AnxietyAnxiety

Karen Crowley, Laura Karen Crowley, Laura Simandl, Vickie RemmelzwaalSimandl, Vickie Remmelzwaal

BackgroundBackground

• AnxietyAnxiety– A normal reaction to stressA normal reaction to stress– Helps one cope Helps one cope – Anxiety can become excessive and irrational, Anxiety can become excessive and irrational,

which leads to a disorderwhich leads to a disorder

• Five main types of Anxiety DisordersFive main types of Anxiety Disorders– Generalized Anxiety DisorderGeneralized Anxiety Disorder– Obsessive Compulsive Disorder (OCD) Obsessive Compulsive Disorder (OCD) – Panic DisorderPanic Disorder– Post-Traumatic Stress Disorder (PTSD) Post-Traumatic Stress Disorder (PTSD) – Social Phobia (or Social Anxiety Disorder)Social Phobia (or Social Anxiety Disorder)

BackgroundBackground

• Anxiety Disorders are the most Anxiety Disorders are the most common mental illness in Americacommon mental illness in America

• Women suffer from anxiety and stress Women suffer from anxiety and stress almost twice as much as menalmost twice as much as men

• Anxiety disorders cost the U.S. over Anxiety disorders cost the U.S. over $42 billion a year$42 billion a year

• People with Anxiety Disorders are 3-5 People with Anxiety Disorders are 3-5 times more likely to go to the doctor times more likely to go to the doctor than non-sufferersthan non-sufferers

BackgroundBackground

Emotional/Psychological Emotional/Psychological SymptomsSymptoms

• Feeling restless or on edge Feeling restless or on edge • Avoidance Avoidance • Irritability Irritability • Confusion Confusion • Behavioral problems Behavioral problems

(especially in children and (especially in children and adolescents)adolescents)

• Nervousness and jumpiness  Nervousness and jumpiness  • Self-consciousness and Self-consciousness and

insecurity insecurity • Fear that you are dying or Fear that you are dying or

going crazy going crazy • Strong desire to escape Strong desire to escape

Physical Symptoms Physical Symptoms • Heart palpitations or racing Heart palpitations or racing

heartbeat heartbeat • Chest pain  Chest pain  • Hot flashes or chills Hot flashes or chills • Cold and clammy hands Cold and clammy hands • Stomach upset or queasiness Stomach upset or queasiness • Frequent urination or diarrhea Frequent urination or diarrhea • Shortness of breath Shortness of breath • Sweating Sweating • Dizziness Dizziness • Tremors, twitches, and jitters Tremors, twitches, and jitters • Muscle tension or aches Muscle tension or aches • Headaches Headaches • Fatigue Fatigue • Insomnia Insomnia

NeurobiologyNeurobiology

• Progress of understanding anxiety in Progress of understanding anxiety in children lags behind understanding children lags behind understanding anxiety in adults anxiety in adults – obstacles in the study of children such obstacles in the study of children such

as recruitment, lack of assessment as recruitment, lack of assessment tools, and ethical problems involving the tools, and ethical problems involving the use of research techniques and use of research techniques and technologies technologies

NeurobiologyNeurobiology

• Brain activates neurophysiological Brain activates neurophysiological responses to increase survival when a responses to increase survival when a threatening cue is presentthreatening cue is present

NeurobiologyNeurobiology• Anxiety disorders originate from an increased Anxiety disorders originate from an increased

arousal in the limbic system arousal in the limbic system – specific patterns of neuronal activity result in the actual specific patterns of neuronal activity result in the actual

sensation of anxietysensation of anxiety– Amygdala, which is in the limbic system, plays a central Amygdala, which is in the limbic system, plays a central

role in fear and anxiety and is involved in the expression role in fear and anxiety and is involved in the expression and acquisition of conditioned fearand acquisition of conditioned fear

Neurobiology – Predictive Neurobiology – Predictive SignsSigns• Thousands of gene products that, if abnormal, could Thousands of gene products that, if abnormal, could

result in altered functioning of the neurotransmitter result in altered functioning of the neurotransmitter and neuroanatomical regions involved in regulating and neuroanatomical regions involved in regulating anxietyanxiety

