Children with GAD have irrational, exaggerated fears and worries about several situations. They are always tense and give the impression that any situation could trigger anxiety. They worry a lot about what other people think of their performance in different areas and they desperately need to be reassured or calmed down. They hardly relax, often have somatic complaints without any apparent cause, signs of autonomic hyperactivity e.
The Neurological Basis of Anxiety | Brain Blogger
GAD usually has an insidious onset; parents do not know exactly when it started, they just say it got worse and worse until it became intolerable, and that is when they often seek medical help. The cognitive-behavioral approach basically consists of a change in the way individuals perceive the environment, specifically on what is causing anxiety cognitive therapy and changes in the anxiety behavior behavioral therapy.
Parents actively participate in the therapy with their children, differently from the therapy involving adult patients. Parents and children agree that exaggerated questions will not be answered, reassuring children of the importance of this attitude in order to alleviate their suffering.
Thus, the more attention this altered behavior comforting or aggressive answers aimed at controlling the child's anxiety receives, the more likely this behavior will be endorsed and intensified; on the other hand, keeping calm and diverting attention away from this behavior will make anxiety subside. GAD has gained little attention from researchers in pediatric psychopharmacology. Open-label studies have shown significant improvement of symptoms with the use of either fluoxetine or buspirone. Specific phobias. A specific phobia is an excessive and persistent fear of a certain object or situation other than fear of public exposure or of panic attacks.
Typical reactions in children with this type of phobia include clinging to a parent or to someone who makes them feel safe, crying, despair, immobility, psychomotor agitation, or even a panic attack. The most common specific phobias observed in children include fear of animals, fear of injections, fear of the dark, fear of heights, and fear of loud sounds.
Specific phobias differ from normal fears in that they are an exaggerated and persistent reaction that gets out of control and leads to escape reactions, preventing the child from functioning. Cognitive-behavioral therapy has been the treatment of choice for specific phobias. Although widely employed, the efficiency of CBT has been underinvestigated, since we lack controlled studies with a reasonable number of patients, with standardized diagnosis and systematic follow-up.
Desensitization is the most commonly used technique which employs a hierarchical list of dreaded situations or objects. Exposure-based treatments often are associated with other cognitive-behavioral approaches "modeling" - practical demonstration by the therapist and imitation by the patient during the sessions; management of contingencies- identification and modification of situations related to phobic stimulus other than the stimulus itself; self-control and relaxation techniques. Pharmacological treatment of specific phobias is seldom used in clinical practice, and there is a paucity of studies on the use of medications to treat these disorders.
As occurs with adults, social phobia in children and adolescents is characterized by intense and persistent fear of being scrutinized by others and of being embarrassed or humiliated by their own actions. Young individuals may express their anxiety by crying, "fits of anger", or withdrawal from social situations in which unfamiliar people are present. In this case, physical symptoms such as palpitations, tremors, shortness of breath, hot and cold sensations, sweating, and nausea are observed.
Several cognitive-behavioral methods have been used to treat the fear of social situations or of social withdrawal in children. Cognitive treatment of social phobia primarily focuses on correcting faulty conceptions that seem to contribute to social avoidance. Negative internal dialogs are common in children with social anxiety e. SSRI are the drugs of choice to treat social phobia. Two controlled studies show the short-term efficiency of fluoxetine and fluvoxamine in treating young patients with social phobia.
Posttraumatic stress disorder PTSD. Children and adolescents are particularly vulnerable to violence and sexual abuse. Traumatic experiences may have a strong and long-lasting effect on them.
PTSD is regarded as a risk factor for the later development of psychiatric diseases. PTSD is the intense fear, feeling of powerlessness or horror due to the exposure to an extreme trauma, such as life threat or sexual assault.
The probability of developing PTSD is reliant on the severity, length, and time of exposure of the individual to the traumatic event. Remarkable changes in behavior are observed, including excessive shyness or disinhibition, agitation, excessive emotional reactivity, hyperarousal, besides obsessive thoughts with the traumatic experience while awake or in nightmares. Quite frequently, patients avoid stimuli associated with the traumatic event, associated with the compromise of their daily activities.
Younger children have difficulty understanding the event clearly and talking about it. There are some studies mostly case reports showing that CBT and brief dynamic psychotherapy are efficient in treating PTSD in children and adolescents. In younger children, therapy should include objects such as toys or drawings in order to facilitate communication, in an attempt to avoid interpretations, without confirmation of what actually happened, and to provide subsidies that allow the therapist to understand the traumatic experience.
CBT is centered on the target symptom s and aims at reversing the anxiety reaction through exposure to the phobic stimulus.
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The therapist should help the child or adolescent to come to grips with the dreaded object by talking about the traumatic event, telling the patient not to avoid the topic or thoughts related to it exposure in imagination. Clinical experience with drug therapy in children and adolescents with PTSD corroborates the results obtained in studies with adults. These drugs also have been used in young patients. Concern with the mortality related to the use of tricyclics and the constant necessity for electrocardiogram monitoring can make physicians opt for SSRI instead of tricyclics.
Considerable improvement has been attained in understanding the neurobiology of anxiety. Scientific evidence has demonstrated that early and long-lasting temperament traits might be correlated with anxiety. Originally described by Kagan in , "behavioral inhibition" BI refers to the temperamental tendency to be quiet and restrained in unfamiliar social situations. Behaviorally inhibited children seem to be at greater risk for developing an anxiety disorder, especially social phobia, in childhood or later on in adulthood.
