What We Treat
Generalized Anxiety Disorder (“GAD”) occurs when a person worries about a wide range of topics.” All individuals worry from time to time, but for someone with GAD the level of worry may be excessive. This worry is often accompanied by physical symptoms. Approximately 1% of adolescents and 3% of adults qualify for a full diagnosis of GAD. While the average age of onset is 30 years, this disorder can occur at any age. GAD thoughts are often a “moving target” of worry, with concerns across many domains of a person’s life. Some people with GAD try to find evidence that contradicts their worry, but even that evidence doesn’t fully alleviate their concerns. For example, a person may worry about having strep throat, but going to the doctor and receiving a negative test result for strep doesn’t fully alleviate their worry about having/getting strep throat.
Common worries include:
- Daily tasks (school, work, driving, etc.)
- Family, friend and relationship worries
- Health/safety concerns
Common physical symptoms include:
- Easily tired
- Difficulty concentrating
- Muscle tightness
- Difficulty with sleep
Cognitive Behavioral Therapy (CBT), offered at CABC, is an evidence-based treatment of GAD and includes recognizing anxious thoughts and worries and identifying the function of the worry. Sometimes people feel that the worries help keep them safe or perform better at school/work. Treatment can help to identify healthier ways to accomplish these functions of the worries. The ultimate goal of cognitive therapy is to acknowledge that worries and anxious thoughts are normal and they don’t have to dominate a person’s thoughts or control their life. For more information about GAD and anxiety, visit www.adaa.org.
Social Anxiety Disorder (previously referred to/interchangeable with “social phobia”) is more than just being shy. It is characterized as an excessive fear of being judged and evaluated negatively by other people in one or more social situations. People with social anxiety often fear they will do something that will humiliate themselves, and as a result, they often avoid situations or hold-back from participating from activities in which this could happen. In children, this fear must occur in peer settings and not just during interactions with adults.
Common difficulties include:
- Meeting new people
- Making small talk
- Public speaking (e.g., presenting or speaking up in class or in a business meeting)
- Performing on stage
- Being the center of attention
- Being watched while doing something
- Being teased or criticized
- Talking with or asking for help from authority figures
- Eating or drinking in public
- Attending parties or other social gatherings
- Making phone calls (e.g., ordering online)
Common physical symptoms include:
- Upset stomach, nausea
- Trembling or shaking
- Red race, blushing
- Racing hear or tightness in chest
- Sweating or hot flashes
- Feeling dizzy or faint
Common negative thoughts:
- “I know I’ll end up embarrassing myself”
- “People will think I’m stupid”
- “I don’t have anything important enough to say”
- “People will think I’m boring”
- “My voice may start shaking and people will know I’m nervous”
At CABC, we offer an evidence-based, comprehensive behavioral treatment program for Social Anxiety Disorder which consists of individual and group treatment. The individual treatment includes psychoeducation, coping skills training, and Exposure Therapy, where the client learns to actively confront their fears in a systematic fashion. The group therapy component utilizes a skills acquisition model in which specific social skills that are commonly difficult for children and teens are taught through psychoeducation, modeling, and behavioral rehearsal. Social skills that are covered include: recognizing social cues, initiating conversations, maintaining conversations, joining groups, extending invitations, giving and receiving compliments, speaking on the telephone, proper assertiveness with peers and authority figures, and resisting peer pressure.
CABC is proud to represent Montgomery County, Maryland and Northern Virginia as a Regional Clinic of the National Social Anxiety Center (NSAC). NSAC was established with the goal of making the highest quality, evidence-based psychotherapy services to treat social anxiety available to those in need. NSAC works to achieve this aim by providing resources to clinicians and the public to promote education, collaboration, and access to care. Visit nationalsocialanxietycenter.com for more information.
Obsessive Compulsive Disorder (“OCD”) is a disorder in which a person experiences obsessions and compulsions. This disorder occurs in about 1% of the total population with the average age of onset at 20 years old. Of those with this disorder, 25% of people develop the disorder before 14 years old.
