5.2.3 Anxiety Disorders including OCD

Anxiety Disorders Including OCD

Anxiety disorders and obsessive-compulsive disorder (OCD) are prevalent mental health issues among children and adolescents. Affecting up to 25% of youth, anxiety disorders are the most common, while OCD impacts 1-2% (Thompson, 2019) (Heyman & Fombonne, 2015). Both genetic and environmental factors contribute to their development, with family history, trauma, and stress being significant risk factors. Symptoms include excessive worry, fear, avoidance, and, for OCD, obsessions and compulsions. Affected children may avoid situations, seek reassurance, and engage in compulsive rituals, sometimes leading to school refusal, self-harm, or suicidal thoughts. Cognitive-behavioural therapy (CBT) and medication, such as selective serotonin reuptake inhibitors (SSRIs), effectively treat these disorders (NIMH, 2021). Early intervention often leads to significant symptom improvement, but some children may need ongoing support.

Subheading	Summary
Prevalence/Incidence	Anxiety disorders affect up to 25% of youth, while OCD affects around 1-2%.
Aetiology	Genetic and environmental factors contribute to the development of anxiety disorders and OCD.
Presentation	Anxiety disorders and OCD can present with a range of symptoms, including excessive worry, fear, and avoidance. OCD is characterized by obsessions and compulsions.
Behaviours	Children with anxiety disorders and OCD may exhibit behaviours such as avoidance, seeking reassurance, and engaging in compulsive rituals. They may also experience school refusal and self-harm.
Treatment	CBT and medication are the most effective treatments for anxiety disorders and OCD.
Outcome	With early and effective treatment, many children and adolescents with anxiety disorders and OCD can experience significant improvement in their symptoms.

Separation Anxiety Disorder, Generalized Anxiety Disorder, and Disorder/Agoraphobia

Separation anxiety disorder, generalized anxiety disorder, and panic disorder/agoraphobia are common anxiety disorders affecting children and adolescents. Separation anxiety disorder is characterized by excessive anxiety around separation from attachment figures or home, impairing normal functioning. Generalized anxiety disorder presents as developmentally inappropriate and excessive worry about various aspects of life, causing distress and dysfunction. Panic disorder/agoraphobia involves recurrent, severe panic attacks accompanied by psychological and physiological symptoms, often leading to anticipatory anxiety and the development of agoraphobia – a fear of being in situations where escape would be difficult or help unavailable. These anxiety disorders can significantly impact the emotional well-being and daily functioning of young patients and often require targeted psychological interventions, such as cognitive-behavioural therapy, to help manage symptoms and improve their quality of life.

	Separation Anxiety Disorder	Generalized Anxiety Disorder	Panic Disorder/Agoraphobia
Description	Excessive anxiety around separation from attachment figures or home, results in impaired functioning.	Excessive worry and anxiety on most days about things not under one’s own control, causing distress and/or dysfunction.	Recurrent, severe panic attacks with psychological and physiological features, and anticipatory anxiety. Agoraphobia may be present, involving anxiety about being in situations where escape would be difficult or help unavailable.
Prevalence	3.5% of children 0.8% of adolescents	~4% of adolescence	3–6%
Causes / Risk Factors	Genetic vulnerability; Anxious, inconsistent, or over-involved parenting; Regression during stress, illness, or abandonment.	N/A	N/A
Symptoms	Anxiety about separation or danger; Sleep disturbances and nightmares; Somatization; School refusal.	Excessive worry; Restlessness, irritability, fatigue; Poor concentration; Sleep disturbances; Muscle tension.	Sweating, flushing, trembling; Palpitations and tachycardia; Chest pain; Shortness of breath and choking; Nausea and vomiting; Dizziness; paraesthesia; Depersonalization and derealization; Fear of dying.
Comorbidities	Depression; Anxiety disorders; ADHD; Oppositional disorders; Learning disorders; Developmental disorders.	Up to 90% comorbidity rate with Other anxiety disorders; Depression; Conduct disorders; Substance abuse.	Depression; Substance abuse; Other anxiety disorders (especially social phobia).
Management	Psychological approach with emphasis on relaxation and managing anxiety using age-appropriate CBT.	CBT (individual, group, or family-based); Psychoeducation; Supportive listening and clarification; Other psychosocial approaches; Use of SSRIs (limited research evidence).	Same as for GAD (CBT, psychoeducation, supportive listening and clarification, other psychosocial approaches, use of SSRIs).

Social Phobia, Simple Phobia and Selective Mutism

Social phobia, simple phobias, and selective mutism are anxiety disorders that can affect children and adolescents. Social phobia, also known as social anxiety disorder, is characterized by an intense fear of social or performance situations, causing distress and avoidance. Simple phobias involve excessive fear of specific objects or situations, resulting in anticipatory anxiety and phobic avoidance. Selective mutism is a rare condition where children consistently fail to speak in certain social situations where speaking is expected, despite being able to speak in other contexts. These disorders can significantly impact a child’s daily functioning and social development, making early diagnosis and intervention crucial. Treatment often includes cognitive-behavioural therapy (CBT) and, in some cases, medication. Family and school involvement is essential for supporting affected children and adolescents in their recovery process.

