Date post: | 07-May-2015 |
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Anxiety Disorders What School Counselors Need to know!
Dr. Iliana Garcia – Ortega PsychiatristResearch Associate
Sun Life Financial in Adolescent Mental HealthDalhousie University & IWK Health Centre
www.teenmentalhealth.org
Most people experience anxiety as…
Feeling tense, edgy, frustrated, irritable or overwhelmed.
Different degrees of physical symptoms such as: neck tension, headache, sweaty palms, shakiness, flushing, stomach sickness, restlessness.
Although unpleasant, most people are able to tolerate it and have become so good at coping that other people often can’t even tell that they are anxious!
Anxiety can be a good thing!
It helps us focus and get things done and can even enhance our performance (ie., exam preparation for a student, performance for a concert pianist)
Anxiety associated with anxiety disorders is different…
It is unreasonable, excessive or inappropriate to the situation
It’s intensity exceeds the person’s capacity to endure it
It may be persistent – continues despite the absence of an acute stressor or situation
It prevents the person from doing what they need to do, achieving their goals, or being who they want to be – it causes functional impairment
It leads to unhealthy coping strategies such as avoidance and withdrawal
What is Anxiety?
Initiation of Physiologic Cascade
Heart Rate
Tension
Alertness
Perception
Anxiety - Behaviour
Perceived danger in an normal situation
What about the brain?
Anxiety Disorders
• They are the most common of all the mental disorders and usually begin in childhood or adolescence - affect 8-10% .
• Anxiety disorders run in families (anxious young people often have anxious parents)
• Despite their high lifetime prevalence they remain poorly identified, diagnosed, and treated.
• They lead to high utilization of health services (many un-necessary investigations)
• Are frequently very amenable to treatment (psychotherapy; medications)
Fast Facts About Anxiety in Youth
• Different anxiety disorders throughout life – Separation anxiety disorder = childhood– Social Anxiety Disorder; Panic Disorder = teen onset
• Anxiety disorder can lead to:– Poor economic, vocational, interpersonal outcomes– Significant negative impact on family, social and school functioning– Increased morbidity:• comorbid anxiety disorders, major depressive disorder and
alcohol and drug abuse
• Chronic anxiety disorder can lead to:– Poorer physical health outcomes– Increased cardiovascular morbidity and mortality in mid-life
Common Anxiety Disorders
Panic Disorder
Agoraphobia
Panic Disorder with Agoraphobia
Social Phobia
Separation Anxiety
Obsessive Compulsive Disorder
Posttraumatic Stress Disorder
Generalized Anxiety Disorder
Anxiety Disorders
= Anxiety Symptoms (Physical +
Psychological)
+ Avoidance Behaviors
+ Functional Impairment
Diagnosis of Anxiety Disorders
There are no biological tests that are diagnostic of any specific anxiety disorder.
Diagnosis of anxiety disorders is reliant on a careful clinical assessment of the person’s presenting signs and symptoms and clinical history taking.
The symptoms of the anxiety disorders cluster into 3 groups:
1. Physical Symptoms
2. Psychological Symptoms – Thinking/Cognition Symptoms
3. Behavioral Symptoms
What’s the difference between Mental distress and Mental disorders?
Distress
Caused by event or trigger of brain driven activities
Normal/usual Response
Temporary, ADAPTIVE
No professional treatment needed
Not associated with sustained disability
Does not meet recognized diagnostic criteria for a mental
disorder
Disorder
Caused by abnormal brain functioning
May have environmental trigger
Complex interaction between genetic and environment
Prolonged
Usually needs professional treatment
Associated with sustained disability
Meets recognized diagnostic criteria: DSM; ICD
Behavior
Normal emotional response to distress: The Acute Stress Response
Thinking
Perception
WORRY!!
AvoidanceWithdrawal
WORRY!!
WORRY!!
Signaling
Physiologic Hyper-arousal
EmotionPanicIrritability
PhysicalLoss of AppetiteDifficulty SleepingHeadaches
Thinking / Cognition Symptoms
Excessive worry, obsessive ruminations,
apprehension, difficulties making
decisions, trouble focusing and
concentration, etc.
People with anxiety disorder often have
dysfunctional thinking patterns –
distorted ways of thinking about
situations, themselves, and others.
Faulty logic is a dysfunctional pattern of thinking that is biased, based on personal assumptions.
• All-or-nothing thinking
• Catastrophizing
• Discounting the positive
• Emotion over logic
• Magnification/Minimization
• Mental Filter
• Mind reading
• Overgeneralization
• Jumping to Conclusions
What does faulty logic look like?
If you listen closely to a person who is anxious you will find they tend to do the following:
Expect the worst Worry about things before they happen Predict the future Underestimate their strengths Underestimate their ability to cope Unrealistic negative thinking
Examples of behavioral symptoms
1. Social Withdrawal • Dropping out of recreational activities• Spending time alone• Avoiding social situations and events• Not speaking with or going out with friends
2. Avoidance of stressful situations • School refusal• Staying home from school, work or from planned social activities• Refusing to ride in a car• Refusing to leave the house• Refusing to sleep alone or with the lights out
Behavior symptoms
• People with anxiety disorders will do what they can to reduce their anxiety and they quickly learn that by avoiding the things that make then anxious they can prevent themselves from feeling worse. DO NOT SUPPORT AVOIDANT BEHAVIORS
• In addition, self-soothing habits and rituals, repetitive reassuring behaviors and the may be using of substances such as drugs and alcohol may be used to reduce anxiety.