Obsessions are persistent thoughts/images/urges that are disturbing or bothersome and cause impairing distress. Despite a person’s efforts to rid themselves of these unwanted thoughts, they continue to occur leading to distress. Compulsions are repetitive behaviors, mental rituals, and avoidance that a person engages in, in order to reduce the distress associated with the obsessions.
Common obsessive thoughts include:
- Thoughts about safety of self/others
- What if I hurt my child?
- I will get in a car accident if _____
- What if I don’t lock my doors?
- My house will catch on fire if _____
- Thoughts about health, germs, diseases, contaminants
- What if I encounter germs that will make me sick?
- I will get cancer if _____
- What if my headache is actually a sign of a tumor?
- Thoughts about sexuality
- Did I find that person attractive?
- What if I’m actually gay? (not an indication of homophobic beliefs, but difficulty tolerating the uncertainty of not knowing for sure)
- What if I’m secretly a pedophile?
- Thoughts about relationships
- What I don’t really love my partner/spouse?
- What if my spouse isn’t really “the one”?
- What if I’m not actually attracted to them?
- Thoughts about religion/faith
- I won’t get into heaven if I do/don’t _____
- What if I just sinned?
- What if my parents/friends end up in hell?
Common compulsive behaviors include excessive:
- Washing (hands, surfaces, knobs, etc.)
- Checking (locks, doors, object placement, etc.)
- Praying or reading of religious texts in a manner out of the norm for that person’s culture/religion
- Reassurance seeking about behaviors and thoughts (from friends, parents, teachers, priest, doctor, etc.)
- Avoidance of situations/settings one fears might trigger unwanted thoughts
- Doing something to feel “just right”
Exposure and Response Prevention (ERP) is the gold standard treatment for OCD. It is an effective evidence-based treatment for reducing obsessions and compulsions. With the guidance and support of a therapist, individuals with OCD learn how to resist engaging in compulsions as a means of emotion regulation leading to reduced suffering. Typical “talk-therapy” approaches to treating OCD, invariably lead to more suffering from these often debilitating symptoms.
In addition to ERP, some classes of medications can help reduce OCD symptoms. Consulting with a psychiatrist in addition to a psychologist at CABC may be beneficial to treatment progress.
For more information about OCD, visit https://iocdf.org/about-ocd/.
Many aspects of life can be stressful and challenging. A trauma is a specific incidence that can lead to even more distress and emotional difficulties. Types of traumatic incidences include:
- Natural disaster (e.g., tornado, flood, fire, hurricane)
- Physical abuse, assault
- Domestic violence
- Sexual violence, assault, rape
- Exposure to terrorism
- Serious car accident
- Exposure to war, torture
- Community violence
- Actual or near death
- Serious medical illness
- Witnessing and learning about any of the above events happening to another person can also be considered a trauma
*For a parent/caregiver of a child who has experienced a trauma, simply hearing/learning about the child’s trauma can be a trauma for the parent/caregiver.
Everyone responds to trauma differently and having a strong emotional response after a trauma is normal. Extreme distress from trauma that extends for longer than about a month may be considered Posttraumatic Stress Disorder (PTSD). For example, about 80% of people will experience a traumatic event in their lifetime, but only 9% will develop PTSD. Signs and symptoms that a response to trauma that may require treatment and not resolve on its own over time include:
- Frequent, intrusive memories or thoughts of the trauma
- Distressing dreams
- Flashbacks or feeling like the trauma is occurring again
- Shakiness, muscle tension, headaches, stomach aches
- Avoidance of memories, people, places, or things associated with the trauma
- Difficulty remembering parts of the traumatic event
- Distancing self from family/friends
- Altered thoughts
- Negative thoughts about oneself (e.g., “I am bad/tainted/broken”)
- Self-blame for the trauma
- Feeling persistent fear, guilt, shame, anger
- Not being able to enjoy things one used to enjoy
- Difficulty concentrating
- Difficulty sleeping
- Being overly alert or on lookout for danger
Sometimes those who have experienced a trauma experience these negative experiences occur shortly after the trauma and others don’t notice these symptoms until much later after the trauma.
