PSY3018

Child and Adolescent

Psychopathology
Chapter 11 – Anxiety Disorders,
Obsessive-Compulsive Disorder, and
Somatic Symptom Disorder
Delivered by Kammy K. M. LAU (Reg. Psychol.)

1
 Outline
• Developmental Tasks and Challenges Related to
Fear vs. Worry
• Anxiety Disorders
– Generalised anxiety disorder (廣泛性焦慮症)
– Separation anxiety disorder (分離焦慮症)
– Social anxiety disorder (社交焦慮症)
• Obsessive-Compulsive Disorder
• Somatic Symptom Disorder
• Etiology
• Intervention
DEVELOPMENTAL TASKS AND
CHALLENGES RELATED TO FEAR
VS. WORRY
Developmental Tasks and Challenges Related to
Fear vs. Worry
• Worries commonly observed in children
– Future oriented
– Possible threats tied to health, school, & personal harm
• Relatively minor (e.g. getting poor grades, being sent to the
principal, or having parents argue)
• More troubling (e.g. falling from high places or not being able
to breathe)

• Fear commonly observed in children

– Present oriented
– E.g. Fear of darkness
– Dangerous/ life-threatening events (e.g. being hit by a
car, getting burned in a fire, death or dead people, or
being bombed or attacked)
Developmental Tasks and Challenges Related to
Fear vs. Worry
• Is it normal for children to feel fear or worry?
– Emotional arousal
•  accompanied by emotional regulation (emotional control)
• The development of emotion regulation in children
• From birth, there is an ongoing balance of independent and
coordinated ER.
• Infants and toddlers are mostly supported by their caregivers in
their ER efforts.
• Babies also initiate ER by physically turning away from
overwhelming stimulation, or by cuddling with a special blanket.
• Preschoolers and young children are often ER partners with
adults, as when a teacher and a child work together through an
episode of anger.
• Older children and adolescents are usually expected to manage
ER independently.
– With the growth of knowledge, self-confidence, and ER strategies,
most fears decline with age.
 ANXIETY VS. ANXIETY DISORDER
• 焦慮是一種由緊張、不安、焦急、憂慮、擔心或恐
懼等感受交織而成的複雜情緒狀態。當焦慮出現時，
常伴隨一些生理的病徵，包括心悸、心跳加快、暈
眩、呼吸困難、出汗增多、身體顫抖、胃部不適、
或腹瀉等。
• 其實，每個人都可能因為某些事、人物、或場合的
不確定而感到焦慮，例如面對考試或上台表演，這
些焦慮常是短暫性的，是對特定情況下可以理解的
正常反應，並非是一種精神病。
• 但如果兒童焦慮的程度較嚴重，而且持續一段時期
以致影響日常生活、社交及學習，他/她便有可能
患上焦慮症。(Dysfunction)
 FACTS ABOUT ANXIETY DISORDER
AMONG CHILDRED AND ADOLESCENT
IN HONG KONG
• 焦慮症則是與焦慮有關的精神病的總稱。常見於兒
童及青少年的焦慮症包括分離焦慮症、恐懼症、社
交焦慮症和廣泛性焦慮症。硏究結果顯示兒童及青
少年患有焦慮症的情形並非罕見，大約一百個兒童
或青少年有三至四個案例 (資料來源: 青山醫院)

https://www3.ha.org.hk/cph/imh/mhi/article_02_01_04_chi.asp
Generalised anxiety disorder; Phobias; Separation anxiety disorder; Social
anxiety disorder

ANXIETY DISORDERS
 Anxiety disorders
• Anxiety disorders
• the maladaptive experience of anxiety in terms of intensity,
duration, and pervasiveness
• Anxiety disorders are diagnosed when fears and
worries are painful and disabling
• Causing clinically significant distress or impairment in social,
occupational, or other important areas of functioning
[Applies to all disorders]
• Characterized by exaggerated and unrealistic fears
and anxieties, withdrawal/avoidance & somatic
symptoms
• Among the most frequently diagnosed disorders in
children, adolescents, and adults
• In DSM-5, descriptions of anxiety disorders and their diagnostic
criteria are roughly similar for children and adults.
– One important difference is that children need not understand the
irrationality or excessiveness of their anxieties
 Video Time

https://www.youtube.com/watch?v=mvJFeI6zjH4
 Anxiety disorders:
Generalised Anxiety Disorder (GAD)
• Generalised Anxiety Disorder (GAD)
– Excessive and unrealistic anxiety and worry about a variety
of stimuli and situations occurring more days than not for at
least 6 months
– Difficult to control
– Associated with at least one of the following physical
symptoms
1. Restlessness
2. Being easily fatigue
3. Difficulty in concentration or mind going blank
4. Irritability
5. Muscle tension 
6. Sleep disturbance

• Children with GAD receive comorbid diagnoses of

obsessive-compulsive disorder and mood disorders more
frequently than children with other anxiety disorders.
 Generalized Anxiety Disorder (GAD)

• GAD suffers = pathological worrier

“What do they really worry about?”

