case study for anxiety disorders jerome

Module 4: Anxiety Disorders

Case studies: examining anxiety, learning objectives.

• Identify anxiety disorders in case studies

Case Study: Jameela

Jameela was a successful lawyer in her 40s who visited a psychiatrist, explaining that for almost a year she had been feeling anxious. She specifically mentioned having a hard time sleeping and concentrating and increased feelings of irritability, fatigue, and even physical symptoms like nausea and diarrhea. She was always worried about forgetting about one of her clients or getting diagnosed with cancer, and in recent months, her anxiety forced her to cut back hours at work. She has no other remarkable medical history or trauma.

For a patient like Jameela, a combination of CBT and medications is often suggested. At first, Jameela was prescribed the benzodiazepine diazepam, but she did not like the side effect of feeling dull. Next, she was prescribed the serotonin-norepinephrine reuptake inhibitor venlafaxine, but first in mild dosages as to monitor side effects. After two weeks, dosages increased from 75 mg/day to 225 mg/day for six months. Jameela’s symptoms resolved after three months, but she continued to take medication for three more months, then slowly reduced the medication amount. She showed no significant anxiety symptoms after one year. [1]

Case Study: Jane

Jane was a three-year-old girl, the youngest of three children of married parents. When Jane was born, she had a congenital heart defect that required multiple surgeries, and she continues to undergo regular follow-up procedures and tests. During her early life, Jane’s parents, especially her mother, was very worried that she would die and spent every minute with Jane. Jane’s mother was her primary caregiver as her father worked full time to support the family and the family needed flexibility to address medical issues for Jane. Jane survived the surgeries and lived a functional life where she was delayed, but met all her motor, communication, and cognitive developmental milestones.

Jane was very attached to her mother. Jane was able to attend daycare and sports classes, like gymnastics without her mother present, but Jane showed great distress if apart from her mother at home. If her mother left her sight (e.g., to use the bathroom), Jane would sob, cry, and try desperately to open the door. If her mother went out and left her with a family member, Jane would fuss, cry, and try to come along, and would continually ask to video-call her, so her mother would have to cut her outings short. Jane also was afraid of doctors’ visits, riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was too afraid to take part in her gymnastics performances.

Jane also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say “ow, ow” if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties. [2]

• Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. ↵
• Hirshfeld-Becker DR, Henin A, Rapoport SJ, et alVery early family-based intervention for anxiety: two case studies with toddlersGeneral Psychiatry 2019;32:e100156. doi: 10.1136/gpsych-2019-100156 ↵
• Modification, adaptation, and original content. Authored by : Margaret Krone for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Treatment of anxiety disorders. Authored by : Borwin Bandelow, Sophie Michaelis, Dirk Wedekind. Provided by : Dialogues in Clinical Neuroscience. Located at : http://Treatment%20of%20anxiety%20disorders . License : CC BY: Attribution

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Understanding the Anxious Mind

By Robin Marantz Henig

• Sept. 29, 2009

Jerome Kagan’s “Aha!” moment came with Baby 19. It was 1989, and Kagan, a professor of psychology at Harvard, had just begun a major longitudinal study of temperament and its effects. Temperament is a complex, multilayered thing, and for the sake of clarity, Kagan was tracking it along a single dimension: whether babies were easily upset when exposed to new things. He chose this characteristic both because it could be measured and because it seemed to explain much of normal human variation. He suspected, extrapolating from a study he had just completed on toddlers, that the most edgy infants were more likely to grow up to be inhibited, shy and anxious. Eager to take a peek at the early results, he grabbed the videotapes of the first babies in the study, looking for the irritable behavior he would later call high-reactive.

No high-reactors among the first 18. They gazed calmly at things that were unfamiliar. But the 19th baby was different. She was distressed by novelty — new sounds, new voices, new toys, new smells — and showed it by flailing her legs, arching her back and crying. Here was what Kagan was looking for but was not sure he would find: a baby who essentially fell apart when exposed to anything new.

