CPRI Brake Shop clinic: Anxiety
- How does TS affect or influence anxiety?
- How does stress influence OCD?
- When reviewing the criteria for OCD in the DSM (the Diagnostic & Statistical Manual), and in reading various books, much of what is said about OCD doesn’t seem to capture this student’s issues. Are there unique aspects to OCD when it is early-onset and comorbid with tics?
- OCD is supposedly an anxiety disorder, yet our son isn’t what we would consider an anxious person at all. Why is that?
- What are some common ways that OCD can be misperceived?
- How do I know if something is a tic, or a compulsion?
- How can OCD symptoms and sensory symptoms be distinguished?
- My son is diagnosed with both OCD and ADHD, and presents with a number of self-injurious behaviours. Would this be impulsivity, or is it OCD?
- What things do I need to know when parenting a child with OCD?
- Is there a higher likelihood of substance abuse when a person has OCD?
- Can you tell us more about what is happening in the brain to cause anxiety disorders?
- Why is this child withdrawing socially?
- Why is it so hard for my child to separate from me?
- Will (s)he eventually overcome his/her separation anxiety? How can we support him/her in that?
1. How does TS affect or influence anxiety?
This can happen in a number of ways. First, TS and OCD (which is an anxiety disorder) commonly occur together. They are very similar disorders, in that both involve engaging in certain actions (tics for TS, compulsions for OCD) to try and relieve an uncomfortable sensation (premonitory urges for TS, obsessions for OCD). Finally, the brain circuitry implicated in both TS and OCD is very similar, and overlaps.
Social anxiety or separation anxiety (from parents) can develop over time in children with TS as well: in an environment under-informed about tics and TS, children may come to learn that social interactions only lead to humiliation, embarrassment, teasing, or accusations borne of misperceptions because of their tics. If parents are their sole source of advocacy and validation, they will naturally begin to ‘cling’, particularly in novel (i.e. ‘dangerous’) social situations.
2. How does stress influence OCD?
Generally, stress increases o/c symptoms. Stressors may include being tired, hungry, being hot, being surrounded by many people, or having many or unexpected demands put upon you.
For this reason, the more anxious the individual with OCD is, the more likely (s)he is to become even more “stuck” in obsessions or the compulsive rituals that ease this anxiety. In the moment, this “stuckness” may appear to family, school personnel, or residential staff members to be oppositional or defiant behaviour. If this “stuckness” is responded to as if it IS wilful defiance (e.g. by punishing the child), this will likely only increase the stress and anxiety, resulting in the individual being even more “stuck” and a larger conflict will ensue.
Hence, it is imperative to remember that, in these cases, “opposition” isn’t always what it appears to be on the surface. Very often times you are all actually on the same side in that NO ONE is happy that this “stuckness” is happening. Using a number of anxiety-reduction techniques WITH the individual in a supportive, lighthearted manner (as identified in our “Exposure and Response Prevention” answer in the “Treatment” section of our FAQ page) will likely be a quicker and more effective way of helping this individual to “shift” and move on. Remember: anything that increases the tension or stress in the situation (e.g. acting rushed, raising your voice, threatening consequences) will in this case work AGAINST your goals, not help further them!
3. When reviewing the criteria for OCD in the DSM (the Diagnostic & Statistical Manual), and in reading various books, much of what is said about OCD doesn’t seem to capture this student’s issues. Are there unique aspects to OCD when it is early-onset and comorbid with tics?
Yes… and for this reason it is not uncommon for the diagnosis to be completely missed in these students. Most literature on OCD describes symptoms typical for adult-onset ‘pure’ cases. In actual fact, it is now known that there are four subtypes or ‘flavours’ of OCD, each with its own degree of heritability, comorbidity pattern, neurological correlates, and treatment response.
Contamination obsessions and rituals (i.e. fear of germs, and excessive hand-washing) are the best-known ‘flavour’, but more common in children with TS and OCD are ‘Bad Thoughts OCD’ (intrusive and distressing imagery) and symmetry/neatness/ ordering/arranging symptoms. Family history for anxiety disorders also tends to be stronger in cases of pediatric-onset OCD comorbid with tics, and the probability of a child with tics also developing OCD increases with intelligence level.