• Children: “What if” ??

• Need only one physical symptom

• Worry about minor, everyday concerns
• Academic, social, sport performance or family issue
• Problems in sleeping

F: M =
2:1 16
 中文版
• 廣泛性焦慮症的徵狀則包括緊張不安、煩躁、容易
疲倦、注意力無法集中、肌肉僵硬難以放鬆和失眠。
患者隨時隨地容易感到焦慮不安，但是他並不清楚
造成焦慮的原因，好像感到隨時將有禍事發生。他
們所憂慮和害怕的事物、情境或活動可十分廣泛。
 Anxiety disorders:
Separation Anxiety Disorder
Separation Anxiety Disorder
• Intense fear or anxiety when separating from attachment
figures (e.g. parents)
– age-inappropriate distress when separated from the caregiver and
clingy behaviors in the presence of the caregiver
• Unrealistic and persistent worry that danger (possible
harm) will happen to their significant others or themselves
• Avoidance behaviors may occur in the workplace as well
as at school  associated with academic/ social
impairments
• Somatic problems are common
• Applied to all ages, typically last for at least 6 months

20
 中文版
• 分離焦慮症的徵狀主要是與害怕離開身邊常照顧他
/她的重要成人(通常是父母或照顧者)有關。當面臨
分離時，或知道將要分離時，該兒童會變得十分驚
惶，會擔心大人會遭遇不測，或有禍事發生以致不
可再重聚；不肯上學；沒有熟人陪伴下不睡覺；惡
夢的內容多數與分離有關；不能獨自留在熟悉的地
方；時常抱怨身體不適 (例如頭痛、胃痛、或嘔吐)。
 Anxiety disorders:
Social Anxiety Disorder
Social Anxiety Disorder
• A marked and persistent fear of one or more social or
performance situations in which the person is exposed to
unfamiliar people or to possible scrutiny by others. The
individual fears that he will act in a way (or anxiety symptoms)
that will be humiliating or embarrassing.
• Exposure to the feared social situation almost provokes anxiety,
which may take the form of cued panic attack.
• The feared social or performance situations are avoided or are
endured with intense anxiety or distress.
• The avoidance, anxious anticipation, or distress in the feared
social or performance situation(s) interferes significantly with
the person’s normal routine, occupational (academic)
functioning, or social activities or relationships.
• Applied to all age; duration is at least 6 months
• Onset usually begins early in adolescence (why?)
• Peak age = 13
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https://www.bbc.com/news/uk-england-derbyshire-
49726011?intlink_from_url=https://www.bbc.com/news/topics/cwlw3xz04egt/mental-
health&link_location=live-reporting-story
 中文版
• 至於社交焦慮症，患者主要是害怕面對陌生人，當
需要接觸陌生人時，會顯得尷尬、害羞、或過度在
乎自己的行為是否恰當；十分憂慮出席一些可能被
人注意的場合；在某些社交場合顯得非常緊張、沈
默，渴望儘早離開。
 To be considered a
Panic attack – panic attack, the
episode must be
Four or more symptoms accompanied by four
or more of the
following symptoms
 Palpitations , pounding heart, or accelerated heart rate
 Sweating
 Trembling or shaking
 Sensations of shortness of breath or of smothering
 Feeling of choking
 Chest pain or discomfort
 Nausea or abdominal distress
 Feeling dizzy, unsteady, lightheaded, or faint
 Derealization(feelings of unreality) or depersonalization (being
detached from oneself)
 Fear of losing control or going crazy
 Fear of dying
 Paresthesias (numbness or tingling sensations )
 Chills or hot flushes

