How much anxiety is too much anxiety? In the first part of a two episode series, Dr. Beth Brannan, a Triple Board Trained Physician, will talk with us about diagnosing anxiety disorders and the role of exposure therapy in treating anxiety.
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When anxiety is time-limited and in the right context, it can be a helpful, adaptive response. Anxiety becomes a disorder when: it is excessive for the situation, it doesn’t go away, or it leads to impairment in functioning (DSM-5).
Signs and symptoms of anxiety disorders can include emotional symptoms (i.e. feeling fear, scared, unease), cognitive symptoms (i.e. thoughts about worry) and physical symptoms (i.e. heart racing, breathing quickly, headaches, stomachaches) (DSM-5).
When assessing for anxiety disorders, it is important to understand an individual child’s context around emotions. For example, if a child has grown up with less emotion focused vocabulary, they may express symptoms of anxiety more physically than emotionally.
The GI system and the brain are connected and the majority of serotonin is in our GI system (Banskota, 2019). This helps explain why anxiety can present with GI symptoms and why it is invalidating to say “it’s all in your head” to someone who has physical symptoms of anxiety.
The following are two screening tools that Dr. Brannan recommends to help give an overall picture of a child’s symptoms and their level of impairment. They are a good starting point and should be followed up with asking more questions.
Here are some tips to keep in mind when assessing a child for anxiety:
Dr. Brannan’s expert opinion is that we should have widespread screening for anxiety during primary care visits. This would help with early identification of anxiety disorders, which is important because anxiety disorders are very common, they are treatable, and there are lots of comorbidities in adolescence and adulthood if they go untreated.
Anxiety disorders are under assessed and undertreated for all children, and particularly for children from minoritized ethnic and racial backgrounds. This is due to many factors (including implicit bias from physicians and inequitable distribution of mental health resources). Monnica Williams and her group have published research on mental health equity and anxiety disorders.
First line treatment of anxiety and OCD in youth is a form of CBT called exposure therapy. If the child has moderate to severe anxiety or OCD, then the combination of exposure based CBT and medication (SSRI) is more effective than either alone (CAMS and POTS). When referring a patient for CBT,, check to see if the therapist has experience with exposure therapy.
Exposure therapy is a form of CBT that involves exposing the child to things that cause anxiety in a gradual way. For example, if someone has a fear of snakes, the child could first look at a picture of a snake. The next step could be having the child sit next to a pretend rubber snake. This process is uncomfortable and an exposure therapist will coach the child to sit with the anxiety. With time, the child will habituate and the anxiety will decrease (APA 2017).
Dr. Brannan’s expert opinion: If a patient becomes unsafe in the context of being distressed, then they likely are not ready to do exposure therapy. The child would first need to learn skills to build a stronger foundation for tolerating distress.
If a patient has moderate to severe anxiety or OCD, then consider starting a patient on a medication (SSRI) in addition to exposure therapy. CAMS (Child/Adolescent Anxiety Multimodal Study) is a seminal study for pediatric anxiety which showed that for patients with moderate to severe anxiety disorders, the combination of exposure-based CBT plus an SSRI is more effective than either alone. The POTS (Pediatric OCD Treatment Study) showed similar findings for patients with OCD (exposure based CBT plus an SSRI is more effective than either alone).
Dr. Brannan’s expert opinion: If you have mild anxiety and you are able to access an exposure therapist, it is reasonable to start with exposure based CBT. If you are in a region of the country where you don’t have access to an exposure therapist, it is reasonable to consider starting a child on an SSRI.
Medications for OCD and anxiety are tools in the toolbox. A medication can help reduce the background level of anxiety to bring it down to a level where the child is able to engage in the exposures, but it is highly unlikely that a medication will completely eliminate all the anxiety.
Listeners will learn about screening, diagnosing and treating pediatric anxiety in the outpatient setting.
After listening to this episode listeners will…
Dr. Brannan reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures.
Elliott S, Raymond-Kolker R, Brannan E, Lee N, Masur S, Chiu C, Berk J. “50: Facing the (Core) Fear! Pediatric Anxiety Pt 1: Living the Exposure Lifestyle”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ May 11, 2022.
The Cribsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit cribsiders.vcuhealth.org and search for this episode to claim credit.
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