While no therapy will be able to erase a person’s traumatic experience, there are specific therapies that have been shown to be very effective in treating these unwanted symptoms and intrusive memories of the trauma. Trauma Focused Cognitive Behavioral Therapy (TF-CBT) for children has been shown to be a very effective treatment for reducing trauma symptoms.
For more information on TFCBT, visit: https://tfcbt.org/
Cognitive Processing Therapy and Prolonged Exposure (PE) are similar treatments for adults that are also offered at CABC.
Cognitive Processing Therapy focuses on confronting thoughts that arise in the aftermath of a trauma, as well as on the connections between those thoughts and the emotions and behavioral urges in response to those thoughts. Working together with a therapist, individuals can learn new strategies to challenge those thoughts, generating more compassionate, balanced, and flexible thinking habits that allow them to re-engage with their lives. This process is called cognitive restructuring.
PE teaches individuals to gradually approach trauma-related memories, feelings, and situations that they have been avoiding either intentionally or unintentionally. This is called exposure. It may seem counterintuitive but confronting fear directly can actually reduce it in the long run. Exposures can be in vivo (e.g., revisiting and confronting situations, places, people, or activities that a survivor has been avoiding since the trauma), or imaginal (i.e., visualizing a past event/place/person and talking in detail about the trauma).
Separation Anxiety Disorder is a developmentally inappropriate, excessive fear or anxiety regarding being apart from a caregiver (or someone whom a child is closely attached), or home. It is the most common anxiety disorder of childhood.
Common worries include:
- Worries of never being able to see the caregiver again
- Worries that the caregiver will die or experience severe injury/illness (e.g., being in a car accident or plane crash)
- Worries about experiencing an event that would cause separation from caregiver (e.g., getting lost, being kidnapped)
- Avoidance of activities that may require separation from caregiver (e.g., school, camp, parties, sleepovers)
- Nightmares about separation from caregiver
Common physical symptoms (when anticipating separating from caregiver) include:
- Bed wetting
Separation anxiety can begin at any age in childhood and typically appears beginning in preschool. About 2-4% of children and adolescents experience separation anxiety disorder.
Exposure therapy is a very effective treatment of this disorder. In this type of therapy, a child practices facing their fear and being away from their caregiver in different settings and for varying durations. In a supportive environment, a child can progress through a “hierarchy” of fearful situations; for example, sitting in a separate room from the caregiver to going on an overnight outing without the caregiver.
What is Selective Mutism?
Selective mutism (SM) is an anxiety disorder that renders children speechless in school and community settings, despite speaking in other settings, for example, at home with family members. SM affects up to 2% of children and commonly begins in children ages 2.5 – 4 years old.
Children with SM can vary in (non)speaking behaviors depending on the person, place, or situation/activity. If untreated, SM can interfere with social and emotional development as well as impede academic progress. Early identification and intervention can help children find their voice.
Difficulty talking despite a ‘warm up’ period
Chatty at home, but mostly or completely silent at school
Points, gestures, or nods, instead of speaking directly with others
Known by peers as the child who ‘does not speak’
Issues impact friends, class participation, and seeking help
Provide extra warm-up and 1:1 time
Use forced-choice questions (is it red or blue?), instead of yes/no (is this red?) or open-ended (what color is this?) questions
Wait 10-15 seconds for a response
Praise simply (“thanks for telling me”), then quickly redirect back to the topic or activity
Be patient and don’t take it personally!
The Good News… evidence based assessment and treatment for SM is available! Services include:
Weekly individual or group therapy
School training and ongoing consultation with school teams
Parent and caregiver training
Sessions in the clinic, school, or in the community
Intensive therapy involving multi-day and/or multi-hour treatment sessions
Selective Mutism Resources
Many people fear specific objects or situations like heights, insects, snakes, etc. But when does a fear become a phobia that requires treatment?
- Does the fear prevent you from doing things you need to do or would like to do? For example, maybe you aren’t able to go on certain vacations because of a fear of flying. Or you haven’t been to the doctor for necessary appointments because of a fear of needles.