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 ANXIETY DISORDERS
Etiology [Individual level]
• Biological causes
1) Inherited tendency to be tense (i.e. diathesis)
•  No single gene
• A general vulnerability rather than a disorder-specific risk
2) Physiological contributors to risk for anxiety disorders
− Brain areas associated with processing of negative emotions
(e.g, amygdala activity)
− Systems involved in regulation of stress response
(e.g., autonomic nervous system, HPA axis
[hypothalamic-pituitary-adrenocortical] is
activated)
 ANXIETY DISORDERS
Etiology [Individual level]
• Psychological causes
– Cognitive styles [Cognitive distortion]/杞人憂天的悲觀想法
• Beliefs/perceptions about the world
– Controllable vs. uncontrollable
• Beliefs about your coping ability
• Over-estimate the threat ( attentional biases to the threatening
stimuli)
• Exaggerate the danger of a situation
• Cognitive appraisals of ambiguous situations as -ve
– Behavioural perspective
• Learning from the early experience/modeling
– Real traumatic experiences with the phobic objects/ situations
– Experienced “lack of control”  a lack of security
• “Information transmission”
 ANXIETY DISORDERS
Etiology [Individual level]
• Psychological causes
– Temperament of a child
• The temperamental trait most associated with anxiety is
inhibition
– E.g. timid, shyness, distress of unfamiliarity
– Insecure attachments
• lead to both short- and long-term outcomes
involving anxiety disorders

− Emotion regulation/dysregulation are key components

in the development of anxiety disorders
− Children who experience frequent or intense negative
emotions and are unable to regulate these emotions are
especially vulnerable to develop anxiety disorders.
 ANXIETY DISORDERS
Etiology [Individual level]
• Psychological causes
− Depositional characteristics
− E.g. easily anxious, nervous
 ANXIETY DISORDERS
Etiology [Family level]
Parents
• Parenting factors associated with anxiety
disorders
− Parental psychopathology
− E.g. Mother with anxiety disorder   anxiety disorders in
offspring
− Over-protection/ over-controlling and negative/critical
parenting
− Children do not know the proper way to control situations when
they grow up
− Weaken their coping skills
− Modeling of anxious and avoidant behavior
 ANXIETY DISORDERS
Etiology [Socio-cultural level]
• School system
– Teachers
• Attitudes towards the children
• Number/ frequency of assessment
–  number   stress

• Community
– Foster the culture of competitiveness
• Poverty
 「誘因」
• 焦慮症會隨著某些「誘因」的出現而一觸出發。這些「誘因」包括於應
付不來的外在壓力或生活轉變，例如轉校、功課壓力、親人患病或離異
等等。亦有一些焦慮症是在患者經歷過一次心理創傷之後才開始出現的。

• 潛伏因素 (predisposing factors)

遺傳、與生俱來的脾性(比較敏感、容易炆憎)、過往的恐懼經歷、習染家長
的焦慮

• 引發因素 (precipitating factors)

生活壓力 (如: 測驗/考試等)、重大的人生轉變 (如: 親友或寵物離世等) 、突

發意外、藥物影響/突然病重/長期病患，賀爾蒙失調

• 持續因素 (perpetuating factors)

家長的管教因素(如: 間接鼓勵子女逃避的習慣；過份嚴厲的管教方法；反
覆無常的管教方法) 、偏向負面的思考模式、生活失衡、感覺不到親人、朋
輩的關愛、支持
 https://www.youtube.com/watch?v=ua9zr16jC1M

OCD is not included with anxiety disorders in DSM-5.

OBSESSIVE-COMPULSIVE
DISORDERS
 Obsessive-Compulsive Disorder (OCD)
Obsessions
• Recurrent and persistent thoughts, impulses, or images that are experienced, at
some time during the disturbance, as intrusive and inappropriate and cause
marked anxiety of distress [internal stressor]
• The person attempts to ignore or suppress such thoughts, or to neutralize them
with some other thought or action

Compulsions
• Repetitive behaviours (e.g. handwashing, ordering, checking) or mental acts (e.g.
repeating words, counting, praying) that the person feels driven to perform in
response to an obsession, or according to the rules that must be applied rigidly
[rituals]
• They aimed at preventing or reducing distress

• The obsessions and compulsions cause marked

distress, are time consuming, or significantly
interfere with the person’s normal routine,
occupational (academic) functioning, or usual
social activities or relationships 44
 Obsessive-Compulsive Disorder (OCD)
• Boys are at greater risk than girls
• 2 subtypes:
– Children with earlier onsets (between 5-9 years)
• Tends to be boys, family history of OCD, & comorbid disorders
– Those with later onsets (after 17 years)
• Obsession and compulsion must be
examined within a developmental
framework
– many children display
specific preferences
and rituals that are not
pathological.
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 Case Study
Danny is a 13-year-old boy referred because of concerns noted by both his
parents and teachers about some of his increasingly unusual behaviors.
Danny 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 and become
increasingly socially isolated. During the initial assessment, Danny took an
unusually long time to complete some simple questionnaires. When asked
about this, Danny admitted that he felt compelled to count the words in each
sentence before reading the sentence. He said that this has become a real
problem because he can no longer complete his homework on time. Danny
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 that 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 that he does not have to touch things like
door knobs or public telephones. 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.
Symptom subtypes Obsession Compulsion