4. OCD is supposedly an anxiety disorder, yet our son isn’t what we would consider an anxious person at all. Why is that?
This is yet another place where the presence of a tic disorder tends to change the presentation of OCD a bit. Specifically, rather than traditional, fullblown, coherent fears of horrible consequences if a ritual is not adhered to, those with both OCD and tics often experience more of a ‘cognitive unrest’, a preoccupying and vague mental discomfort which dissipates when the compulsion is completed.
Secondly, and more importantly, once families learn what it is OCD wants them to do, they may all begin preempting the anxiety altogether by completing compulsions before the discomfort even begins. Hence, even though on the surface there doesn’t appear to be any anxiety driving certain behaviours, once treatment begins and compulsions are resisted this underlying anxiety is revealed. Also, while this avoidance training certainly alleviates any immediate tensions, doing so ultimately leads to much stronger compulsions and increasingly compromised living.
5. What are some common ways that OCD can be misperceived?
- Rudeness or disagreeableness: internal difficulty in managing unexpected transitions can show on one’s face, creating a false impression of harshness or insolence. Identifying and labelling these physical manifestations (e.g. talking about one’s, “OCD face”) can help others to recognize these moments as signs of cognitive discomfort and not necessarily a reaction to the content of their message or personally directed.
- Bossiness or selfishness: think of OCD as holding the diagnosed individual hostage, forcing the person to do its bidding. Since OCD is an invisible instigator, though, it is easy for others to mistake a bossy & selfish OCD for a bossy & selfish person in front of them.
- Lack of empathy: it is hard to think about the feelings of others when you yourself are struggling. Just as a drowning person’s sense of self-preservation will override normal considerations for others, this behaviour is borne not of indifference but of an OCD-driven sense of impending peril.
- Non-compliance: this misinterpretation may come about because of an automatic, “no” to your request (which is more accurately interpreted as, “I need some time to process this shift”). Misinterpretations may also result from continual requests to change a response you’ve given (which is more about OCD wanting things phrased, ‘just right’ than it is about your actual decision).
- Psychosis: sometimes when youth attempt to describe OCD to others, their choice of language (e.g. “a voice telling me to do things”, “something inside of me putting ideas in my head”) can sound like hallucinations or delusions rather than an attempt to describe distressing thoughts they cannot stop.
6. How do I know if something is a tic, or a compulsion?
To just look at the behaviour itself usually isn’t enough. The best way to figure this out is to ask what is “driving” the behaviour. If there is some kind of anxious thought or ‘rule’ behind the behaviour (e.g. “it has to be done three times”, or “if I don’t do this then ____ will happen!!!”), then the behaviour is likely a compulsion and a symptom of OCD. If there is some kind of uncomfortable bodily sensation behind the behaviour (e.g., “I feel a tickle in my throat until I make that noise”, or “my arm feels itchy so I have to move it a lot), then the behaviour is likely a tic and a symptom of TS.
7. How can OCD symptoms and sensory symptoms be distinguished?
Given that it feeds on anxiety, OCD tends to opportunistically seize on any pre-existing source of consternation. In so doing, OCD amplifies and takes control of various issues or fears. In this respect, one need not distinguish sensory issues from OCD issues. Naturally a person would feel some anticipatory anxiety regarding certain upcoming sensory experiences anyway; what OCD does is warp and heighten this understandable trepidation (e.g. by creating many proactive ‘rules’ for people to rigidly follow so as to avoid any undesired sensory experiences).
8. My son is diagnosed with both OCD and ADHD, and presents with a number of self-injurious behaviours. Would this be impulsivity, or is it OCD?
These kinds of behaviours present in youth with TS often only when symptoms of OCD are also present.