Physical symptoms
• Rapid heart rate or racing
heart
• Headache
• Muscle Tension
• Chest pains
• Dizziness or faintness
• Sweating
• Trembling or shakiness
• Upset stomach: nausea,
vomiting, indigestion,
heart-burn.
• Diarrhea or loose stools
• Shortness of breath or
difficulty breathing
• Sleep trouble
Signs of Trouble - Warning signs
• Marked changes in personality
• Declining in school performance or failure to achieve expected levels of
functioning
• School refusal or avoidance of age appropriate social activities or dating
• Inability to cope with usual problems and daily activities
• Excessive / irrational fears, worries or anxiety
• Abuse of alcohol, cigarette or other drugs
• Significant changes in eating or sleeping patterns
• In younger children: crying, tantrums, freezing, clinging, staying close to parents
…What others might notice
• Consistent late arrivals or frequent absences at school or work
• Low morale, low self-esteem
• Social withdrawal
• Difficulties in completing school work
• Lack of cooperation or frequent altercations with others
• Frequent complaints of unexplained aches and pains
• Withdrawal from usual activities
…What teachers might notice
• Problems concentrating, making decisions, or remembering things
• Missed deadlines, delays in completing assignments, poor exam grades
• Constant excuses for missed deadlines, or poor quality work
• Decreased interest or involvement in class topics or academics in general
Note: Such behavior could indicate the student is having a bad day or week. A pattern that continues for a long period of time, or repeats, may indicate an underlying serious mental health problem or mental illness.
Differential Diagnosis
A variety of physical conditions can present with or be
accompanied by anxiety symptoms. The most common of these
are the endocrine/hormone disorders.
Think of physical disorder as the cause of anxiety if:
Physical findings on clinical examination
No family history of anxiety or depression
No avoidance behaviors or social withdrawal
Anxiety and other common mental disorders
Depression vs. Anxiety
– Low mood, sadness
– sleep disruption
– poor concentration
– fatigue/energy loss
– diminished interest
ADHD vs. Anxiety
– poor attention
– easily distracted
– forgetful
– difficulty organizing
– fidgety
– restlessness
– Impulsiveness
– doesn’t wait turn
Medication that can produce
Anxiety symptoms
• Ephedrine
• Pseudo-ephedrine
• Albuterol, Theophylline
• Thyroid medicines
Substances that can produce Anxiety symptoms
• Caffeine
• Cocaine
• Abstinence from alcohol
• Abstinence from narcotics
• Abstinence from sedatives
School Counselors Collaborate with
ParentsStudent
with Mental Disorder
Community
Health Providers
Administrators
OtherStudents
Teachers School Counselor
Anxiety Disorders are treated in two primary ways… and often used concurrently
Two Pathways
Psychosocial Treatments
MEDICATIONS/OTHERS
Biological Treatments
COUNSELING/THERAPY
Treatment of Anxiety Disorders in Children and youth
• 1st Line: Cognitive Behavioural Therapy (CBT)
• 2nd Line: Medication plus CBT
SSRI medication has strongest evidence:
fluoxetine – prozac
sertraline – zoloft
citalopram – celexa
SSRIs and School Counselors
• If GP choose to use one of the SSRIs. Predict side effects onset soon after treatment has started.
• Patients with anxiety tend to be very sensitive to the side effects to medications , they may experience an initial increase in their anxiety symptoms on initiation of the SSRI.
• Educate that clinical response may not be fully present for 4 – 12 weeks
• Educate that maintenance treatment will be for 12 months or longer
What are the expectations of school counselors ?
– Academic support
– Goal setting and decision-making
– Career awareness
– Education on understanding self and
others
– Peer relationships, coping strategies and
effective social skills
– Communication, problem-solving and
conflict resolution
– Substance abuse education
– Multicultural/diversity awareness
– Individual student planning
– Individual and small-group counseling
– Individual/family/school crisis
intervention
– Conflict resolution
– Consultation/collaboration
– Referrals
How can you help?
∙ Provide information about what you think the problem – Mental health education.
∙ Provide supportive psychological assistance, give reassurance and help the person challenge the worrying thoughts
∙ Help the family (others) understand what the problem is
∙ Help the person find activities that can “get their mind off their worries”
∙ Teach the person how use thinking skills to counter the symptoms and calm themselves
∙ Teach the person how to focus on positive thoughts and feelings
∙ Teach the patient how to deep breath
∙ Monitor and refer if problems worsen or if other problems arise
What else?
Help people learn more balanced ways of thinking!
Learning more realistic ways of thinking about events, situations, themselves, and others is really hard to do! Remember that using faulty logic is a habit that people have practiced for MANY YEARS!
Promote self-esteem by offering praise for small accomplishments and rewarding participation even if the student gives a wrong answer.
If avoidance of social situations persists go with the patient to these locations and help them face their worries there
In your interactions with the student, speak softly and calmly.
Help the student confront feared situations with gentle encouragement.