Problems We Treat
Obsessive Compulsive Disorder (OCD)
People with obsessive-compulsive disorder suffer from persistent beliefs (obsessions) that can come in the form of thoughts, images or urges. These obsessions are unwanted, repetitive, and cause life-interfering distress. Often, people suffering from OCD engage in behaviors (compulsive rituals) that reduce the distress associated with their obsessions for a brief period only to make them more difficult to eliminate. Individuals with OCD often describe feeling as if they have little to no control over these thoughts and behaviors. They also report having difficulty functioning at home or at work. Obsessions can take an infinite number of forms, but common obsessions include:
- contamination (e.g., HIV/AIDS, dirt/germs, or not-just-right feeling)
- harm to loved ones/self
- symmetry/order and exactness
- unwanted religious or sexual thoughts
- excessive doubting
- not-just-right-feeling about numerous (or single) thoughts, objects, emotions, or body sensations
Corresponding rituals include:
- hand washing or excessive cleaning
- excessive checking
- arranging or ordering
- praying or mental compulsions like replacing a bad thought with a good thought
- mentally reviewing situations
- repeating (e.g., erasing, re-ordering or adjusting, re-reading)
There are three primary features of compulsive hoarding:
- Accumulating a large quantity of possessions typically seen by others as useless and not valuable. Individuals who hoard exhibit great difficulty discarding items. Common reasons include attachment or sentimentality, facilitating memories, emotional comfort, and responsibility not to waste.
- The saving and acquiring behaviors interfere with the use of the space (e.g., can not cook in the kitchen or accommodate a guest in spare bedroom).
- The individual experiences life-interfering distress or impairment.
It is usually recommended that this subtype of OCD is treated, at least in part, in the home or location in which the items are stored.
Generalized Anxiety Disorder (GAD)
Individuals with GAD experience excessive worry during more than 30% of the day. The chronic worry creates significant anxiety and physiological sensations (e.g., stomach distress, muscle tension, fatigue, irritability). Individuals with GAD typically worry about topics that are concerns shared by most people but have difficulty “turning off a worry” and often “spiral” to imagining the worst-case scenario. Individuals with GAD often experience sleep difficulties secondary to the physical sensations brought on by worry. In general, most individuals with GAD have trouble trying new experiences (travel; recreational activities) as they have difficulty tolerating the uncertainty. GAD in children presents in a similar way, however, they may not be as aware of the worries as they are of physical problems brought on by worry (e.g., stomachaches)
Panic Disorder with Agoraphobia
Panic attacks are common in all anxiety disorders and in the general public (33% of people have had a panic attack in the past year). However, those who suffer from panic disorder have persistent fear of having a panic attack in a situation in which they cannot escape or get help. A panic attack is defined as the emergence of four or more physiological sensations (e.g., heart race, dizziness, light-headedness, stomach distress) peaking in intensity within 10 minutes. Those with panic disorder typically fear one of four catastrophic outcomes resulting from panic: “I am going to lose control of myself,” “I am going to die,” “I am going to go crazy,” and “I am going to embarrass myself.” Often, people with Panic Disorder tend to avoid situations that might elicit a panic attack (called agoraphobia). Examples of avoided situations: locations (airplanes, traffic, large open spaces); foods (caffeine, sugar, alcohol); emotions (excitement, anger, anxiety); and activities (exercise, sex). Further, people with panic disorder tend to use benzodiazepines (e.g., Xanax, Ativan) to control the onset of and recovery from panic sensations.
Individuals with health anxiety have an excessive fear of illness and/or death. Frequently, these individuals engage in excessive health “safety behaviors” such as scanning their body for “symptoms” or seeking excessive reassurance from loved ones and health professionals regarding their health status. Despite these efforts, they rarely find relief. Some individuals with health anxiety excessively avoid health information and health professionals to “magically” prevent illness. Individuals with health anxiety feel more vulnerable to disease, and, as a result, are intolerant of uncertainty regarding diseases and illness.
Post-traumatic Stress Disorder (PTSD)
PTSD is an anxiety disorder that can develop following a traumatic event (i.e., exposure to a threat to the physical integrity of self or others). The traumatic event is experienced with a sense of intense fear, horror, or helplessness. In children, the reaction involves disorganized or agitated behavior. Symptoms of PTSD include:
- re-experiencing the trauma (i.e., flashbacks, nightmares, recurrent intrusive thoughts)
- hyperarousal (i.e., feeling jumpy or easily startled, difficulty sleeping and restlessness, irritability, difficulty concentrating, and hypervigilance or feeling on guard)
- avoidance (i.e., avoiding places, people, events, or objects that remind a person of his or her trauma, emotional numbness, loss of interest in previously-enjoyed activities, difficulty remembering important aspects of the trauma, feeling cut-off from people)
Many individuals experience a few of the symptoms described above following a trauma. However, a person develops PTSD when these symptoms last more than one month and become life-interfering. In some cases, it can be months or years following a trauma before symptoms emerge.
PTSD symptoms can arise in people of all ages who have experienced a traumatic event; however, symptoms may appear differently in children compared to adults. Younger children may develop the following symptoms: repetitively acting out the event during play, separation anxiety, decrease in speech, bedwetting, and/or stomachaches and headaches. Symptoms in teenagers are more likely to resemble those of adults but may also include disruptive and destructive behaviors. In addition to the symptoms described above, those with PTSD often have emotional reactions such as anger, guilt and shame as well as disruption in sleep, diet, and exercise habits.
