Anxiety Disorders

Q & A with Dr. Paul Foxman

by Paul Foxman, Ph.D., is Director of the Center for Anxiety Disorders, a private practice and therapist training program in Burlington, Vermont. Dr. Foxman is the author of The Worried Child (2004) and Dancing With Fear (1996), and other publications on the topic of anxiety. Dr. Foxman's web site is www.drfoxman.com.

Why and how does anxiety develop?

Anxiety is related to the survival instinct. Normally, we react self-protectively to threat or danger with the “fight or flight response.” This state of high mental alertness and physical arousal prepares us to “fight” or “flee” from danger. However, the fear reaction can occur when there is no present danger or threat. For example, if a child is a victim of bullying in school he is likely to perceive school as a dangerous place and experience anxiety in that setting. He may even refuse to go to school or develop separation anxiety. In other words, anxiety is the fear reaction to a perception or anticipation of danger when no actual threat is present. Sensitive people—those who react strongly to external or internal experiences—have a higher risk of developing anxiety.

In an effort to control anxiety, we may avoid certain situations, worry frequently, or develop obsessive-compulsive and other behavior. These patterns are not productive and they usually interfere with daily life.

What is the difference between normal and abnormal anxiety?

Some anxiety is normal. Taking an exam, starting school or college, meeting with a boss or authority figure, or having a near accident can all evoke anxiety. Anxiety can even be helpful in preparing for a challenge or change. There are also some normal worries in childhood and adolescence, such as concerns about school performance, appearance, social acceptance, and death of parents.

When anxiety is intense or persistent, or when it interferes with performance in daily life, it may become an anxietydisorder requiring professional help. Children are susceptible to the same anxiety disorders as adults. The key anxiety disorders are:

• Separation anxiety disorder
• Generalized anxiety disorder
• Panic disorder
• Phobias (including social phobia)
• Obsessive-compulsive disorder
• Post-traumatic stress disorder
• Anxiety associated with a medical condition

Are certain personality traits associated with anxiety?

People who develop anxiety disorders tend to match an “anxiety personality profile.” This is a set of personality traits that include the following:

• Perfectionism
• Frequent worry
• Difficulty relaxing
• High need to feel in control
• High sensitivity to criticism or rejection
• Tendency to please others at one’s own expense
• Difficulty with assertiveness

These traits have a positive and a negative side. The positive side is that this type of person generally has high standards, does quality work in school or on the job, and is kind and sensitive to the feelings of others. The negative side is that this personality style creates stress, and this type of person is vulnerable to exploitation by less sensitive people.

What is the relationship between depression and anxiety?

Depression and anxiety are two distinct emotional conditions but they frequently occur together. Depression is diagnosed when a person shows a loss of interest in pleasurable activities, social withdrawal, and lack of motivation and energy. When a person is chronically anxious, or when anxiety interferes with restorative sleep, depression may develop as a secondary component. Depression is common in social anxiety due to avoidance of social contact and loneliness. Such “secondary depression” usually subsides when a person gets help for anxiety. In other cases, there may be both an anxiety disorder and a depressive disorder. For example, a child whose parents divorce may develop both anxiety and depression, especially when there is a significant loss of parental contact. Anxiety and depression are also common in cases of post-traumatic stress disorder when there is a loss or other significant consequence.

What are some typical signs and symptoms of anxiety?

While there are distinct symptoms for each of the key anxiety disorders, the typical symptoms of anxiety include the following:

• excessive and unrealistic worries
• somatic complaints with no established medical basis
• difficulty relaxing
• excessive avoidance of situations associated with anxiety
• repetitive and nonproductive behaviors
• difficulty sleeping
• lower concentration and attention
• drop in academic or work performance

What is the relationship between stress and anxiety?

Stress is one of three ingredients in the development of anxiety (genetic sensitivity, anxiety personality traits, and stress overload). Stress is the when factor that triggers an anxiety reaction in sensitive people. Stress may consist of a single, powerful event, or a series of changes or stresses occurring over a period of time. In virtually all cases, the onset of anxiety is preceded by a period of high stress. Sometimes, anxiety spontaneously subsides without professional help when stress level goes down. One of the best ways to counteract anxiety is to manage stress on a regular basis. The three key steps for managing stress are:

• Signals—recognizing the signs of stress
• Sources—changing (if possible) the causes of stress
• Solutions—regular stress management (e.g. adequate rest/sleep, exercise, proper nutrition, time management skills, relaxation)

What are some steps parents can do to counteract anxiety in children?