	Social Phobia	Simple Phobias	Selective Mutism
Description	Marked fear of social or performance situations, exposure causing anxiety reaction, avoidance or discomfort.	Excessive fear of an object/situation, anticipatory anxiety, and phobic avoidance.	Consistent failure to speak in social situations where speaking is expected, despite speaking in other situations.
Prevalence	5-15% in adolescents and 1% in children	Very common (10% in some studies)	3-8/10,000 in the UK
Causes/Risk Factors	2-fold risk in relatives; 3-fold risk in MZ twins.	Genetic influence; Inhibited temperament; Parental influence; Specific conditioning.	N/A
Comorbidities	30-60% other anxiety disorders; 20% mood disorders; Substance abuse.	Depression; Substance abuse.	Premorbid speech and language problems; Developmental delay/disorder; Communication disorder; Elimination disorders; Anxiety disorders.
Management	CBT (individual, group, or family-based); SSRIs; Psychoeducation; Other psychosocial approaches.	Family involvement; CBT (desensitization, modelling, contingency management, relaxation training, self-statements).	Behavioural therapy; CBT; SSRIs; Individual psychotherapy; Family and school involvement.

Obsessive Compulsive Disorder

Obsessive-compulsive disorder (OCD) is characterized by intrusive, ego-dystonic obsessions or compulsions, often driven by anxiety or magical thinking. To meet diagnostic criteria, symptoms must persist most days for at least two weeks and cause significant distress or impairment. Related disorders include body dysmorphic disorder, trichotillomania, and others. OCD affects 1-3.6% of adolescents and can start as early as 5 years of age, with a mean onset of around 10 years. It is more common in males during childhood but becomes equally prevalent in both genders during adolescence. While mild subclinical symptoms are relatively common, OCD is a persistent disorder, often hidden due to secrecy, leading to delayed presentation. The disorder is associated with genetic and non-genetic factors, with chromosome 3 and serotonin systems implicated, and only 15% of cases show a clear precipitating factor.

Neuropsychiatric causes of OCD symptoms:

Assessment scales:

The CY-BOCS, or the Children’s Yale-Brown Obsessive-Compulsive Scale, is a commonly utilized tool for assessing and monitoring the severity of OCD in children and adolescents. It’s a clinician-rated, semi-structured instrument. The CY-BOCS comprises two main sections: one for obsessions and the other for compulsions. Each section is scored based on time consumed, distress, interference, resistance, and control, allowing professionals to gauge the severity and impact of the symptoms. The total score can range from 0 to 40, with higher scores indicating more severe OCD symptoms. The CY-BOCS is an invaluable instrument for clinicians not only to diagnose but also to track the progress and efficacy of treatments for pediatric OCD over time.

OCD comorbidity: 70% have at least one comorbid disorder. Includes:

Other anxiety disorders
ADHD
ODD
Tourette’s syndrome
Autism Spectrum Disorder
Mood disorders
Sydenham’s chorea
PANDAS.

For mild impairment in OCD cases, guided self-help can be considered initially. If the patient is more severely affected, developmentally appropriate cognitive-behavioural therapy (CBT) and exposure response prevention (ERP) should be offered in group or individual settings, involving family and school as needed. If there is no response, a multidisciplinary review may suggest adding an SSRI, with close monitoring and awareness of delayed onset. After remission, medication should continue for at least six months before gradual withdrawal. If the SSRI fails, consider changing to a different SSRI or clomipramine (with an ECG beforehand). In specialist settings, antipsychotic augmentation may be appropriate. In severe cases unresponsive to outpatient care, inpatient care should be considered, especially if there is significant self-neglect or suicide risk. Successful outcomes are more likely with the absence of comorbidity and good insight.

An Understanding of How Anxiety Disorder Including OCD Relate to Behaviours (e.g. Self-harm, Refusal to Attend School etc.) and Contexts (e.g. Pre-school Behaviours)

Anxiety disorders, including obsessive-compulsive disorder (OCD), can significantly impact the behaviours and contexts in which children and adolescents function. These disorders often manifest through various maladaptive behaviours, as young individuals attempt to cope with overwhelming anxiety and distress.

Self-harm is one such behaviour that can be associated with anxiety disorders and OCD. The act of self-harming may serve as a means for children and adolescents to manage their intense emotions or regain a sense of control. For instance, the physical pain inflicted through self-harm can act as a distraction from the emotional pain caused by anxiety.

Refusal to attend school is another behaviour that may arise from anxiety disorders, particularly separation anxiety and social phobia. Children with separation anxiety may fear being away from their caregivers, while those with social phobia may avoid school due to the fear of humiliation or judgment in social situations. This school refusal can result in academic struggles, social isolation, and further exacerbation of anxiety symptoms.

Anxiety disorders can also affect pre-school behaviours. Young children with anxiety might display excessive clinginess to caregivers, reluctance to participate in activities, or heightened sensitivity to perceived threats. These behaviours can create difficulties in the child’s social development and ability to adapt to new environments.

In terms of context, anxiety disorders and OCD can affect how children and adolescents interact with their surroundings. For example, a child with OCD may develop rituals or compulsions, such as excessive handwashing or repetitive checking, which can interfere with daily activities and social interactions. Similarly, a child with a phobia may avoid specific contexts or situations that trigger their fear, limiting their ability to engage in age-appropriate experiences.

It is crucial to identify and address anxiety disorders and OCD in children and adolescents early on to minimize their impact on behaviours and contexts. Effective interventions, such as cognitive-behavioural therapy (CBT) and, in some cases, medication, can help young individuals learn to manage their anxiety and develop healthier coping mechanisms. This can ultimately improve their overall well-being and ability to function in various contexts.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.
Heyman, I., & Fombonne, E. (2015). Obsessive-compulsive disorder. BMJ clinical evidence, 2015, 1002.
National Institute of Mental Health. (2021). Anxiety disorders. Retrieved from https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml
Thompson, R. S., Laver-Bradbury, C., Ayres, M., & Le Poidevin, E. (2019). Anxiety disorders in children and young people. BMJ, 366, l986.