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.