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Anxiety and
How do we identify
and treat anxiety
Anxiety Disorders
• Affects 2–5% of the child population.
• Affects 20–30% of students referred to
clinics for behavior problems.
• Equal prevalence in boys and girls.
• Have both social and biological causes.
• Appear amenable to social learning
Interventions for School
• Desensitize the child’s fear by role
• Reinforce school attendance, even for
brief periods.
• Include matter-of-fact parental
statements that child will go back to
• Remove reinforcers for staying home.
Dr. Aubrey H. Fine
Obsessive Compulsive
• OCD may include:
– Washing, checking, or other
repetitive motor behavior
– Cognitive compulsions consisting of
words, phrases, prayers, or
sequences of numbers
– Obsessional slowness
– Doubts and questions that elevate
Facts and Figures
• Prevalence
– Originally believed to be rare
• >0.1%
– Recent evidence suggests 1-3% Onset
/ Characteristics:
– Males:, high prevalence of checking
– Females:, high prevalence of washing
OCD Diagnosis (1): DSM IV
• Obsessions defined by all of the following:
– Recurrent and persistent thoughts, impulses or
images experience at some time during the
disturbance, as intrusive and inappropriate and
that cause marked anxiety or distress.
– The thoughts/impulses/images are not simply
excessive worries about real life problems.
– The person attempts to ignore or suppress such
thoughts/impulses/images, or neutralize them
with some other thought or action.
– The person recognizes that the obsessional
thoughts/impulses/images are a product of their
own mind (not imposed from without).
OCD Diagnosis (2): DSM IV
• Compulsions defined by:
– Repetitive behaviors or mental acts that the
person feels driven to perform in response to an
obsession, or according to rules which must be
applied rigidly
– 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
• Not better accounted for by other diagnosis
What is an Obsession?
• Involuntary intrusive cognition
• Types
• Doubts (74%)
• Thinking (34%)
• Fears (26%)
• Impulses (17%)
• Images (7%)
• Other (2%)
Examples of Obsessions
• Doubt “Did I lock the door”
• Thought that he had cancer
• Thought / Image that he had
knocked someone down in his car
• Impulse + thought to shout
obscenities in church
• Image of corpse rotting away
• Impulse to drink from inkpot and to
strangle son
Themes in Obsessions
• Obsessions often have common themes
Contamination, dirt, disease, illness (46%)
Violence and aggression (29%)
Moral and religious topics (11%)
Symmetry and sequence (27%)
Sex (10%)
Other (22%)
• The themes often reflect contemporary
concerns (the devil, germs, AIDS)
Examples of Compulsions
• Scanning text for “life” having read
• Touching the ground after
swallowing saliva
• Driving back to check he hadn’t
knocked someone down in his car
• Counting 6,5,8,3,7,4 in your head
• Hand washing
Linking Obsessions and
OCD and “Normal” Experience
• Obsessional thoughts found in 90% of
– It is well replicated that 80%+ of normal people
have intrusive thoughts
– There thoughts are similar in content and form
to OCD patients
• Compulsions
– Many people have compulsions such as
stereotyped or superstitious behaviors
– 66% of normal people report some form of
checking behavior
• Is OCD qualitatively distinct?
OCD Experiences
A man who washes his hands
100 times a day until they are
red and raw
A woman who unfailingly
washer her hands before
every meal
A women who locks and relocks
her door before going to work
every day – for half an hour
A woman who doublechecks that her apartment
door and windows are
locked each night before
she goes to bed.
A college student who must tap
on the door frame of every
classroom 14 times before
A musician who practices a
difficult passage over and
over again until its perfect
A man who stores 19 years of
newspapers “just in case” – with
no system for filling or retrieving
A woman who dedicates all
her spare time and money
to building her record
Cognitive Aspects of OCD
• Responsibility for harm to self/others
– Any influence over outcome = responsibility
for outcome
– Omission: “I will omit to do something that
leads to myself/others being hurt”
– Magical thinking
• Thought Action Fusion
– Thought = action “I will harm my child”
• Obsessions = “going crazy”
• Control: “Trying to hard”
– Suppression: “white bears”
– Pre-Occupation: “Looking for trouble”
OCD: Therapy
• Exposure and Response Prevention (ERP)
• Responsibility
– Am I a murderer or just worried about being
– Normalizing / Other explanations
• Thought = action
– Can I think myself to death?
• Neutralizing
– Experiment to show how thought suppression
increases thought frequency
• Exposure: Cued Intrusions
Key Issues
• What are the strengths and limitations of
behavioral models of OCD?
– Think about the empirical findings of current
psychological models such as Salkovskis’
• Have cognitive models of obsessions and
compulsions helped us understand OCD
and how it should be treated?
• How are intrusive thoughts in OCD
different from “normal” intrusive thoughts?
– Are they different at all?
Posttraumatic Stress
• Repeatedly perceived memories of the
• Repetitive behaviors that may be
similar to obsessions or compulsions.
• Fears linked to the traumatic event.
• Altered attitudes toward people, life, or
the future, reflecting feelings of
Stereotyped Movement
• Involuntary, repetitious, persistent,
nonfunctional acts over which the
individual can exert at least some
voluntary control.
• Self-stimulation
• Self-injury
• Tics
• Tourette’s syndrome
Selective Mutism
• Children who are reluctant to speak although
they know how to converse normally.
• May be a response to:
– Trauma
– Abuse
– Social Anxiety
• Most effective interventions incorporate social
learning principles.
Eating Disorders
Highly exclusive food preferences
Elimination Disorders
• Enuresis
• Encopresis
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