Anxiety and

psychosexual
disorders in child

BMR 3105
Normal versus Pathologic Anxiety

• Normal anxiety is adaptive. It is an inborn response to

threat or to the absence of people or objects that signify
safety can result in cognitive (worry) and somatic
(racing heart, sweating, shaking, freezing, etc.)
symptoms.
• Pathologic anxiety is anxiety that is excessive, impairs
function.
Primary versus Secondary Anxiety

Anxiety may be due to one of the primary anxiety

disorders OR secondary to substance abuse (Substance-
Induced Anxiety Disorder), a medical condition (Anxiety
Disorder Due to a General Medical Condition), another
psychiatric condition, or psychosocial stressors
(Adjustment Disorder with Anxiety)

The differential diagnosis of anxiety. Psychiatric and Medical disorders. Psychiatr Clin North
Am 1985 Mar;8(1):3-23
Anxiety disorders

• Specific phobia • Anxiety Disorder due to a

• Social anxiety disorder General Medical Condition
(SAD) • Substance-Induced
• Panic disorder (PD) Anxiety Disorder
• Agoraphobia • Anxiety Disorder NOS
• Generalized anxiety
disorder (GAD)
 Comorbid diagnoses

• Once an anxiety disorder is diagnoses it is critical to

screen for other psychiatric diagnoses since it is very
common for other diagnoses to be present and this can
impact both treatment and prognosis.

What characteristics of primary anxiety disorders predict subsequent major depressive disorder. J Clin
Psychiatry 2004 May;65(5):618-25
Social Anxiety Disorder
Social Anxiety Disorder (SAD)

• Marked fear of one or more social or performance

situations in which the person is exposed to the possible
scrutiny of others and fears he will act in a way that will
be humiliating
• Exposure to the feared situation almost invariably
provokes anxiety
• Anxiety is out of proportion to the actual threat posed
by the situation
• The anxiety lasts more than 6 months
• The feared situation is avoided or endured with distress
• The avoidance, fear or distress significantly interferes
with their routine or function
What is going on in their brains??
• Study of 16 SAD patients and 16 matched controls undergoing
fMRI scans while reading stories that involved neutral social
events , unintentional social transgressions (choking on food
then spitting it out in public) or intentional social
transgressions (disliking food and spitting it out)

Blair K. Et al. Social Norm Processing in Adult Social Phobia: Atypical Increased Ventromedial Frontal cortex
Responsiveness to Unintentional (Embarassing) Transgressions. Am J Psychiatry 2010;167:1526-1532
 What is going on in their brains??
• Both groups ↑ medial prefrontal cortex activity in response
to intentional relative to unintentional transgression.
• SAD patients however showed a significant response to the
unintentional transgression.
• SAD subjects also had significant increase activity in the
amygdala and insula bilaterally.

Blair K. Et al. Social Norm Processing in Adult Soical Phobia: Atypical Increased Ventromedial Frontal cortex Responsiveness
to Unintentional (Embarrasing) Trasgressions. Am J Psychiatry 2010;167:1526-1532
Functional imaging studies in SAD

• Several studies have found hyperactivity of the amygdala

even with a weak form of symptom provocation namely
presentation of human faces.
• Successful treatment with either CBT or citalopram showed
reduction in activation of amygdala and hippocampus

Furmark T et al. Common changes in cerebral blood flow in patients with social phobia treated with citalpram or
cognitive behavior therapy. Arch Gen Psychiatry 2002; 59:425-433
Panic Disorder
Panic Disorder

• Recurrent unexpected panic attacks and for a

one month period or more of:
• Persistent worry about having additional attacks
• Worry about the implications of the attacks
• Significant change in behavior because of the
attacks
A Panic Attack is:
A discrete period of intense fear in which 4 of the
following
Symptoms abruptly develop and peak within 10 minutes:
• Palpitations or rapid • Chills or heat sensations
heart rate • Paresthesias
• Sweating • Feeling dizzy or faint
• Trembling or shaking • Derealization or
• Shortness of breath depersonalization
• Feeling of choking • Fear of losing control or
• Chest pain or discomfort going crazy
• Nausea • Fear of dying
Things to keep in mind

• A panic attack ≠ panic

disorder
• Panic disorder often has a
waxing and waning course
Panic Disorder Etiology

• Drug/Alcohol
• Genetics
• Social learning
• Cognitive theories
• Neurobiology/condi-
tioned fear
• Psychosocial stessors
• Prior separation
anxiety
Agoraphobia
Agoraphobia

• Marked fear or anxiety for more than 6 months

about two or more of the following 5
situations:
• Using public transportation
• Being in open spaces
• Being in enclosed spaces
• Standing in line or being in a crowd
• Being outside of the home alone
Agoraphobia

• The individual fears or avoids these situations

because escape might be difficult or help
might not be available
• The agoraphobic situations almost always
provoke anxiety
• Anxiety is out of proportion to the actual
threat posed by the situation
• The agoraphobic situations are avoided or
endured with intense anxiety
• The avoidance, fear or anxiety significantly
interferes with their routine or function
Generalized Anxiety Disorder
Generalized Anxiety Disorder

