella and her grandmother were
cooperative. The psychologist observed that although
Isabella verbalized concern about missing school, she
appeared relaxed and calm. In addition, although Isabella
reported no lessening of her pain, she showed none of
the obvious symptoms generally associated with extreme
discomfort. When asked if she felt stressed or anxious
about starting high school, Isabella denied having any
worries about this, other than those related to falling
behind in her work since being hospitalized.
Recurrent complaints of somatic (physical) symptoms
are quite frequent among children and, under certain
conditions, in adolescents. Somatization refers to a variety
of processes in which aspects of psychological distress
manifest themselves in physical symptoms (Garralda, 2010;
Williams & Zahka, 2017). Somaticizing persons generally
do not differentiate between emotional and physical
experiences and have difficulty using emotion language to
express anxiety or distress. Rather, they use somatic language
to describe both physical and emotional problems. Some of
the most common somatic symptoms include headaches,
fatigue, pain, sore muscles, and abdominal distress.
Although somatic symptom disorders (called
somatoform disorders in previous DSMs) are at the severe end
of a continuum, occasional somatization (at least in mild
and transient forms) is extremely common (Garralda, 2010;
Williams & Zahka, 2017). Indeed, it is the rare adult who
does not have a childhood memory of the early-morning
stomachache on the day of a big test. For some children
and families, however, this process of somatization leads to
clinically significant distress and impairment. Youth with
somatic symptom disorders display a varied mix of physical
problems, neurological symptoms, and health anxieties
(Rask et al., 2018; Williams & Zahka, 2017).
As with anxiety disorders, anxiety sensitivity appears to
influence somatization (Mahrer et al, 2012). An especially
common and well-studied somatic symptom disorder
involves recurrent abdominal pain, as seen in the case of
Isabella. Recurrent abdominal pain involves three or more
episodes over a three-month period of severe pain that
compromises a child’s functioning. Studies of recurrent
abdominal pain suggest that it tends to occur in families
where illness is a central concern and where there is both
somatic and emotional distress (Garralda, 2010). It is
important to note that chronic pain in youth is a difficult
phenomenon to evaluate and explain, with multiple clinical
and research perspectives. Most youth who experience
chronic pain are not diagnosed with somatic symptom
disorder (Edwards et al., 2021; Neville et al., 2019).
Conversion disorder (functional neurological
symptom disorder) is characterized by unexplained deficits
in voluntary motor or sensory function that cannot be
adequately accounted for by known pathophysiological
mechanisms; psychological factors are clearly associated
with the emergence of symptoms. Typical motor
dysfunctions include paralysis, problems with balance, and
difficulty swallowing. Typical sensory dysfunctions include
loss of touch or pain sensation, double vision or vision loss,
deafness, and hallucinations.
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Developmental Course 203
Developmental Course
Continuity and Course of Anxiety
Disorders
Anxiety disorders are among the earliest-appearing disorders
and are associated with diverse outcomes, from clear
improvement for some to persistent struggles for others (Klein
et al., 2019; Vasey et al., 2014; Weems, 2008). The stability
of diagnoses over time (e.g., social anxiety disorder diagnosed
at age 9 and again at 14) reflects homotypic continuity (the
disorder identified early is the same disorder identified
at a later time). From a developmental psychopathology
perspective, however, we also need to keep in mind the
possibility of change in the kinds of anxiety experienced over
time. If anxiety diagnoses change over time, these changes
may reflect heterotypic continuity (underlying similarity
between early and later diagnoses despite differences in
observed patterns of emotion, cognition, and behavior).
Maladaptive anxious emotion is the core feature (the similarity)
that contributes to heterotypic continuity.
Many trajectories of anxiety have been described for
children and adolescents. In preschoolers, separation
anxiety disorder and generalized anxiety are highly stable
over early childhood. Greater stability is associated with
the temperament dimension of behavioral inhibition, with
insecure attachment, and with parent depression (Gouze et
al., 2022). In two studies of children at increased risk for
internalizing disorders, several pathways were identified.