Tics are performed in response to an involuntary premonitory urge (i.e. the tic is the ‘scratch’ to the premonitory urge’s ‘itch’). In children with comorbid OCD, sometimes that ‘scratch’ involves the sensation of pain (e.g. poking oneself with a pin). Scab-picking can be part of this phenomenon as well, but it can also occur for a variety of other reasons:
– it can be part of a grooming subtype of OCD (other symptoms in this subtype include continuous handwashing or long ritualized showers)
– it can also be the result of a ‘just right/perfectionism’ subtype of OCD (e.g. picking the scab to make the wound look symmetrical or to feel smooth, etc.)
9. What things do I need to know when parenting a child with OCD?
Many ideas are contained in our handout, “Putting The Brakes on Obsessions & Compulsions” (found on our website) and in the Frequently Asked Questions section on Treatment. In addition, the following “T(r)IC(k)S” will also be helpful:
1. Choose your battles, but be consistent in which battles you will choose. It is unfair to expect an individual with OCD to suddenly “boss back” a particular symptom that has been ignored every other day. The bulk of flexibility in situations cannot be expected from the individual least neurologically capable of BEING flexible. The child may very much want to “go with the flow” and accommodate a changed schedule or a parental whim, but unfortunately the disorder will not typically comply.
2. Allot the necessary time to complete compulsions not “chosen”. If you’ve decided that a certain battle is not worth fighting, it will be important to plan accordingly the time that compulsion will take to occur. For example, if the amount of you’re your daughter usually needs to arrange her room is more time than you have before the family needs to leave to go to an appointment, it is unfair to ask her to go arrange her room right now before the family leaves.
3. Avoid surprises. There is no such thing as a “good” or “safe” surprise with OCD. Any surprise is a sudden transition.
4. Use “soft” transitions. The more warning an individual has that a transition is about to occur the better. Proactive discussions about situations where those “bossy thoughts” tend to create problems will also soften the impact of transitioning when that time arrives. Finally, rigid routines that incorporate transitions as part of that rigid routine can, on the surface, “fake” flexibility where none exists.
10. Is there a higher likelihood of substance abuse when a person has OCD?
There is indeed some data to suggest that individuals diagnosed with OCD (especially with juvenile onset) may be especially vulnerable to developing substance use issues. If an individual does not possess the skills for, ‘bossing back’ OCD (such as those taught in ERP therapy), perhaps the (ab)use of consciousness-altering substances serves as a method to escape or avoid unrelenting, intrusive, and aversive thoughts.
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11. Can you tell us more about what is happening in the brain to cause anxiety disorders?
Our thoughts are connected to our emotions – in other words, depending upon what thoughts we have about a particular situation we are going to feel different things. For example, let’s say a car honks at you on the street. If you think the person honking the horn was rudely telling you to get out of her way, the resulting emotion might be anger. If you think she thought you were cute and was checking you out, then you might feel happy or excited. And finally, if you think she may have hit the horn by accident then this thought probably doesn’t elicit any emotion at all.
In the brain, we can see that thoughts and emotions are connected. Specifically, there are connections between the “thinking” area of our brain (the frontal cortex) and the “feeling” area of our brain (the basal ganglia). There is a “go” circuit (to start thinking and worrying about something) and there is also a “stop” circuit. When you have, ‘leaky brakes’ over your thoughts, guess which one doesn’t work well! The thoughts get stuck on, and so around and around they go, stirring up more and more emotion in their travels.
12. Why is this child withdrawing socially?
Individuals with ‘leaky brakes’ are coping with considerably more internal dyscontrol and disruption than others need contend with. Tic suppression is roughly akin to being covered in mosquito bites yet holding back from scratching them despite an evermounting urge to do so. They may also be contenting with trying to consciously inhibit impulses, hyperenergy, a roving attention, sensory hypersensitivities, and obsessions creating significant anxiety.
Hence, it is of little surprise that these individuals may appear inattentive, can at times be quicker to irritate than their peers, and have more severe symptoms in the evenings and on weekends (when all of this pent-up frustration ‘rebounds’).