Baby 19 grew up true to her temperament. This past summer, Kagan showed me a video of her from 2004, when she was 15. We sat in a screening room in Harvard’s William James Hall — a building named, coincidentally, for the 19th-century psychologist who described his own struggles with anxiety as “a horrible dread at the pit of my stomach ... a sense of the insecurity of life.” Kagan is elfin and spry, balding and bespectacled. He neither looks nor acts his age, which is 80. He is one of the most influential developmental psychologists of the 20th century.

On the monitor, Baby 19 is a plain-looking teenager, hiding behind her long, dark hair. The interview, the same one given to all 15-year-olds in the longitudinal study, begins with questions about school. She has very few extracurricular activities, she says in a small voice, but she does like writing and playing the violin. She fidgets almost constantly as she speaks, twirling her hair, touching her ear, jiggling her knee. “This is the overflow of her high-reactive nature,” Kagan told me, standing near the monitor so he could fast-forward to the good parts.

Here was a good part: The interviewer asks Baby 19 what she worries about.

“I don’t know,” Baby 19 says after a long pause, twirling her hair faster, touching her face, her knee. She smiles a little, shrugs. Another pause. And then the list of troubles spills out: “When I don’t quite know what to do and it’s really frustrating and I feel really uncomfortable, especially if other people around me know what they’re doing. I’m always thinking, Should I go here? Should I go there? Am I in someone’s way? ... I worry about things like getting projects done... I think, Will I get it done? How am I going to do it? ... If I’m going to be in a big crowd, it makes me nervous about what I’m going to do and say and what other people are going to do and say.” Baby 19 is wringing her hands now. “How I’m going to deal with the world when I’m grown. Or if I’m going to sort of do anything that really means anything.”

Her voice trails off. She wants to make a difference, she says, and worries about whether she will. “I can’t stop thinking about that.”

Watching this video again makes Kagan fairly vibrate with the thrill of rediscovery: here on camera is the young girl who, as an infant, first embodied for him what it meant to be wired to worry. He went on to find many more such children, and would watch a big chunk of them run into trouble with anxiety or other problems as they grew up.

The tenuousness of modern life can make anyone feel overwrought. And in societal moments like the one we are in — thousands losing jobs and homes, our futures threatened by everything from diminishing retirement funds to global warming — it often feels as if ours is the Age of Anxiety. But some people, no matter how robust their stock portfolios or how healthy their children, are always mentally preparing for doom. They are just born worriers, their brains forever anticipating the dropping of some dreaded other shoe. For the past 20 years, Kagan and his colleagues have been following hundreds of such people, beginning in infancy, to see what happens to those who start out primed to fret. Now that these infants are young adults, the studies are yielding new information about the anxious brain.

These psychologists have put the assumptions about innate temperament on firmer footing, and they have also demonstrated that some of us, like Baby 19, are born anxious — or, more accurately, born predisposed to be anxious. Four significant long-term longitudinal studies are now under way: two at Harvard that Kagan initiated, two more at the University of Maryland under the direction of Nathan Fox, a former graduate student of Kagan’s. With slight variations, they all have reached similar conclusions: that babies differ according to inborn temperament; that 15 to 20 percent of them will react strongly to novel people or situations; and that strongly reactive babies are more likely to grow up to be anxious.

They have also shown that while temperament persists, the behavior associated with it doesn’t always. Kagan often talks about the three ways to identify an emotion: the physiological brain state, the way an individual describes the feeling and the behavior the feeling leads to. Not every brain state sparks the same subjective experience; one person might describe a hyperaroused brain in a negative way, as feeling anxious or tense, while another might enjoy the sensation and instead uses a positive word like “alert.” Nor does every brain state spark the same behavior: some might repress the bad feelings and act normally; others might withdraw. But while the behavior and the subjective experience associated with an emotion like anxiety might be in a person’s conscious control, physiology usually is not. This is what Kagan calls “the long shadow of temperament.” The oldest high-reactive subjects in Kagan’s and Fox’s studies, like Baby 19, are in their 20s now, and for many of them, no matter how much they manage to avoid looking anxious to an outsider, fears still rattle in their skulls at 3 o’clock in the morning. They remain anxious just below the surface, their subconscious brains still twitchy, still hypervigilant, still unable to shift attention away from perceived threats that aren’t really there.