- Do you have to make accommodations because of your fear? For example, maybe you have a friend or family member drive you to appointments or pick up groceries for you because of a fear of driving.
A specific phobia exists when the fear or anxiety is out of proportion to the actual danger that the object or situation poses, or more intense than is deemed necessary. Individuals with a specific phobia often recognize that their reactions are disproportionate, but still overestimate the danger in their feared situations. Phobias may develop following a traumatic event (e.g., being attacked by an animal or stuck in an elevator), observing others going through a traumatic event (e.g., witnessing someone drown), an unexpected panic attack in the to-be feared situation (e.g., out of the blue panic attack on the subway), information transmission (e.g., media coverage of a plane crash), etc. Many individuals, however, are unable to recall the reason for the onset of their phobia(s).
It is common for individuals to have multiple specific phobias. Specific phobias often fall into the following categories:
- Animals (e.g., spiders, bees, dogs)
- Natural environment (e.g., heights, storms, water)
- Blood-injection-injury (e.g., needles, invasive medical procedures)
- Situational (e.g., airplanes, elevators, enclosed places)
- Other (e.g., situations that may lead to choking or vomiting)
Exposure therapy is used to gradually and repeatedly expose an individual to the feared object or situation in a safe and controlled environment. Exposures to fears often follow a hierarchy, for example, an individual afraid of spiders may start treatment by looking at a picture of a spider, then work up to being in the same room as a real spider, getting closer to the spider, and eventually holding the spider in their hand. This would be an example of in vivo exposure. Exposure can also be imaginal (e.g., vividly imagining boarding an airplane, taking a seat, and taking off from the runway). Another type of exposure is called interceptive exposure, in you deliberately bring on physical sensations that are harmless, yet feared (e.g., someone with a fear of vomiting may spin around in a chair until they feel dizzy or nauseas). Exposures can help to weaken previously learned associations between feared objects/situations and over time, people find their reactions to feared objects/situations decrease (habituate).
*Blood-injection injury phobia is unique in that following an initial increase in heart rate and blood pressure that are typical of phobic responses, a subsequent drop in blood pressure and/or heart rate may cause a person to faint. Before exposure, individuals with BII phobia will be taught Progressive Muscle Relaxation. Progressive muscle relaxation is a process of applying muscle tension to a specific part of the body (e.g., target just the left foot) and then slowly releasing this tension – continuing contracting and relaxing muscle groups throughout the body. Applied muscle tension (during exposure to a feared object/situation) can help to increase blood pressure and therefore interfere with a fainting response.
Panic disorder refers to recurrent, unexpected (or “out of the blue”) panic attacks. A panic attack is a sudden experience of intense fear or intense discomfort. Panic attacks usually reach their peak within 10 minutes and may last up to around 20 to 30 minutes, although people may feel the effects last longer.
How do you know if you’re having a panic attack?
Common symptoms include:
- Palpitations, pounding heart, or accelerated heart rate
- Trembling or shaking
- Sensations of shortness of breath or smothering
- Feelings of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, light-headed, or faint
- Chills or heat sensations
- Numbness or tingling sensations
- Derealization or depersonalization (feeling detached from self/out-of-body)
- Fear of losing control or “going crazy”
- Fear of dying
Panic disorder, in addition to panic attacks, includes one or both of the following:
- Worries about having another panic attack or their consequences (e.g., losing control, having a heart attack)
- Changing your behavior in an effort to avoid having panic attacks (e.g., avoiding exercise or unfamiliar situations)
Similar to the treatment of phobias, panic disorder is treated with Exposure therapy. In a safe, controlled manner, your therapist will help you gradually re-create the symptoms of a panic attack or confront objects/situations that trigger panic attacks. Interoceptive exposure is used to re-create panic symptoms (e.g., breathing through a straw quickly to induce hyperventilation). Cognitive behavioral therapy also includes psychoeducation and tools such as relaxation/muscle tension/breathing techniques to help recognize and modify actions/reactions associated with panic triggers.