• Positive relationship between neurological Positive relationship between neurological abnormalities at age 7 and later affective disorders in abnormalities at age 7 and later affective disorders in adolescenceadolescence

• Amygdala is well developed at birth, and develops Amygdala is well developed at birth, and develops before the hippocampus completes its development before the hippocampus completes its development – early traumatic experiences may leave their traces in the early traumatic experiences may leave their traces in the

amygdala as emotional memoriesamygdala as emotional memories– may lead to an emotional response of anxiety without the may lead to an emotional response of anxiety without the

cognitive memory of the triggercognitive memory of the trigger

NeurobiologyNeurobiology

• Physiological differences have been found Physiological differences have been found between inhibited and uninhibited childrenbetween inhibited and uninhibited children– Behavioral inhibition is a temperament that Behavioral inhibition is a temperament that

predisposes 20% of children to be highly reactive to predisposes 20% of children to be highly reactive to unfamiliar situations or peopleunfamiliar situations or people

– higher heart rates, decreased heart rate variability, higher heart rates, decreased heart rate variability, increased tension in the vocal chords, and increased tension in the vocal chords, and increased salivary cortisol levelsincreased salivary cortisol levels

– EEG measurements have shown greater activity in EEG measurements have shown greater activity in the right amygdala as neural activity in the the right amygdala as neural activity in the amygdala is transmitted to the frontal lobesamygdala is transmitted to the frontal lobes

Neurobiology – Specific Neurobiology – Specific LinksLinks

• Panic DisorderPanic Disorder– SerotoninSerotonin– HereditaryHereditary– Decreased blood flow in frontal cortexDecreased blood flow in frontal cortex

• OCDOCD– SerotoninSerotonin– HeredityHeredity– Brain DamageBrain Damage

NeuroimagingNeuroimaging

• Role of the GABA A Receptor in AnxietyRole of the GABA A Receptor in Anxiety• Benzodiazepine receptorsBenzodiazepine receptors• Benzodiazepine agonist increases sensitivity of Benzodiazepine agonist increases sensitivity of

GABA-binding site reduces anxietyGABA-binding site reduces anxiety• Benzodiazepine antagonist reduces sensitivity Benzodiazepine antagonist reduces sensitivity

of GABA-binding site increases anxietyof GABA-binding site increases anxiety• Suggesting: A secretion of a neuromodulator that Suggesting: A secretion of a neuromodulator that

blocks the binding site at the GABA A receptor or a blocks the binding site at the GABA A receptor or a diminished number of benzodiazepine receptors are diminished number of benzodiazepine receptors are the cause of Anxiety Disordersthe cause of Anxiety Disorders

• Benzodiazepines are often used to treat anxiety, Benzodiazepines are often used to treat anxiety, but they can have intolerable side effects and be but they can have intolerable side effects and be addictiveaddictive

NeuroimagingNeuroimaging

• Brain imagining techniques such as Brain imagining techniques such as PET, fMRI show altered patterns of PET, fMRI show altered patterns of brain activity in a number of anxiety brain activity in a number of anxiety disordersdisorders

• Altered regional cerebral blood flow, Altered regional cerebral blood flow, metabolism or oxygenationmetabolism or oxygenation

NeuroimagingNeuroimaging

• Patients with Simple phobia, OCD, PTSD: Patients with Simple phobia, OCD, PTSD: Share cerebral blood flow alterations in Share cerebral blood flow alterations in medial orbitofrontal cortex (OFC), rostral medial orbitofrontal cortex (OFC), rostral anterior cingulate cortex (rACC), inferior anterior cingulate cortex (rACC), inferior frontal cortex, and insula frontal cortex, and insula

• Patients with OCD: Exhibit specific Patients with OCD: Exhibit specific alterations in blood flow or metabolism within alterations in blood flow or metabolism within the basal gangliathe basal ganglia

• Patients with Panic Disorder: Differential Patients with Panic Disorder: Differential brain metabolism in hippocampus, rACC, and brain metabolism in hippocampus, rACC, and OFCOFC