There are many steps parents can take to reduce anxiety in children. Here are some suggestions:

• create a stable, consistent family environment with predictable routines
• encourage emotional communication at home
• use discipline methods that do not frighten children (use positive rewards for desirable behavior)
• make time for relaxation, play and recreation
• use an organized system for keeping track of appointments and activities
• be a good role model for stress reduction by taking care of yourself
• slow down and simplify if your family life is overbooked or overstressed
• recognize the role of spirituality or religion in counteracting anxiety
• seek advice from reliable sources when in doubt about what is best for your child

What are some ways to help children relax?

Quiet activities such as arts and crafts, board games, reading, and listening to soft music tend to be the most relaxing. Children can also learn how to meditate and do yoga or other physically relaxing practices. Competitive sports are usually not relaxing even though they have other benefits such as physical exercise, learning teamwork, and developing self-confidence. Some books and resources for relaxing activities geared to children will be found in the anxiety reading list on this web site.

Does television contribute to anxiety in children and how much is appropriate?

Television has been found to produce anxiety in children due to both the frequency of violent content as well as the medium’s stimulating effect on the brain. The American Psychological Association reports that children who watch two or more hours of television per day are likely to experience three effects:

• Fear of the world around them
• Aggressive behavior
• Less sensitivity to the feelings of other children

Parents are advised to monitor the amount and content of television viewed by their children. Content ratings are one source of information about what is appropriate for children by age. The American Pediatric Association recommends no television for children under two years of age.

The issues associated with television also apply to movies and video games. These forms of media often involve violence and sexuality that are not appropriate for children.

What can schools do to reduce anxiety in children?

School is anxiety arousing for many children due to tests and grades, social issues, excessive homework, safety issues, and learning styles that do not match the usual teaching methods. Schools can reduce anxiety in children by taking these steps:

• Ensure safety with clearly defined codes of conduct and adult supervision
• Instead of numerical grades, use narrative assessments of student progress towards learning goals and standards
• Emphasize social development using responsive classroom techniques
• Multi-age classes foster teamwork, learning partnerships, and communication skills
• Maintain appropriate teacher-student ratios
• Invest in support staff such as guidance counselors and special educators
• Encourage parent involvement in school programs and activities
• Offer classes in conflict-resolution skills and diversity sensitivity

What can children do to manage their own anxiety?

There are many steps children can take to manage their own anxiety. Naturally, some skills will need to be taught by knowledgeable parents or other adults but children should be encouraged to learn and practice on their own. Here are some suggestions:

• Read “ A Chapter for Young People: What You Can Do to Help Treat Your Own Anxiety,” in The Worried Child by Paul Foxman, Ph.D.
• Recognize the positive as well as negative aspects of emotional sensitivity
• Manage stress with adequate sleep, regular exercise or recreation, and good nutrition
• Practice relaxing regularly (listen to soft music, read a good book, play a quiet game, go for a slow walk)
• Choose a special word and repeat it while relaxing (“peaceful,” “calm,” “safe,” “tranquil”)
• If you are a perfectionist, make enjoyment a new goal for yourself
• If you worry a lot, choose one time (about 10 minutes) each day for worrying and do it only then
• Write down your worries to get them out of your mind
• Learn to organize your time by using a schedule

Does cigarette smoking contribute to anxiety?

Nicotine, the addictive substance in cigarettes, is essentially a stimulant. As with caffeine, nicotine is inadvisable for people with a disposition towards anxiety since the chemical is likely to increase nervousness and arousal.

Tobacco companies have historically marketed to young people (ages 14-25) in an effort to create a sustainable market for their products. Ninety percent of adult smokers become addicted as kids, and the younger a child begins to smoke the more likely that child is to become a regular smoker. Unfortunately, there appears to be a backwards trend towards marketing tobacco products to children. For example, Reynolds Tobacco has introduced candy flavored cigarettes (“Beach Breezer,” Bayou Blast,” and “Kauai Kolada”). According to two former secretaries of health and human services who served under Presidents Clinton and Bush, 4,000 children under 18 each day will try smoking for the first time, and 1,500 other children and adolescents will become addicted.

Are there any dietary recommendations for reducing anxiety?