Some children experience significant anxiety about going to school. This anxiety often gets worse during the start of school in the fall, after long holiday breaks, or even after weekends. Children may exhibit oppositional behavior as early as weeks before school begins and report physical symptoms in an effort to remain at home. Often, children will negotiate with parents to get out of going to school, promising to go the following day or later in the day. Parents commonly feel conflicted about sending their child to school with complaints of illness and extreme distress, and often give in to their child’s pleadings.
Separation Anxiety Disorder
Children, teens, and adults with separation anxiety typically fear being away from loved ones and/or home. Common worries of separation include harm to themselves or loved ones as well as fears of having uncomfortable sensations associated with anxiety (e.g., stomach distress) or illness while away. While the worry of separating can occur during daytime activities, anxiety tends to escalate around nighttime and during extended trips. Some children will exhibit oppositional behaviors (e.g., “meltdown”, tantrums, aggression) in an effort to avoid leaving parents/home. Separation anxiety can interfere with social relationships given reluctance to enter new social situations that require temporary separation from loved ones.
Individuals with social phobia are excessively concerned with the negative judgment of others. While they remain interested in social connections, they tend to avoid social interactions to reduce their distress and discomfort. The vast majority of adults with social phobia report having experienced this worry “for as long as they could remember,” and typically describe having been shy and quiet during their school years. Physical sensations accompanying anxiety (such as stomach distress, concentration challenges, and blushing) can increase fear and embarrassment in social situations. Most adults and children with social anxiety find it difficult to initiate conversations, express opinions, speak in groups, make eye contact, tell jokes, and take risks, particularly in dating situations. In the worst cases, people with social anxiety become very isolated and depressed. In some cases, individuals with social anxiety will overextend themselves socially in order to please everyone. These people appear socially comfortable and connected, but express very little social enjoyment due to their constant need for impression management and social approval.
A specific phobia refers to the excessive and persistent fear of specific objects or situations that is understood as out of proportion to any actual danger. The fear causes life-interfering distress and/or impairment. Common types include:
- Animal Type (e.g., dogs, cats, spiders, insects, rats, birds, and snakes)
- Natural Environment Type (e.g., heights, storms, and water)
- Blood-Injection-Injury Type (e.g., seeing blood, receiving a blood test or injection, watching medical procedures)
- Situational Type (e.g., driving, flying, elevators, and enclosed places)
- Other Type (e.g., choking or vomiting, loud noises, or fears of costumed characters)
Major Depressive Disorder (MDD)
Individuals with MDD experience either loss of interest in pleasurable activities and/or persistent sadness for at least two weeks. Approximately 13% of U.S. adults report that they experienced a major depressive episode at some point in their lives. Typical symptoms of MDD include fatigue, concentration difficulties, feelings of hopelessness, thoughts of death or dying, and changes in appetite and sleep patterns. However, individuals with MDD can endorse numerous additional symptoms including anxiety, physical pain, and extreme social sensitivity. It is common to develop depression secondary to a severe anxiety disorder. Common symptoms of depression seen in children are irritability/aggression, social withdrawal, low self-esteem, and poor school performance.
Impulse Control Disorders
Clients suffering from impulse control disorders experience a strong uncontrollable urge in their body and relieve it by engaging in repetitive body behaviors. One out of 20 people report engaging in repetitive body-focused behaviors including scab picking, nail biting, and knuckle cracking. However, clients with Repetitive Body Focused Disorders (RBFD) report weak control over these urges and behaviors, excessive distress, and significant life interference.
Trichotillomania, or hair pulling, is a very common RBFD. Clients with trichotillomania will pull hair from any site on their body, but the most common sites include eyelashes, eyebrows, scalp hair, underarm and pubic regions, and arm and leg. Individuals with trichotillomania have noticeable gaps or patches in hair growth. Pulling behavior can be focused (with awareness) or automatic (without awareness). The behavior can be experienced as soothing in the moment but can lead to feelings of shame and anxiety. For some people, the pulling ritual includes examination of hair and root, as well as root chewing. Pulling behavior may be triggered by a variety of emotions (e.g., stress, anxiety, anger, boredom), situations (e.g., work, T.V., driving, falling asleep), or contexts (e.g., seclusion, mirrors, grooming).
Skin Picking is an impulse control disorder in which people excessively pick or scratch at their blemishes, scabs/sores, etc. Individuals with skin picking often pick to accelerate the healing of a blemish, achieve symmetry, or soothe an uncomfortable urge. Most individuals will describe feeling out of control or “once I start, I can’t stop.” The damage to skin is often noticeable and leads to embarrassment and shame. As a result, individuals with skin picking will typically attempt to conceal the skin picking sites.
Body Dysmorphic Disorder (BDD)
People with BDD suffer from the obsession that a part of their body is defective, deformed, or flawed. All parts of the body are susceptible, but common sites include hair, skin, nose, and legs. Clients with BDD engage in a number of “safety behaviors” to relieve their distress including body camouflaging with make-up or extra clothes, excessive mirror checks, reassurance seeking from loved ones, research on how to correct the perceived defect, avoidance of social/public gatherings and, in extreme cases, surgery. Clients suffering from BDD can experience significant life interference on every level (e.g., financial, emotional, social, and occupational). Although BDD affects a percentage of the population similar to other anxiety disorders (1-2%), it’s not a widely recognized condition.
Sleep disruption often co-occurs with anxiety and depression. Common problems include long time to fall asleep, waking up at night, or waking up early. Over time, many also develop sleep-related anxiety. CBT has been shown to be the most effective treatment for insomnia in several studies. Treatment includes assessment of sleep behaviors and related history, monitoring of sleep habits, alteration of sleep habits and environmental interference, implementation of an individually-tailored sleep schedule based on current sleep patterns, and addressing disruptive beliefs about sleep.