These include high levels of anxiety symptoms that persist
over time, moderate levels of anxiety symptoms that persist,
and low levels of anxiety symptoms. For some children
whose anxiety persisted, a mix of anxiety and depression
symptoms were observed. For others, externalizing
symptoms were present. Stability was associated with greater
sociodemographic adversity and more maternal depression
(Kertz et al., 2019; Klein et al., 2019).
Early onset of specific phobias predict a range of
internalizing disorders across time. Even though the diagnosis
of a specific phobia is viewed as more mild than other anxiety
disorders, it is important to consider the associations between
phobias and problematic outcomes. The greater the number
of phobias, the greater the risk for severity, persistence, and
comorbidity (de Vries et al., 2019; Husky et al., 2021).
In young adolescents, distinctive trajectories were observed
for generalized anxiety disorder, social anxiety disorder, and
panic disorder (de la Torre-Luque et al., 2020). Most adolescents
(approximately two-thirds) displayed low levels of symptoms
across time while others (approximately one-third) displayed
increasing difficulties. High levels of negative affectivity, low
levels of effortful control, and being a girl were associated with
greater risk. Social anxiety disorder and generalized anxiety
disorder were more likely to be associated with later depression
(de la Torre-Luque et al., 2020). The transition to young
adulthood is an especially important time for the development
of adult anxiety disorders (Copeland et al., 2014).
Across age, social anxiety disorder is highly persistent and
impairing (Burstein et al., 2011). Children and adolescents
with social anxiety disorder and other anxiety disorders are
more likely to exhibit below-average social skills and more
peer difficulties (Kertz et al., 2019; Klein et al., 2019). The
presence of positive peer relationships contributes to better
outcomes; rejection or victimization is associated with
worse outcomes (Frenkel et al., 2015). Loneliness may be a
distressing experience for many youth with anxiety (refer to
Box 11.1).
School refusal may be another complication of anxiety
disorders. School refusal can occur in the context of
separation anxiety disorder, social anxiety disorder, or
school phobia. Depending on specific fears, phobias, or
obsessive-compulsive patterns, children and adolescents
may be unwilling to attend school or to continue with
important school-related activities. Youth distress related to
school must be addressed to prevent adverse academic and
social outcomes (Elliott & Place, 2019).
The continuity and severity of anxiety disorders
over time is often related to parent behavior. Parents of
young children who display wariness and fear in many
situations and parents of older children and adolescents
who resist activities that elicit anxiety may, with every
good intention, manage and/or work around their
children’s distress by altering routines or expectations.
These types of accommodation, while helpful in the
short term, are associated with greater severity of disorder
and worse outcomes (Kagan et al., 2018; Lebowitz et al.,
2014; refer to the expanded summary in the next section
on OCD).
Continuity and Course of ObsessiveCompulsive Disorder
As with anxiety disorders, there are a number of
developmental pathways observed for children and
adolescents diagnosed with OCD. Child-onset of OCD is
common and typically occurs between 7 and 13 years of
age (Chessell et al., 2021; Dell’Osso et al., 2016). Because
obsessive-compulsive symptoms are often observed in
typically-developing children and adolescents (involving
preferred routines and rituals), it is important to differentiate
more typical ritualized behaviors from more atypical
obsessive-compulsive symptoms. Many young children who
display these behaviors show declines after kindergarten age
(Luke et al., 2021). Other young children show increases
across childhood and adolescence. The persistence and
severity of obsessive-compulsive symptoms are correlated
with comorbid disorders such as other anxiety disorders,
depression, and ADHD (Luke et al., 2021). Adolescents may
also display sub-clinical obsessive-compulsive symptoms,
and most of them do not meet the diagnostic criteria for
OCD. Sub-clinical symptoms are more common in females,
and the symptom factor involving bad thoughts is predictive
of later OCD diagnosis (Barzilay et al., 2019).
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.