ANXIETY IS NOT fear, exactly, because fear is focused on something right in front of you, a real and objective danger. It is instead a kind of fear gone wild, a generalized sense of dread about something out there that seems menacing — but that in truth is not menacing, and may not even be out there. If you’re anxious, you find it difficult to talk yourself out of this foreboding; you become trapped in an endless loop of what-ifs.

“I was flesh bereft of spirit,” wrote the journalist Patricia Pearson in “A Brief History of Anxiety (Yours and Mine),” in a pitch-perfect description of this emotional morass, “a friable self, grotesque... I got an AIDS test. I had my moles checked. I grew suspicious of pains in my back. If I was nauseous, I worried about cancer and started reading up obsessively on symptoms. I lay in bed whenever I could, trying to shut up the clamor of terror with sleep.”

When the “clamor of terror” starts to interfere with functioning, as it did for Pearson when she was a crime reporter in her early 30s, worrying turns into a clinical anxiety disorder, of which there are several forms: panic, social anxiety, phobia, obsessive-compulsive, post-traumatic stress and a catch-all called generalized anxiety disorder. Taken together, they make anxiety the most common mental illness in America, affecting an estimated 40 million adults, according to the National Institute of Mental Health. And that figure doesn’t even count the far greater swath who are garden-variety worriers, people who fret when a child is late, who worry when they hear a siren headed toward home, who are sure that a phone call in the middle of the night means someone is dead.

In the brain, these thoughts can often be traced to overreactivity in the amygdala, a small site in the middle of the brain that, among its many other functions, responds to novelty and threat. When the amygdala works as it should, it orchestrates a physiological response to changes in the environment. That response includes heightened memory for emotional experiences and the familiar chest pounding of fight or flight. But in people born with a particular brain circuitry, the kind seen in Kagan’s high-reactive study subjects, the amygdala is hyperreactive, prickly as a haywire motion-detector light that turns on when nothing’s moving but the rain. Other physiological changes exist in children with this temperament, many of them also related to hyperreactivity in the amygdala. They have a tendency to more activity in the right hemisphere, the half of the brain associated with negative mood and anxiety; greater increases in heart rate and pupil dilation in response to stress; and on occasion higher levels of the stress hormones cortisol and norepinephrine.

But having all the earmarks of anxiety in the brain does not always translate into a subjective experience of anxiety. “The brain state does not make it a disorder,” Kagan told me. “The brain state exists, and the statement ‘I’m anxious,’ exists, and the correlation is imperfect.” Two people can experience the same level of anxiety, he said, but one who has interesting work to distract her from the jittery feelings might do fine, while another who has just lost his job spends all day at home fretting and might be quicker to reach a point where the thrum becomes overwhelming. It’s all in the context, the interpretation, the ability to divert your attention from the knot in your gut. These variations also happen when someone grows up from an anxious infant to someone either fretful or tranquil. One aim of Kagan’s and Fox’s longitudinal studies is to watch how the life stories of these high-strung babies unfold.

The quintessential longitudinal study, the one often mentioned because it set the standard, is the Framingham Heart Study, which enshrined the idea of risk factors. It was through Framingham, for instance, that scientists learned that high blood pressure was a risk factor for cardiovascular disease, since it followed its subjects for long enough to detect that those who had high blood pressure in their 30s and 40s were more likely to have heart disease later in life.

But such studies draw conclusions about trends, not destinies. If someone with high blood pressure treats it early, the risk of heart disease can be reduced significantly. Similarly, if someone with an anxiety-prone temperament grows up in the right surroundings, he or she might never develop a full-blown anxiety disorder.

Kagan’s first exposure to longitudinal studies came shortly after he received his Ph.D. from Yale in 1954. He was working at the Fels Research Institute on the campus of Antioch College in Ohio, where a longitudinal study of middle-class children had been going on for nearly 30 years. He stumbled upon a gigantic room “loaded with prose summaries of what these children were like from the age of 1 month on,” he told me recently. He knew a treasure trove when he saw one.

Among these prose summaries, which ultimately Kagan and a colleague, Howard Moss, turned into the book “Birth to Maturity,” were descriptions indicating that babies had different innate temperaments. Kagan studiously ignored this finding; it didn’t fit with his left-leaning politics, which saw all individuals as born inherently the same — blank slates, to use the old terminology — and capable of achieving anything if afforded the right social, economic and educational opportunities. “I was so resistant to awarding biology much influence, I didn’t follow up on the inhibited temperaments I was seeing,” he told me. It took another 20 years of listening to arguments about nature versus nurture for Kagan finally to entertain the possibility that some behavior might be attributed to genes.