It is important to note that personal strength, interest in peers or willingness to socialize, personality factors, or potential “depression” is not at issue here. The best way to conceptualize the struggles of our clients is not to think that they have a lower threshold for tolerating stimulation, but rather that they have considerably more stimulation TO tolerate. Because anyone with that much “in their beaker” would withdrawal or be hesitant to enter into high-stimulation situations, in effect these individuals are having a quite natural response to an abnormal circumstance.
As our clients’ comfort with their symptoms increases, they oftentimes feel freer to release their symptoms. This can have the effect of ‘lowering their beakers’, and can result in an increased capacity to socially interact.
13. Why is it so hard for my child to separate from me?
This could be for various reasons.
One possibility is this: when most other individuals in your child’s life either do not know of his/her ‘leaky brakes’ or misunderstand them (e.g. past school staff, peers, extracurricular groups), it is likely that your child sees you as one of the only “safe” individuals in his/her life. Put another way, the separation issues are less about a genuine fear of separating from you, and more about learning that over time it is important to keep you near as this seems to help to avert misconceptions and disaster.
Another possibility is that your child is suffering from recurrent thoughts of harm befalling you if (s)he does not keep you in sight. This may be a sign of an anxiety disorder such as OCD or separation anxiety disorder, and an assessment may be warranted.
14. Will (s)he eventually overcome his/her separation anxiety? How can we support him/her in that?
While anxiety disorders are often chronic conditions, they can be well-treated and managed with the proper interventions in place. As a general rule anxiety that is given in to or avoided only becomes worse, and anxiety that is confronted improves. With this in mind, a number of recommendations are suggested:
- A good rule of thumb to keep in mind regarding anxiety: anything that increases stress will make the separation anxiety worse. Hence, arguments about getting to school, threatening consequences for not attending, and appearing very worried about the situation or a symptom in front of the child should be avoided.
- On the other hand, anything that decreases stress (e.g. validating the child’s discomfort, or using humour) will improve anxiety.
- Throwing a child into a feared situation, in hopes that this will “cure” them, backfires in children and ends up worsening the anxiety considerably. - Hence, a slow desensitization is preferable. This may take the form of having the parent initially stay in the situation, and then gradually phase him/her out while class time (or play time at a friend’s) without the parent present is increased.
- This slow desensitization should be consistent; occasional “give-ins” to pleas to stay home actually makes it exceedingly harder to eventually eliminate that behaviour than if you stay firm. It will also ultimately take much longer to eliminate the behaviour.
- When phasing yourself out, it is very important not to “sneak off” while the child is distracted, as the negative surprise and anxiety the child will feel when (s)he realizes the adult has disappeared will only heighten the need to “cling” and closely monitor that adult’s presence.
- Partnering your child with a mentor or friend at school is a good idea, as is having that mentor or friend sometimes pick your child up and walk with him/her to school.
- If you suffer from anxiety yourself, a plan should also be in place for this mentor/friend to always pick up and/or take your child to school on days when your own anxiety may amplify your child’s anxiety, or on days when your own anxiety may be a reason why your child wishes to stay at home (i.e. staying at home will decrease both of your anxiety, and so you both give in).
- Allowing your child to take a personal and valued article of yours (called a “transitional object”) to school or the feared situation can help him/her to manage his/her anxiety better throughout the day.
- Reinforcing your child’s efforts to manage his/her anxiety is a good idea. Reinforcing him/her only for a particular output (e.g. stay at school all day) is not.
- Acknowledge any somatic complaints the child may have (e.g. stomachaches), but treat them casually.
- The teacher could provide the child with a special task or role in the classroom that (s)he is ‘needed’ for.
- When group work is required, involve the child in a small group that is in a quiet, separate place from the other groups.
- Discourage home tutoring.
- As the child progresses through school and oral requirements increase (e.g. speeches, class presentations, reading passages), (s)he should have the option to do the assignment on video or audio recorder at home, or to present to only the teacher and one peer alone. Grades would then be based on the recorded or limited-audience performance.
Frequently Asked Questions home page.