Special attention has been paid to possible genetic aspects associated with anxiety disorders. Family and twin studies show that genetic factors play a crucial role in the etiology of PD, in which increased serotonergic transmission may cause or be related to this disorder.
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It has been suggested that serotonin receptor genes, especially the HTR2A gene, play an important role in the pathogenesis of PD. In addition to genetic studies and investigations into temperament traits, specific brain regions have been analyzed in neuroimaging studies of patients with different anxiety disorders, especially PD, social phobia, specific phobias and PTSD. Results obtained from neuroimaging studies with PD patients show abnormal findings in the hippocampus of resting patients; when symptomatic, these patients show activation of the insular and striatal motor cortices, as well as decreased activity in cortical regions such as the prefrontal cortex.
In support of the current theory of neurobiological models of PD, major changes in the monoaminergic neurotransmitter systems originating from the brainstem are likely to underlie metabolic, hemodynamic and biochemical disorders observed diffusely in the cortex. On top of that, medial temporal lobe disorders reinforce theories that involve dysfunctions of the hippocampus and amygdala in PD. Neuroimaging studies are restricted in social phobia and specific phobias, though. In social phobias, there is an exaggerated response of medial temporal structures during symptom provocation and in response to aversive and nonaversive symptoms triggered by images of human faces.
This reinforces the hypothesis of a hypersensitive system in the assessment of threats regarding stimuli provoked by human faces, as a neural substrate for anxiety occurring in social situations in social phobias. However, results of neuroimaging studies still have not provided clear anatomical information on the pathophysiology of specific phobias. Neuroimaging studies reinforce the neurobiological model of PTSD, which emphasizes the functional relationship between amygdala, prefrontal cortex and hippocampus.
When exposed to memories of traumatic events, individuals with PTSD seem to activate anterior paralimbic regions. In comparison with the control group, however, PTSD patients show less activation of the anterior cingulate cortex, exaggerated increase in blood flow in the amygdala region, in addition to exaggerated decrease in blood flow in diffuse areas associated with higher cognitive functions.
In short, the various anxiety disorders share similarities as to the brain circuits involved in the etiology of symptoms. Nevertheless, their heterogeneity also suggests some peculiarities regarding their psychopathologies. Neuroimaging studies seek to identify single and combined patterns of activated or dysregulated brain regions in certain anxiety disorders.
For instance, obsessive-compulsive disorder may involve the orbitofrontal cortex, basal ganglia and thalamus: 43 PD includes the hippocampus, parahippocampus, and amygdala: social phobia involves the corpus striatum and amygdala; finally, PTSD affects the amygdala, hippocampus and anterior cingulate cortex.
Studies on the time dynamics of certain brain regions e. A study suggests that the right amygdala is part of the dynamic, time-sensitive system for detection of emotional stimuli, whereas the left amygdala specializes in assessing continuous stimuli and is sensitive to their emotional value. Thus, anxiety disorders seem to be associated with problems in the right amygdala, while mood disorders seem to be related to the left amygdala.
Until the s, it was believed that fears and preoccupations during childhood were transient and benign. It is known today that they can represent frequent pathological disorders, causing distress and interfering with several daily activities. The early detection of anxiety disorders may avoid negative effects such as excessive school absence and consequent dropout, overuse of pediatric services to treat somatic symptoms associated with anxiety, and possibly, the occurrence of psychiatric disorders in adulthood.
Despite their high prevalence, childhood-onset anxiety disorders are underinvestigated. If left untreated, they can deprive children from family, social and educational interactions. Efficient treatment consists of different interventions, such as cognitive-behavioral therapy, family intervention, and also drug therapy. Neuroimaging studies have remarkably influenced the neurobiological models of anxiety disorders. While the amygdala plays a central role in pathophysiological theories of PTSD and social phobias, diffuse alterations characterize the pathophysiology of PD.
Of these articles, 27 were selected based on the quality of evidence and their clinical importance. Exposure-response prevention CBT is a structured form of psychotherapy whereby the patient is exposed to situations that would provoke the obsessions and associated anxiety and distress and then instruct the patient to resist the associated compulsions or avoidance behaviours.
Exposure-response prevention CBT is advised to have a frequency and duration of 13 to 20 weekly sessions or 3 weeks of daily sessions. If necessary, additional sessions can then be offered to the patient 3 to 6 months after the first session. High dose SSRIs have been shown to be more effective than lower doses.
The medication and target doses are. It can be started at 25 milligrams per day. A target dose of milligrams per day is recommended. However, patient tolerability is poor due to significant anticholinergic side effects dry mouth, blurred vision, fatigue, tremor and hyperhidrosis. Haloperidol is an effective augmentation agent in OCD with comorbid tics.
Ablative neurosurgery involves producing lesions in specific regions of the CSTC circuit. Neurosurgery is indicated in only severe cases of OCD.
Neurobiology and neurogenetics of anxiety and depression
Approximately 60 percent of patients improve months post surgery. Depression  :. Anxiety Disorders  :. This association may be related to. The Global Burden of Disease: Update. Geneva, Switzerland: World Health Organization. Subramaniam M et al. CNS Drugs. Hirschtritt M et al. Goodman W et al. Archives of General Psychiatry. Ost L et al. Clinical Psychology Reviews. Alonso P et al. PLoS One. Nestadt G et al. Psychological Medicine. Posted on: January 28, Last Updated: January 13, Diagnosis The diagnostic criteria and diagnostic interviewing for OCD are covered previously.
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