When should you consider medication for your child’s anxiety?

Posted by David Russ on Jul 27, 2012 in Anxiety, Children, Medication

It is no surprise that there could be significant reluctance for parents to use medication to treat their child's anxiety. There are legitimate concerns such as side effects that any parent must consider. So when should a parent set aside those reservations and consider medication?(I am not a physician and ultimately this is something a parent and a physician must decide.) We are often asked if anxiety can be treated without medication. Generally speaking the answer is yes. Nevertheless, there are some circumstances that may warrant medical intervention and I would recommend a conversation with a physician. Consider the following:

1. If your child has significant anxiety symptoms they should have a complete physical in order to rule out organic or biological factors.
2. Are the symptoms so intense that you or your child’s life routine are profoundly impaired? Is your child unable to attend school? Are they withdrawing socially? Is the fear of the disorder so strong that the distress is nearly constant?
3. Is sleep seriously impacted? Is your child having trouble falling asleep? Are they sleeping less than 8 hours routinely? Sleep deprivation will only make it worse.
4. Did the anxiety symptoms happen very suddenly following an illness? In particular, OCD can be a result of an infection.
5. Is the anxiety leading to depression? Has your child made any comments about not wanting to live?
6. Are any of the symptoms causing physical harm?

If these apply I would recommend at least a medical consult. This is not a complete list and we welcome comments from our readers as well. We interviewed a NeuroPsychiatrist, Dr. James Lee, about medical issues/medications and include that interview as part of the Turnaround Program. However, it is available as a separate purchase if you would like an in-depth discussion of this issue.

Nowhere to Hide: The cycle of involuntary blushing (and what to do about it)

Posted by David Russ on Oct 26, 2011 in Anxiety, Blushing, erythrophobia, Medication, Social Anxiety, Uncategorized

Everyone blushes but for some people their lives can be dominated with trying to prevent it. The fear of involuntary blushing impacts the daily life of more people than you would think. It is a very common characteristic of social anxiety. It is rarely spoken about by those who struggle with it because attention to it could lead to it. Biologically, it is a result of the activity of the sympathetic nervous system (activates bodies response to danger). Blood vessels near the skin dilate and the increase in blood flow reddens the face. Typically fear redirects blood flow from the skin and extremities to skeletal muscles but the opposite seems to happen with blushing. Why this happens is not clear.

Everyone blushes and typically this is a result of embarrassment, surprise, modesty, or shame. However, for some people there is no clear reason for it to happen. This painfully unpredictable disorder is called Idiopathic Craniofacial Erythema (ICE).The phobia of blushing is called Erythrophobia. Because reddening of the face can be quite visible (depending on natural skin coloration), someone who is socially anxious might connect blushing with the possibility of embarrassing attention and so it becomes part of their anxiety. It may be for others that the biological tendency to blush easily is first and then anxiety about it follows. When anxiety associates with blushing then the anxiety activates the sympathetic nervous system and that causes blushing and so a self-reinforcing cycle forms. This can be debilitating as people avoid any circumstance that might lead to blushing. This is often social because it is one of those things that people seem to feel free to comment upon, “Wow, your face is so red! Why is your face red?” Research shows that verbal feedback like this increases blushing. Fearing or expecting to blush can be a self-fulfilling prophecy. Often the anxiety starts in childhood because kids are more likely to comment about it.

Here is a working list of suggestions for treatment that I have found in various places. I am curious if you have some suggestions. If you have this or know someone who does, is there anything that has helped you on my list or not?

1. Task concentration training (TCT) appears to be most effective treatment based on research I found. The theory is that anxiety and blushing cause an inward focus thus increasing subjective awareness of feelings, thoughts and symptoms. This increases the blush response as well as anxiety. Training in outward focus (a similar treatment is effective with athletes) has been proven to be the most effective approach even after a year. This article has a good summary of the process although it is a bit technical.
2. Cognitive-Behavioral Therapy. More specifically that would mean examining and revising beliefs (cognitive) about blushing. Also, it would involve behaving differently. Rather than avoiding it could mean voluntarily exposing yourself to a fearful situation. A number of suggestions I found fall under this treatment
   1. Activate the counterbalancing part of your nervous system (parasympathetic) by relaxing and breathing differently. This has to be practiced at some length before it will be effective.
   2. Draw attention to it rather than hiding it. This paradox, as hard as it seems, often works with anxiety. Many people with social anxiety mistakenly think that disclosing anxiety is worse than hiding it.
   3. Accept it rather than resist it. Accept that at this point you are a person who blushes easily and that is simply the way it is. You may wish it was different but it is what it is.
   4. Revise what you imagine other people are thinking. Collect some data. Ask some people what they think. What would a friend tell you about it? Explain it to people. Research suggests that blushing-fearful people inflate the both the probability it will happen and the social cost of blushing. In other words, they think it is way worse than it is and that others are thinking more critically than than they are.
   5. Practice the symptom. Try to make yourself blush by creating the circumstances. Do that over and over on purpose. You can do this gradually or all at once. This process is called systematic desensitization or exposure.
   6. Reframe the meaning of blushing. Historical evidence demonstrates that redness of cheeks is a sign of beauty and youth as well as markers of modesty and charm. As an expression of shame or embarrassment that can be very positive depending on the context.
3. Some sites suggest hypnosis. I couldn’t find any research support but there are a number of personal stories or single cases that showed improvement on the web.
4. Medication. Some people experience relief with medications that treat anxiety. Typically these are medication like Celexa, Prozac, Zoloft and other similar medications. Medications like Xanax, Klonopin and other benzodiazepines are sometimes prescribed. Sometime blood pressure medications such as beta blockers can be effective. A few sites suggest that botox may be helpful. Consult your physician for more information about this treatment.
5. There is a surgical operation available for severe cases. It is called Endoscopic thoracic sympathectomy. Frequently this is used to treat severe sweating but there appear to be cases that have been effective for blushing. It is recommended that a dermatologist be consulted if this disorder exists to rule out any underlying disorders.