BY THE TIME Kagan moved to Harvard in 1964, the notion of an inborn temperament was on the ascent, in part because of the findings of Stella Chess and Alexander Thomas of New York University, who divided children into three categories: easy children, difficult children and those who were slow to warm up. Remembering the Fels data, Kagan embarked on his own longitudinal study of temperament. In 1979, he screened about 400 preschoolers, exposing them to new toys and new people in a laboratory playroom, videotaping them and coding their behavior. About 15 percent ended up in the group Kagan called “behaviorally inhibited”: wary, subdued, tending to hover near their mothers. Another 15 percent were “behaviorally uninhibited.” They were the fearless ones, who ran around trying to play with every new toy and chatting happily with the examiner. When Kagan talks about such children, he uses one of his favorite words: “ebullient.”

Over the next five years, 107 of these children — half of them timid, half bold — came back to the lab for more testing. (To keep environmental differences to a minimum, Kagan restricted his sample to children who were white, middle class and healthy at birth.) Their behavior was again recorded and again coded. Temperament, it turned out, tended to be stable over those five years, at least in children who started out at the extremes. There was a shift toward the middle between ages 2 and 7, but only 3 of the 107 changed categories completely from uninhibited to inhibited or vice versa. In addition, the most inhibited 7-year-olds showed some physiological differences that indicated an exaggerated response to stress.

Kagan and his colleagues, Nancy Snidman and J. Steven Reznick, published their results in Science in 1988. The physiological measurements led them to believe something biological was at work. Their hypothesis: the inhibited children were “born with a lower threshold” for arousal of various brain regions, in particular the amygdala, the hypothalamus and the hypothalamic-pituitary-adrenal axis, the circuit responsible for the stress hormone cortisol.

Though its findings seem almost self-evident today, the Science paper made a splash at the time. “There are two kinds of great research,” Susan Engel, a developmental psychologist at Williams College, told me when I discussed Kagan’s study with her. “There’s research that is counterintuitive, that shows you something you’d never guess on your own, and there’s research that shows you irrefutably what you had an intuition about, something you thought was true but didn’t have evidence to support.” Kagan’s research was of the second type, she says: “a beautiful, elegant experimental demonstration of an old intuition.”

But these subjects were preschoolers when Kagan first met them, already too old for him to know how much to attribute to nature rather than nurture. Couldn’t the inhibited children somehow have been raised to be wary instead of born that way? So the following year, Kagan began a new study he said he hoped would minimize the effects of the environment. He recruited infants who were just 4 months old, planning to categorize them according to temperament and to follow them as they grew to see whether temperament in infancy predicted anything about subsequent personality.

How to measure temperament in babies so young, at an age when some parents are still wondering whether a smile means happiness or gas? Kagan couldn’t measure the amygdala directly, so he looked for signs of its rampant firing that would be meaningful — and measurable — in infants. Since projections from the amygdala connect it to brain regions that control motor activity and the autonomic nervous system (heartbeat, breathing and other involuntary actions), he reasoned that if the amygdala was highly reactive, it would show up as increased motor activity, fretting and crying, as well as increases in heart rate, respiration and blood pressure.

Showing that a few physical measurements could offer insight into a baby’s psyche was one of Kagan’s real contributions. “Where his work had so much depth was not only in the longitudinal follow-up,” says Joan Kaufman, a Yale psychologist who was a research assistant at Harvard when the study began, “but in thinking about the behavioral phenotype of an inborn temperament and really assessing it with such rigor.”

Kagan brought about 500 babies — as before, all white, middle class and healthy — into the laboratory, placed them in infant seats in front of a video camera and exposed them to a series of novel stimuli. He showed them a schematic face that emitted words in a synthetic voice designed to be what he called “discrepant but not terrifying.” He dangled a dancing mobile with plastic Winnie the Pooh characters — again, nothing scary, but something new. He brought to their noses a cotton swab that had been dipped in diluted alcohol. The battery of novel stimuli took 45 minutes. Some of the babies gazed contentedly throughout. Others were in constant motion, kicking and moving their arms fitfully, furrowing their brows, arching their backs or crying if they were really upset.