• Excessive worry more days than not for at

least 6 months about a number of events and
they find it difficult to control the worry.
• 3 or more of the following symptoms:
• Restlessness or feeling keyed up or on edge, easily
fatigued, difficulty concentrating, irritability,
muscle tension, sleep disturbance
• Causes significant distress or impairment
Generalized Anxiety Disorder
Epidemiology
4-7% of general
population
Median onset=30 years
but large range
Female:Male 2:1
Obsessive-Compulsive and Related
Disorders
• Obsessive-Compulsive
Disorder
• Body Dysmorphic Disorder
• Hoarding Disorder
• Trichotillomania
• Excoriation Disorder
Prevalence of Obsessive-
Compulsive Related Disorders

• Body Dysmorphic Disorder-2.4%

• 9-15% of dermatologic pts
• 7% of cosmetic surgery pts
• 10% of pts presenting for oral or maxillofacial surgery!

• Hoarding Disorder- est. 2-6% F<M

• Trichotillomania 1-2% F:M 10:1!
• Excoriation Disorder 1.4% F>M
Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder
(OCD)
Obsessions or compulsions or both defined by:
• Obsessions defined by:
• recurrent and persistent thoughts, impulses or
images that are intrusive and unwanted that cause
marked anxiety or distress
• The person attempts to ignore or suppress such
thoughts, urges or images, or to neutralize them
with some other thought or action (i.e.
compulsion)
OCD continued

• Compulsions as defined by:

• Repetitive behaviors or mental acts that the person
feels driven to perform in response to an obsession
or according to rigidly applied rules.
• The behaviors or acts are aimed at reducing distress
or preventing some dreaded situation however
these acts or behaviors are not connected in a
realistic way with what they are designed to
neutralize or prevent.
OCD continued

• The obsessions or compulsions cause marked

distress, take > 1 hour/day or cause clinically
significant distress or impairment in function
• Specify if:
• With good or fair insight- recognizes beliefs
are definitely or most likely not true
• With poor insight- thinks are probably true
• With absent insight- is completely
convinced the COCD beliefs are true
• Tic- related
OCD Epidemiology

• 2% of general
population
• Mean onset 19.5
years, 25% start by
age 14! Males have
earlier onset than
females
• Female: Male 1:1
OCD Comorbidities

• >70% have lifetime • 12% of persons with

dx of an anxiety schizophrenia/
disorder such as PD, schizoaffective
SAD, GAD, phobia disorder
• >60% have lifetime
dx of a mood
disorder MDD being
the most common
• Up to 30% have a
lifetime Tic disorder
OCD Etiology

• Genetics
• Serotonergic
dysfunction
• Cortico-striato-
thalamo-cortical loop
• Autoimmune-
PANDAS
Treatment

• 40-60% treatment response

• Serotonergic antidepressants
• Behavior therapy
• Adjunctive antipsychotics, psychosurgery
• PANDAS – penicillin, plasmapharesis, IV
immunoglobulin
 Childhood Anxiety
DSM III: Separation Anxiety Disorder
• Excessive anxiety concerning separation from those
to whom the child is attached as manifested by at
least three of the following:
• Unrealistic worry about possible harm befalling major
attachment figures or fear that they will leave and not
return,
• Unrealistic worry that an untoward calamitous event
will separate the child from major attachment figures
(e.g., killed, kidnapped).
• Persistent reluctance or refusal to go to school in order
to stay with major attachment figures or at home,
• Persistent reluctance or refusal to go to sleep without
being next to a major attachment attachment figure or
to go to sleep away from home.
DSM III: Separation Anxiety
Disorder Criteria
• Persistent avoidance of being alone in the home and
emotional upset if unable to follow major attachment
figure around the home,
• Repeated nightmares involving a theme of separation.
• Complaints of physical symptoms on school days,
• Signs of excessive distress upon separation, or when
anticipating separation from major attachment figures.
• Social withdrawal, apathy, sadness, or difficulty
concentrating when not with major attachment figure.
• Duration: 2 weeks – Not due to another disorder – If 18
or older, does not meet criteria for agoraphobia.
 DSM III: Avoidant Disorder
• Persistent and excessive shrinking from contact
with strangers.
• Desire for affection and acceptance, and generally
warm and satisfying relations with family
members and other familiar figures.
• Avoidant behaviors sufficiently severe to
interfere with social functioning in peer
relationships.
• Age at least 2 ½. If age 18 or older, does not meet
criteria for avoidant personality disorder.
• Duration of at least 6 months.
 DSM III: Overanxious Disorder
• Predominant disturbance: Generalized & persistent
anxiety or worry reflected in at least 4 of the
following;
• Unrealistic worry about future events
• Preoccupation with the appropriateness of past behavior,
• Overly concerned about competence
• Excessive need for reassurance about worries
• Somatic complaints without physical basis
• Marked self-consciousness or susceptibility to
embarrassment or humiliation.
• Marked feeling of tensions or inability to relax.
Symptom present for 6 months - Does not meet criteria for
GAD - Symptoms not attributable to another disorder.
 Child Anxiety Disorders: Changing
Criteria
• While DSM IV no longer includes a separate "Anxiety Disorders
of Childhood" section, it does provide for the diagnosis of the
same types of anxiety related problems.
• Separation Anxiety Disorder continues to be listed in the
"child/adolescent" section under "Other Disorders of Infancy,
Childhood, or Adolescence".
• Children, previously diagnosed as Avoidant Disorder, are now
considered for a diagnosis of Social Phobia.
• Children previously diagnosed as Overanxious Disorder, are now
considered for a DSM IV diagnosis of Generalized Anxiety Disorder.
• Children, with excessive fears of specific objects or situations, are
diagnosed as having a Specific Phobia.
Sexual Dysfunctions

