Anxiety

1. Anxiety Karen Crowley, Laura Simandl, Vickie Remmelzwaal

2. Background • Anxiety • A normal reaction to stress • Helps one cope • Anxiety can become excessive and irrational, which leads to a disorder • Five main types of Anxiety Disorders • Generalized Anxiety Disorder • Obsessive Compulsive Disorder (OCD) • Panic Disorder • Post-Traumatic Stress Disorder (PTSD) • Social Phobia (or Social Anxiety Disorder)

3. Background • Anxiety Disorders are the most common mental illness in America • Women suffer from anxiety and stress almost twice as much as men • Anxiety disorders cost the U.S. over $42 billion a year • People with Anxiety Disorders are 3-5 times more likely to go to the doctor than non-sufferers

4. Emotional/Psychological Symptoms Feeling restless or on edge Avoidance Irritability Confusion Behavioral problems (especially in children and adolescents) Nervousness and jumpiness  Self-consciousness and insecurity Fear that you are dying or going crazy Strong desire to escape Physical Symptoms Heart palpitations or racing heartbeat Chest pain  Hot flashes or chills Cold and clammy hands Stomach upset or queasiness Frequent urination or diarrhea Shortness of breath Sweating Dizziness Tremors, twitches, and jitters Muscle tension or aches Headaches Fatigue Insomnia Background

5. Neurobiology • Progress of understanding anxiety in children lags behind understanding anxiety in adults • obstacles in the study of children such as recruitment, lack of assessment tools, and ethical problems involving the use of research techniques and technologies

6. Neurobiology • Brain activates neurophysiological responses to increase survival when a threatening cue is present

7. Neurobiology • Anxiety disorders originate from an increased arousal in the limbic system • specific patterns of neuronal activity result in the actual sensation of anxiety • Amygdala, which is in the limbic system, plays a central role in fear and anxiety and is involved in the expression and acquisition of conditioned fear

8. Neurobiology – Predictive Signs • Thousands of gene products that, if abnormal, could result in altered functioning of the neurotransmitter and neuroanatomical regions involved in regulating anxiety • Positive relationship between neurological abnormalities at age 7 and later affective disorders in adolescence • Amygdala is well developed at birth, and develops before the hippocampus completes its development • early traumatic experiences may leave their traces in the amygdala as emotional memories • may lead to an emotional response of anxiety without the cognitive memory of the trigger

9. Neurobiology • Physiological differences have been found between inhibited and uninhibited children • Behavioral inhibition is a temperament that predisposes 20% of children to be highly reactive to unfamiliar situations or people • higher heart rates, decreased heart rate variability, increased tension in the vocal chords, and increased salivary cortisol levels • EEG measurements have shown greater activity in the right amygdala as neural activity in the amygdala is transmitted to the frontal lobes

10. Neurobiology – Specific Links • Panic Disorder • Serotonin • Hereditary • Decreased blood flow in frontal cortex • OCD • Serotonin • Heredity • Brain Damage

11. Neuroimaging • Role of the GABA A Receptor in Anxiety • Benzodiazepine receptors • Benzodiazepine agonist increases sensitivity of GABA-binding site reduces anxiety • Benzodiazepine antagonist reduces sensitivity of GABA-binding site increases anxiety • Suggesting: A secretion of a neuromodulator that blocks the binding site at the GABA A receptor or a diminished number of benzodiazepine receptors are the cause of Anxiety Disorders • Benzodiazepines are often used to treat anxiety, but they can have intolerable side effects and be addictive

12. Neuroimaging • Brain imagining techniques such as PET, fMRI show altered patterns of brain activity in a number of anxiety disorders • Altered regional cerebral blood flow, metabolism or oxygenation

13. Neuroimaging • Patients with Simple phobia, OCD, PTSD: Share cerebral blood flow alterations in medial orbitofrontal cortex (OFC), rostral anterior cingulate cortex (rACC), inferior frontal cortex, and insula • Patients with OCD: Exhibit specific alterations in blood flow or metabolism within the basal ganglia • Patients with Panic Disorder: Differential brain metabolism in hippocampus, rACC, and OFC

14. 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

15. 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

16. 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

17. 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

18. 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.

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