Kagan and his research assistants again looked at videotapes and coded movements and cries. Based on the final tally, each infant was categorized as either low-reactive, high-reactive or somewhere in between. The low-reactives were the classic easy babies, the ones who take unfamiliarity in stride. The high-reactives, among them Baby 19, thrashed and whimpered when exposed to the same unfamiliar things. It was clear, as they twisted about in their infant seats, that these babies were high-maintenance, difficult to comfort.

About 40 percent were low-reactive, and about 20 percent were high-reactive. Kagan brought most of them, as well as those with intermediate temperament, back for testing at ages 1 and 2. About half of them — primarily those at each extreme — returned for further testing at ages 4, 7, 11 and 15. That pattern continues to this day, even after Kagan retired in 2000 and handed over his records to a collaborator, Carl Schwartz, an adolescent psychiatrist at Harvard and Massachusetts General Hospital, who tested some of Kagan’s subjects when they were 18 or 21.

By the earliest assessments, certain patterns had already emerged. At age 4, children who had been high-reactive were four times as likely to be behaviorally inhibited as those who had been low-reactive. By age 7, almost half of the jittery babies had developed symptoms of anxiety — fear of thunder or dogs or darkness, extreme shyness in the classroom or playground — compared with just 10 percent of the more easygoing ones. About one in five of the high-reactive babies were consistently inhibited and fearful at every visit up to the age of 7.

“Fear is an incredibly heterogeneous construct,” says Daniel Pine, a child psychiatrist at the National Institute of Mental Health. Pine collaborates on the two longitudinal studies at the University of Maryland, conducting psychiatric interviews and functional M.R.I. scans on subjects at several stages. “Fear of social things is different from fear of physical things.” The same brain circuitry is probably involved in both, he said, but different fears tend to show up at different points in development: fear of things like clowns, balloons or spiders emerging early in life; fear of things like social situations with peers emerging later. In addition, it’s relatively easy to avoid the physical things that frighten you; if you’re afraid of dogs, you can just take a different route to school to keep from passing that bull terrier down the street. It’s much harder to avoid social fears — you can avoid the dog on the way to school, but you still have to go to school.

The children tended to get a better grip on their fearfulness as they got older. By adolescence, the rate of anxiety in Kagan’s study subjects declined overall, including in the high-risk group. At 15, about two-thirds of those who had been high-reactors in infancy behaved pretty much like everybody else.

One such person was Mary, now a 21-year-old junior at Harvard, who was in the high-reactive group as a baby and was moderately fearful at ages 1 and 2. She didn’t think of herself as anxious, just dutiful. “I don’t stray from the rules too much,” she said when we spoke by telephone not long ago. “But it’s natural for me — I never felt troubled about it. I was definitely the kid who worked really hard to get good grades, who got all my homework done before I watched TV.” Mary also was an accomplished ballet dancer as a child, which gave her a way to work off energy and to find a niche in which she excelled. That talent, plus being raised in what Kagan called a “benevolent home environment,” might have helped shift Mary’s innate inhibition to something more constructive. If Mary’s high-reactive temperament is evident now, it comes out in the form of conscientiousness and self-control.

PEOPLE WITH A nervous temperament don’t usually get off so easily, Kagan and his colleagues have found. There exists a kind of sub-rosa anxiety, a secret stash of worries that continue to plague a subset of high-reactive people no matter how well they function outwardly. They cannot quite outrun their own natures: consciously or unconsciously, they remain the same uneasy people they were when they were little.

Most of the high-reactive kids in Kagan’s study did well in adolescence, getting good grades, going to parties, making friends. Scratch the surface, though, and many of them — probably most of them — were buckets of nerves. “It’s only the high-reactives who say, ‘I’m tense in school,’ ‘I vomit before examinations,’ ‘If we’re going on a class trip to D.C., I can’t sleep the night before,’ ” Kagan told me. “They don’t like it, but they’ve accepted the fact that they’re just tense people.” Invoking Jungian terminology, he called it the difference between persona (the outer-directed personality) and anima (the inner-directed thoughts and feelings). The persona can be controlled, but the anima often cannot.

