Anxiety Disorders

By Dr Sacks & Dr. Driver, Toronto

Anxiety disorders are the most common form of psychopathology in children (1,2,3) Many forms of anxiety disorders previously considered adult disorders are now noted to be present at a much earlier age (4). Children with anxiety disorders are more likely to develop mood disorders and severe behavior problem (5), One third to one half of children with anxiety are found to be clinically depressed (6). There is strong evidence for childhood and adolescent anxiety disorders to be risk factors for significant psychopathology in adulthood (7,8). Anxiety disorders are often very disabling during childhood and adolescence. One can see the roadblock anxiety would place in the way of accomplishing the tasks of adolescence. Separating from one's parents, obtaining a self-identity, forming a peer group and setting goals for educational and economic progress can all be ground to a halt because of anxiety? The not infrequently seen comorbidity of obsessive-compulsive disorder and depression make normal development even more difficult. ADD also seen in children with anxiety further marginalizes these children and youth from their peers. Many of these adolescents present to their physician with physical complaints of headaches, stomach pains, dizzy spells, shortness of breath, chest pain and other symptoms that keep them from participating in normal day to day activities. These youth are put through enormous amount of testing at great expense to their anxious bodies and minds as well as to the health care system. These tests also keep them out of school and add greatly to their parents anxieties. Cognitive therapies have been used for a long time in anxiety disorders but was integrated with behavioral techniques by Beck as presented in his text "Cognitive Therapy and the Emotional Disorders" (9). Cognitive behavioral therapy (CBT) is a short term active highly structured psychotherapy that helps the children assess their thoughts, images, attitudes and beliefs which lead to cognitive distortions and errors that make their world a very dangerous place for them, in addition, children and youth with anxiety disorders underestimate their ability to deal with these presumed dangers. In groups that we run at North York General Hospital, we first teach the adolescents about anxiety disorders. We explain current thoughts on etiology and also the pathophysiology of anxiety. We then teach them to recognize their own bodies response to this anxiety. Instruction in behavioral approaches such as relaxation breathing, progressive muscle relaxation, positive imagery, and problem solving techniques is given to bring their physical symptoms under control. This enables them to identify and question their cognitive distortions and errors. In some cases we even get the adolescents to recognize the core belief that may form the foundation of their anxiety disorder. We run concurrent groups for the parents to educate them about anxiety CBT and how to help their teens. In 1994, Kendall published his results of a randomized trial of CBT of children with anxiety disorders (10), At the end of treatment 64% of patients no longer met diagnostic criteria for anxiety compared to 5% of the untreated group. At long follow-up (2-5 years) these gains were maintained. In 1997, Kendall showed statistically significant clinical improvement with one-year maintenance of gains in another group of children (1 -1). This positive effect has been produced in group cognitive behavioral therapy as well as with individuals (12). We have incorporated within our program a parents group that runs simultaneously but separately from the adolescent group. Adding family anxiety management training has been shown to enhance the efficacy of CBT (1 3).


For information:

Dr. Diane Sacks