Sexual dysfunctions are disorders in which people cannot

respond normally in key areas of sexual functioning

As many as 31% of men and 43% of women in the U.S. suffer

from such a dysfunction during their lives

Sexual dysfunctions are typically very distressing, and often lead

to sexual frustration, guilt, loss of self-esteem, and interpersonal
problems

Often these dysfunctions are interrelated; many patients with

one dysfunction experience another as well
Sexual Dysfunctions

The human sexual response can be described

as a cycle with four phases:
Desire
Excitement
Orgasm
Resolution
Disorder of sexual desires affect one or more of the first three
phases
sexual
and sexual
to others

Disorders of Desire
Disorders of Desire
 de s ire o r s ex u al av e rsi on
mar ily by s oc io cu ltu ra l a n d
ut bi olo gi ca l c o nd itio ns c a n
w er s ex dr iv e s ig n ific an tly

Disorders of Desire
Disorders of Desire
Disorders of Desire
Disorders of Desire
 Disorders of Excitement

Excitement phase of the sexual response cycle

Marked by changes in the pelvic region, general physical arousal, and
increases in heart rate, muscle tension, blood pressure, and rate of
breathing
In men: erection of the penis
In women: swelling of the clitoris and labia and vaginal lubrication

Two dysfunctions affect this phase:

Female sexual arousal disorder (formerly “frigidity”)
Male erectile disorder (formerly “impotence”)
 Disorders of Excitement

 Male erectile disorder (ED)

 Characterized by persistent inability
to attain or maintain an adequate
erection during sexual activity
 This problem occurs in as much as
10% of the general male population
 According to surveys, half of all
adult men have erectile difficulty
during intercourse at least some of
the time
Disorders of Excitement
Disorders of Excitement
Disorders of Excitement
 Disorders of Orgasm

Orgasm phase of the sexual response cycle

Sexual pleasure peaks and sexual tension is released as the muscles

in the pelvic region contract rhythmically
For men: semen is ejaculated
For women: the outer third of the vaginal walls contract

There are three disorders of this phase:

Early ejaculation
Delayed ejaculation
Female orgasmic disorder
 Disorders of Orgasm – Early
Ejaculation
Characterized by persistent reaching of orgasm and
ejaculation with little sexual stimulation
As many as 30% of men experience rapid ejaculation at some
time

Psychological, particularly behavioral, explanations of this disorder

have received more research support than other explanations

The dysfunction seems to be typical of young, sexually

inexperienced men
It may also be related to anxiety, hurried masturbation
experiences, or poor recognition of arousal
Disorders of Orgasm – Delayed
Ejaculation

Characterized by a repeated inability to reach orgasm or by

a very delayed orgasm after normal sexual excitement

Occurs in 8% of the male population

Biological causes include low testosterone, neurological disease,
and head or spinal cord injury
A leading psychological cause appears to be performance anxiety
and the spectator role, the cognitive factors involved in ED
 Disorders of Orgasm- Female
Orgasmic Disorder

 Characterized by persistent delay in or absence of orgasm

 Most clinicians agree that orgasm during intercourse is not mandatory
for normal sexual functioning
 Typically linked to female sexual arousal disorder

 The two disorders tend to be studied and treated together

 Once again, biological, psychological, and sociocultural factors may

combine to produce these disorders
Disorders of Orgasm- Female
Orgasmic Disorder
Disorders of Orgasm- Female
Orgasmic Disorder
Genito-pelvic Pain/Penetration
Disorder

Dysfunctions that do not fit neatly into a specific phase of

the sexual response cycle and are characterized by
enormous physical discomfort during intercourse, and are
called genito-pelvic pain/penetration disorders

Vaginismus
Dyspareunia
Disorders of Sexual Pain

Vaginismus
 Characterized by involuntary contractions of the muscles of the
outer third of the vagina
 This problem has received relatively little research, but
estimates are that it occurs in fewer than 1% of all women
 Most clinicians agree with the cognitive-behavioral theory that
vaginismus is a learned fear response
 Some women experience painful intercourse because of
infection or disease
 Many women with vaginismus also have other sexual disorders
 Disorders of Sexual Pain

Dyspareunia

Characterized by severe pain in the genitals during sexual activity

As many as 14% of women and about 3% of men suffer from
this problem
Dyspareunia in women usually has a physical cause, most
commonly from injury sustained in childbirth
Although psychological factors or relationship problems may
contribute to dyspareunia, psychosocial factors alone are rarely
responsible