Adjustment Disorder is the development of emotional or behavioral symptoms in response to an identifiable stressor(s) out of proportion to the severity or intensity of the stressor. Symptoms may overlap with depression, anxiety, or related disorders. Symptoms typically developing within three months of stressor onset and lasting no more than six months post-stressor.
Stressors may be a single event (e.g., fired from job, diagnosis of medical condition), or multiple stressors (e.g., business difficulties coinciding with marital problems). Stressors may be recurrent (e.g., seasonal business crisis, recurrent hospitalizations for a medical illness), or continuous (e.g., persistent painful illness, unfulfilling romantic relationship).
Cognitive behavior therapy is used to treat adjustment disorder, with focus on the maladaptive thoughts and beliefs associated with the stressor, the practice of relaxation strategies to reduce distress, and the development and use of problem-solving skills.
Attention-Deficit/Hyperactivity Disorder (ADHD) is defined by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with executive functinoing. Individuals can be both inattentive and hyperactive/impulsive (combined type), predominately inattentive, or predominately hyperactive/impulsive.
Common inattentive symptoms:
- Unable to pay close attention to details or make careless mistakes in schoolwork, at work, or during other activities)
- Difficulty sustaining attention in tasks or activities
- Does not seem to listen when spoken to directly
- Does not follow through on instructions and fails to finish schoolwork/chores (e.g., starts tasks but quickly loses focus and is easily sidetracked)
- Difficulty organizing/managing/prioritizing tasks and activities
- Avoids or is reluctant to engage in tasks that require sustained mental effort
- Easily distracted by extraneous stimuli (may include unrelated thoughts)
Common hyperactive/impulsivity symptoms:
- Fidgets with or taps hands or feet or squirms in seat
- Often leaves seat in situations when remaining seated is expected
- Runs or climbs about in situations where it is inappropriate (in adults, this may be limited to feeling restless)
- Difficulty playing or engaging in leisure activities quietly or sitting still for an extended period of time
- Difficulty waiting their turn
- Interrupts or blurts out a response inappropriately
At CABC, ADHD is treated with behavioral therapy. Behavioral therapy addresses specific problem behaviors by structuring time at home, establishing predictability and routines, and increasing positive attention. For the treatment of children, therapists may work with the parents to create a behavior plan. The plan may include a narrow focus on essentials, clear, manageable goals (e.g., getting to bed on time), and a commitment to note and reward improvement when it occurs. We also provide Parent Management Therapy (PMT) individually and in groups, in which parents and a therapist can share behavioral plans/strategies and how to implement and enforce appropriate consequences. Therapists can also communicate with school personnel, helping children receive appropriate accommodations for classroom/testing purposes (i.e., a 504-Plan or an Individualized Education Program [IEP]).
ADHD is also commonly treated with medication, referred to as stimulants (e.g., Adderall [Amphetamine], Ritalin [Methylphenidate], Concerta [Methylphenidate], Focalin [Dexmethylphenidate], Vyvanse [Lisdexamfetamine Dimesylate]) and non-stimulants (e.g., Intuniv [Guanfacine], Strattera [Atometine]).
Some individuals benefit from a combination of medication and behavioral therapy. At CABC, we do not prescribe or manage these medications, but are happy to work as a team with the prescribing doctor.
For more information about ADHD, visit: https://add.org/adhd-facts/
CABC works with individuals experiencing several different types of depressive disorders, most commonly being major depressive disorder (MDD). The common feature of all depressive disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes. Depressive disorders differ depending on duration, timing, or presumed etiology.