There are some dietary guidelines for managing anxiety, and they apply to children as well as adults. One issue is the tendency for sensitive or anxious people to react strongly to fluctuations in blood sugar as well as certain stimulants such as caffeine and food preservatives. Here are some recommendations:

• Avoid caffeine by eliminating regular coffee and caffeinated beverages (many sodas and drinks)
• Maintain consistent blood sugar by reducing sugary and refined foods such as cakes, candies, ice cream, cookies, fruit punch, and highly sweetened cereals
• Eat smaller amounts of food more often (four or fives times a day)
• Drink enough water (carry a water bottle)
• Good foods include fresh fruit, vegetables, grains (bread, pasta, rice), diary, and protein (meat, fish, poultry, beans)
• Healthy snacks include popcorn, pretzels, rice cakes, trail mix, raw vegetables (e.g. carrots) and dried fruit (e.g. raisins) and fresh fruit (e.g. apples)

When should we seek professional help for our anxious child?

It is important for parents, teachers, doctors and other adults to know when to refer an anxious child for professional help. When it appears that anxiety is interfering with a child’s ability to function effectively in daily life, it may be appropriate to seek professional advice. Below are listed some of the conditions under which professional is indicated:

• Frequent physical complaints
• Social isolation
• Persistent difficulty going to sleep (or night waking)
• Avoidance of school, classes, social situations, telephone use
• Frequent crying
• Difficulty relaxing or chronic hyper-arousal (or tension)
• Overeating, weight gain, or loss of appetite
• Significant change in academic achievement
• Behavior problems (e.g. aggression, running away, defiance)

How do I find and choose a therapist for my anxious child?

A variety of mental-health professionals are available to provide therapy and related services for children with anxiety. Differing primarily by training and focus, they include psychologists, clinical mental-health counselors, clinical social workers, psychiatrists, and school guidance counselors. Ask around in your community, consult with your child’s doctor or school personnel, and contact state and national associations of mental health professionals (they often have state-by-state listings). Some good sources of professional listings are the Anxiety Disorders Association of America (www.adaa.com), the American Psychological Association (www.apa.com), and the National Register of Health Service Providers in Psychology (www.nationalregister.com).

Feel free to interview a prospective child-anxiety specialist before deciding whether to go forward. Here are some questions to ask when you call or meet with a mental-health professional:

• How long have you been in practice?
• With what age range do you work?
• What percentage of your clients has anxiety disorders?
• Do you have any specific training or credentials in anxiety treatment?
• Do you have any data on your success rate with anxiety treatment?
• What is your approach to helping children with anxiety problems?
• On average, how long does it take to help a child control anxiety?
• Under what conditions do you refer anxiety clients for medications?
• How often do you refer your anxiety clients for medication?

What are the pros and cons of medication for anxiety?

Medication prescribed by a psychiatrist or physician can be helpful in controlling anxiety symptoms. It is appropriate to consider a referral for medication when anxiety persistently interferes with sleep, concentration, or functioning in daily life. Research has shown that medication is most effective when combined with psychotherapy, and that anxiety relapse rates are lower when people stop taking medication if they have had the benefit of psychotherapy. However, medication is not a good long-term solution for anxiety and there are many pitfalls to consider. The pitfalls include troublesome side effects, difficulty determining the right medication and the correct dose (this can take many visits to the prescribing doctor), addiction potential with certain medications, and safety concerns with children under 18.

Are there any natural alternatives to drugs to help treat anxiety?

There are some safe and effective natural alternatives to medications for anxiety, notably certain herbs and homeopathic preparations. In many European countries, such as France, Germany, and Switzerland, herbal medicines are controlled substances requiring a doctor’s prescription, and medical schools include training in these options. Although research on the use of herbs and homeopathic remedies for anxiety is convincing, the data is not usually reported in American journals. Unfortunately, American physicians are not trained in alternative medicines and they are often skeptical about them. In addition, herbs are not regulated as medicines by the Federal Food and Drug Administration (FDA) and quality control in this country is inconsistent. Nevertheless, naturopathic physicians (N.D.s) and some chiropractors are knowledgeable sources, and homeopathic medicines are regulated by the FDA. Two recommended sources of information are: Healing Anxiety with Herbs by Harold Bloomfield (HarperCollins, 1998) and Spontaneous Healing by Andrew Weil (Knopf, 1995).

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Additional Sources of Information

From SAMHSA's National Mental Health Information Center

• Anxiety Disorders
• Children and Adolescents with Anxiety Disorders

From the School Psychiatry Program and MADI Resource Center

• Anxiety (Generalized Anxiety Disorder)
• Social Phobia (Social Anxiety Disorder)
• Separation Anxiety Disorder
• Panic Disorder