Symmetry/ exactness • Things need to be • Arranging / ordering

symmetrical things in a certain
• Urges to do things order
over and over until
they feel “just right”

Cleaning & • Fears of germs or • Repetitive or

Contamination contamination excessive washing
• Using gloves, masks
to do daily tasks

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SOMATIC SYMPTOM
DISORDER
 Somatic Symptom Disorder
• Somatic symptom disorders
– use of somatic language to describe both physical and emotional
problems
•  cannot differentiate physical & emotional experiences & have difficulties
to use emotional language to express anxiety
– Cause significantly distress and impairment
• Somatization refers to a variety of processes in which
an individual experiences physical symptoms, such as
pain or loss of function, for which a physical cause cannot be
found or, if present, cannot fully account for the level of
impairment
– An especially common and well-studied somatic
symptom disorder is recurrent abdominal pain that
involves three or more episodes over a three-month
period of severe pain that compromises
a child’s functioning
• Like compulsive behaviours in OCD, somatic
symptoms serve to moderate the experiences of
anxiety
 CASE STUDY
Sally 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.
Sally reports feeling ill frequently and each year has missed many school days, including
field trips and special events. Sally’s older sister had an emergency appendectomy several
years ago. Ever since this event, Sally’s parents have been especially vigilant about her
health. Sally’s parents have extremely high expectations for their children’s academic
achievement; any problems with academic performance are viewed with great concern, and
doing well is highly reinforced. Sally’s older sister is a top student at her high school, where
Sally is currently enrolled as a ninth grader. In the spring of eighth grade, Sally 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
ninth grade, Sally began complaining of severe, debilitating abdominal pain. After being
called on several occasions to bring Sally home from school because of pain, Sally’s
parents 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 Sally’s symptoms. Finally, the specialist the family
consulted recommended hospitalization for more extensive and intrusive diagnostic
procedures. After all of the findings from these tests proved negative, a psychology consult
was requested. Although initially skeptical of the involvement of the psychologist, Sally and
her mother were cooperative. The psychologist observed that while Sally verbalized
concern about missing school, she appeared relaxed and calm. Additionally, while she
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, Sally denied having any worries about this other than those related to
falling behind in her work since being hospitalized.
INTERVENTION
 Anxiety Disorders, OCD,
& Somatic Symptom Disorder
Main components of cognitive-behavioral therapy:
− Psychoeducation
− providing families with information about normal anxiety
− Somatic management
− relaxation techniques to treat physiological symptoms
− Cognitive restructuring
− identification and modification of negative thoughts that elicit and
prolong anxiety
− Problem solving skills
− step-by-step, active, behaviorally oriented approach for coping
− Exposure (e.g. social skill training)
− systematic and controlled exposure to the stimuli and situations
that are associated with anxiety
− Relapse prevention
− maintenance and generalization of improvements
 Anxiety Disorders, OCD,
& Somatic Symptom Disorder

• Treatments for fears

− Modeling: using observational learning
− Systematic desensitization: teaching an anxious child
how to relax when exposed to the feared stimulus
− Exposure: rewarding a child for desired behavior
− Self-talk: providing positive self-statements
• Combined psychological/pharmacological
therapies seem most appropriate for older children
and those with more severe symptoms
E.g. Selective Serotonin Reuptake Inhibitors
 Treatments
• Exposed-based treatment/
Systematic Desensitization
– Graduated, consistent, & structured
– Under supervision of therapists https://www.youtube.co
m/watch?v=n4m2NJlJV
• Why? uc

– Practise at home alone

– Relaxation & breathing retraining

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 Video time –
Systematic desensitization

https://www.youtube.com/watch?v=08pJJRsF30o
 Upon completion of today’s lecture,
you should be able to …
• Discuss the normal development of fears, worries, and emotion
regulation.
• Define separation anxiety disorder according to the DSM-5.
• Define phobic disorder according to the DSM-5.
• Define social phobia according to the DSM-5.
• Define panic disorder according to the DSM-5.
• Define obsessive-compulsive disorder according to the DSM-5.
• Define somatic symptoms disorder according to the DSM-5.
• Discuss the etiology of anxiety disorders, obsessive-compulsive
disorder and somatic symptom disorder.
• Discuss the different treatment options available to children
who have anxiety disorders, obsessive-compulsive disorder
and somatic symptom disorder.