A Major Depressive Episode includes at least one of the following symptoms:
- Depressed mood most of the day, nearly every day (or irritable mood in children and adolescents)
- Loss of interest or pleasure in all, or almost all, activities most of the day, nearly every day
Other depressive symptoms include:
- Significant weight loss or gain (not due to dieting), or decrease or increase in appetite
- Sleep (e.g., insomnia, sleeping all day)
- Being physically agitated or slowed down
- Fatigue or loss of energy
- Feelings of worthlessness or guilt
- Poor concentration or difficulty making decisions
- Recurrent thoughts of death (not just fear of dying), or suicide (with or without a plan)
Cognitive behavioral therapy is used to treat depression by helping clients recognize, evaluate and challenges negative thoughts/beliefs about themselves, the world, and the future that lead to them feel depressed. Behavioral Activation (BA) is a therapeutic intervention also used to treat depression, focusing on helping clients become more engaged in activities that they value and have given up since becoming depressed. Identifying specific goals for the week and working to meet those goals by re-engaging with previously enjoyed activities/hobbies provides natural positive reinforcement.
Along with CBT, depression may be treated with antidepressant medication, such as Selective Serotonin Reuptake Inhibitors (SSRIs). These medications work by increasing levels of serotonin within the brain. Serotonin is associated with many functions, including mood, appetite, sleep cycle, and sex drive.
Body Focused Repetitive Behavior (BFRB) is a general term for a group of related disorders that cause people to repeatedly touch their hair and/or body in ways that may result in physical damage (e.g., scabs, scarring, tissue damage, and infection). Common BFRBs include: Hair-Pulling Disorder (Trichotillomania), Skin-Picking Disorder (Excoriation) and Nail-Biting Disorder (Onychophagia). Some individuals engage in BFRBs when bored (e.g., lying in bed, sitting at a desk), when anxious, or while fully focused (e.g., looking in the mirror while picking acne). Individuals may engage in BFRBs to relieve stress or to experience gratification or other sensations.
Treatment of BFRBs includes a specific cognitive-behavioral therapy called habit reversal training (HRT) and an enhanced HRT protocol – the Comprehensive Behavioral Model (ComB). HRT includes awareness training to help the person focus on circumstances during which pulling or picking is most likely to occur, and competing response training to teach the person to substitute another response for the pulling or picking behavior that is incompatible with the BFRB. For example, when someone has an urge to pick their hair, they could ball up their hands into fists and tighten their arm muscles to make pulling/picking impossible in that moment.
The comprehensive behavioral (ComB) model, developed by Dr. Charles Mansueto and his colleagues, is based on the assumption that a person engages in their BFRB because it meets one or more need in the individual (e.g., helping to relax, to fall asleep, or to feel like a goal was accomplished). This model focuses on understanding why, where and how a person engages in their BFRB so that individualized interventions can be selected to help the person achieve what they want to achieve without engaging in the BFRB. For more information on BFRBs, visit https://www.bfrb.org/
A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization. Tics are common in childhood but most often transient. Onset of tics is typically between ages 4 and 6 years with peak severity occurring between ages 10 and 12 years, declining in severity during adolescence. An individual may have various tic symptoms over time. Tics are generally experienced as involuntary but can sometimes be voluntarily suppressed for varying lengths of time. Tics can be simple (e.g., eye blinking, shoulder shrugging, clearing throat, sniffing) or complex (e.g., combination of simple tics simultaneously, such as head turning and shoulder shrugging). Tic disorders may be diagnosed as persistent (chronic) motor or vocal tic disorder, provisional tic disorder, unspecified or other tic disorder, or Tourette’s Disorder.
Tourette’s Syndrome is a specific type of tic disorder defined by both multiple motor tics (2+) and at least one vocal tic. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset.
Habit reversal training (HRT) and Cognitive Behavioral Intervention for Tics (CBIT) is used for the treatment of Tics. HRT for tics also includes awareness training, helping the person learn to identify the earliest warning that a tic or is about to take place. These warning signs can be urges, sensations, or thoughts, and may not coincide with the part of the body where a tic occurs. The therapist and individual then work to create competing responses. For example, if someone has tic of tilting their head to the left, a competing response may be to tilt their head to the right when they feel an urge. CBIT incorporates HRT, and helps the person identify situations that may cause tics to be worse than they might otherwise be (e.g., stressful/anxiety-producing situations such as giving a presentation). Components of CBT are used to help manage and alleviate feelings of anxiety which in turn, helps decrease the severity of tics.