It seems that there has been an increase in research and treatment options in the last 10 years. This is hopeful for those struggling with this. Please respond to this blog if you have addition knowledge of this subject or would be willing to share your experience.

PTSD symptoms – problem or attempt to solve?

Posted by David Russ on Oct 16, 2011 in Anxiety, Medication, PTSD, Uncategorized

It is my opinion that the symptoms of Posttraumatic Stress Disorder (PTSD) are actually an attempt by the soul to resolve the problem. One of the symptoms is the stubborn replaying of the experience in dreams, flashbacks, and other all the things that provide the stimulus to remember the trauma. It is clear from the research that cognitive therapy and prolonged exposure are effective at preventing and/or healing PTSD. Exposure is what is naturally occurring anyway every time the memory is replayed. Rather than resist what your body is doing by avoiding thinking of the memory the treatment is to voluntarily think and talk about the experience.I think this is why certain medications are less effective treatments. They mask the normal process of exposure by flashbacks. Here is the result of recent research about PTSD.
At five months, the rates of PTSD were:

• 58.2% in the waiting-list group
• 21.4% with immediate prolonged exposure
• 18.2% with cognitive therapy
• 61.9% with escitalopram (medication)
• 55.6% with placebo

The prolonged-exposure and cognitive-therapy groups had significantly lower rates of PTSD than the other three groups (P<0.001) but did not differ from each other. The medication, placebo, and waiting-list groups also did not differ significantly with respect to the proportion of patients with PTSD. You can read the full summary of this research here: http://www.medpagetoday.com/Psychiatry/AnxietyStress/28852

The absence of joy might indicate depression

Posted by David Russ on May 01, 2011 in Anxiety, Assessment, Child, Depression, Medication

There is a frequently misunderstood indicator of depression. When you think of depression you might imagine great sadness, tearfulness, a loss of hope. These are strong negative emotions that are felt deeply. However, there is another symptom that is equally associated with depression. It is called anhedonia. This is the absence of something. It is the absence of pleasure or joy when there should be pleasure. For example, if your child is invited to a fun event but displays an surprising apathy or she could care less about a favorite holiday, then you might be seeing evidence of anhedonia. Some kids are reserved emotionally, that is not what this is about. This is a distinct change in someone from their normal expression of feelings. Instead of that usual expression there is a flat, detached, neutral reaction to otherwise joyful events. If you or someone you love feels like nothing matters, that life is boring or tasteless, then consider an assessmentfor depression. If it lasts most every day, most of the day for a couple weeks then it should definitely be addressed. Below is a link for an initial self-assessment but it is important to visit a clinician if you think you might be depressed.

http://www.mayoclinic.com/health/depression/MH00103_D

Some thoughts about Medication for Anxiety Problems

Posted by David Russ on Sep 24, 2010 in Anxiety, Child, Children, Disorders, Generalized Anxiety Disorder, Medication, OCD (Obsessive Compulsive Disorder), Panic, Phobia, Social Anxiety, Worry

You will find a lot of online opposition to the use of medication for issues deemed psychological. There are risks and plenty of concerns about medications (not helped by those terrifying fine print documents written by attorneys inside the package!) While I disagree with the naysayers for the most part, I do agree that ultimately medication won’t solve the problem. However, if someone is in the grip of multiple episodes of panic or overwhelming anxiety symptoms then medication is a gift. I know this from working with hundreds of clients helped by medication. (Psychologists cannot prescribe medication, so I don’t have a financial or professional benefit from saying this.) In some situations, withholding from your child or avoiding medication yourself can unnecessarily perpetuate the “loss of control” and allow the anxiety to build momentum. The longer anxiety goes without successful treatment the stronger it can get (not always but often enough).

Medication can switch off the runaway fight-or-flight response or at least settle it down. Once that is experienced, something significant happens psychologically. A sense of control is restored or at least there is hope that this awful feeling can be stopped. But there can be a limitation to treatment with only medication. If you have a belief that it is essentially the medication that is providing the control then you will worry the fear will return if you stop. Even the ideal medication will not prevent panic if the fear of loss of control is strong enough. Ultimately, a person has to believe, apart from an external aid, that they can both control and know what to expect from their own body. This is true even if a person stays on a medication. They have to believe their body is in control.

Consider this analogy for the role of medication. My son introduced me to a video game called Halo. I have to admit, I like killing aliens. However, the only way I can play the game is if it’s put on the easiest possible level. Otherwise, it’s just too frustrating because I get overwhelmed by the alien fiends right away, thus enabling a reign of horror and devas…umm…back to reality. Medication puts the “game” on easy. You still have to work through your problem. There’s no drug in the world that will solve it for you. But the medication gives you a chance to get your bearings and develop the understanding you need without being overwhelmed.