Implications for School Psychologists

• Many children with anxiety disorders do not receive treatment

• Benefits of school-based treatment– School psychologist can play active role in

educating administrators and teachers to recognize symptoms and understand prevalence

– Many commonly feared situations occur in school setting

– Less stigma in school-based help than in clinically-based therapy

– Opportunities for prevention abound

Rationales for School-Based Prevention Efforts

• Many children with anxiety disorders get ignored because of internalizing nature of behaviors and because of co-occuring disorders such as depression and ADHD

• Childhood anxiety disorders often continue into adulthood if left untreated

• School Problems include academic underachievement, school attendance issues, difficulties interacting with teachers, and peers

Cognitive Behavioral Therapy• General CBT techniques

– Relaxation skills, Cognitive restructuring, Problem solving and Graded exposures

• Adaptations for specific childhood disorders – Separation Anxiety Disorder– Social Phobia– Generalized Anxiety Disorder– Selective Mutism

Implications for future

• More research is needed on effectiveness and adaptability of programs for preschool age children

• More research is needed on effectiveness of interventions across cultural, ethnic and socioeconomic groups

• School psychologists need to take an active role in implementing prevention efforts in their schools

References

Barrett, P. & Turner, C. (2001). Prevention of anxiety symptoms in primary school children: preliminary results from a universal school-based trial. British Journal of Clinical Psychology, 40, 399-410.

Carlson, N.  (2005).  Foundations of Physiological Psychology: 6th ed      Boston: Allyn & Bacon.  Cummins, T. K., & Ninan, P. T. (2002). The neurobiology of anxiety in children and

adolescents. International Review of Psychiatry, 14, 114-128.D’Amato, R., Fletcher-Janzen, E., & Reynolds, C.  (2005).  Handbook of School

     Neuropsychology.  Hoboken, NJ: Wiley.Fisher, P.H., Maisa-Warner, C. & Klein, R. (2004.) Skills for social and academic success: a

school-based intervention for social anxiety disorder in adolescents. Clinical Child and Family Psychology Review, 7, 241 – 249.

Gosch, E. A. & Flannery-Schroeder, E. (2006). Principles of cognitive-behavioral therapy for anxiety disorders in children. Journal of Cognitive Psychotherapy: An International Quarterly, 20, 247 -262.

Gray, R. M., Jordan, C. M., Ziegler, R. S., & Livingston, R. B. (2002). Two sets of twins with selective mutism: neuropsychological findings. Child Neuropsychology, 8, 41-51.

Grover, R.L., Hughes, A.A., Bergman, R.L. & Newman Kingery, J. (2006). Treatment modifications based on childhood anxiety diagnosis: demonstrating the flexibility in manualized treatment. Journal of Cognitive Psychotherapy: An International Quarterly, 20, 275-286.

References

Helpguide. (2006). Retrieved June 1, 2007, from Web site: http://www.helpguide.org/mental/anxiety_types_symptoms_treatment.htm.

Hirshfeld-Becker, D. R. & Biederman, J. (2002). Rationale and principles for early intervention for children at risk for anxiety disorders. Clinical Child and Family Psychology Review, 5, 161-172.

Liberzon, I., Phan, K.L., Khan, S., & Abelson, J.L. (2003). Role of the GABA A receptor in anxiety: Evidence from animal models, molecular and clinical psychopharmacology, and brain imaging studies. Current Neuropharmacology, 1, 267-283.

National Institute of Mental Health. (2007). Retrieved June 1, 2007, from Web site: http://www.nimh.nih.gov/healthinformation/anxietymenu.cfm

Perry, B. D. (1998). Aspects of anxiety disorders in children. In C. E. Coffey, & R. A. Brumback (Eds.), Textbook of Pediatric Neuropsychiatry. Washington, DC: American Psychiatric Press, Inc.

Tillfors, M. (2004). Why do some individuals develop social phobia? A review with emphasis on the neurobiological influences. Nord J. Psychiarty, 58, 267-276.

Tomb, M. & Hunter, L. (2004). Prevention of anxiety in children and adolescents in a school setting: the role of school-based practitioners. Children and Schools, 26, 87-101.