Nathan Fox of the University of Maryland says that when the anima erupts in high-risk children, it often takes the form of excessive vigilance and misdirected attention. In the first of his two longitudinal studies of temperament, begun in 1989, he followed 180 children from the age of 4 months and gave them a set of neuropsychological tests when they were between 13 and 15. One test, called the spatial-cuing task, measures vigilance and the ability to disengage attention from a perceived threat. It shows two faces briefly on a computer screen, one on each side — the same face looking threatening on one side and pleasant on the other. The faces fade away, and an arrow appears on one side of the screen, sometimes on the side the threatening face had been on, sometimes on the other. The subject must notice the arrow and press a button to indicate whether the arrow points up or down.

Adults with clinical anxiety consistently are faster at pressing the correct button if the arrow is on the side of the screen where the threatening face had been, and slower if the arrow is on the other side. (Non-anxious adults show no such subconscious preference.) In the kids in Fox’s study, those who were born anxiety-prone — even the outwardly calm, well-adjusted ones — tended to perform this task like anxious adults, paying more attention to the threatening face whether or not they meant to.

A similar result came from another test Fox gave his subjects, called the potentiated startle response. In this test, teenagers are placed in front of a screen and told that when the screen is blue, there is a chance a puff of air will be blasted at their throats — a sensation that, Fox assured me, is surprising and uncomfortable but not painful. When the screen is green, they’re safe; they are told that no puff of air will ever come when the green screen is on. Then, to evoke a startle, the experimenter plays a loud noise and measures the teenager’s response (an involuntary eye blink). All subjects have a robust startle response when the blue screen is on, which reflects the fact that they are tensing up in anticipation of that uncomfortable air puff. But anxiety-prone kids startle just as much with the green, supposedly safe screen. They stay on guard, anxious and wired, even when the situation is not threatening. Again, this finding held no matter how the subjects behaved in real life — and no matter how they were feeling while the test was taking place.

Fox’s collaborator, Daniel Pine of the N.I.M.H., conducted functional M.R.I. scans on 27 of these study subjects when they were adolescents. While they were in the scanner, Pine showed them pictures of fearful faces. Sometimes he told them to try to measure how wide the nose was — in other words, to focus on a detail that is emotionally neutral. Other times he told them to think about how afraid they felt looking at the person in the picture.

Teenagers who were in the group at low risk for anxiety showed no increase in activity in the amygdala when they looked at the face, even if they had been told to focus on their own fear. But those in the high-risk group showed increased activity in the amygdala when they were thinking about their own feelings (though not when they were thinking about the nose). Once again, this pattern was seen in anxiety-prone youngsters quite apart from whether they had problems with anxiety in their daily lives. In the high-risk kids, even those who were apparently calm in most settings, their amygdalas lighted up more than the others’ did.

Temperamental type tends to reveal itself not only in functional M.R.I. scans but also in structural M.R.I.’s, which look at brain anatomy rather than activity. In 2007 Carl Schwartz, the Harvard psychiatrist who has taken over the follow-up work on Kagan’s two longitudinal studies, put 76 of Kagan’s study subjects in an M.R.I. machine. At the time, they were 18 years old. (Baby 19 was part of the sample; Mary was asked to participate, but she declined.) He found that the subjects who were high-reactors at 4 months tended to show significant thickening in the prefrontal cortex compared to those who were low-reactors. “This was amazing,” Schwartz told me. “The temperament they exhibited as infants still seemed to leave a fingerprint in the brain 18 years later.”

He is still trying to work out the exact meaning of this fingerprint; he cannot yet tell, for instance, whether a thicker cortex is a cause of a high-reactive temperament, or an effect, or something else entirely. One job of the prefrontal cortex is inhibitory, putting a damper on signals that come from the amygdala. Could it be that the cortex thickens more in the anxiety-prone as it is busy tamping down the overactive amygdala and growing new neural connections? Or does a thicker cortex come first, and contribute to a tendency to be anxious in the first place?

One way Schwartz tried to untangle his uncertainties was by winnowing from his sample the 14 subjects who had ever been given a diagnosis of social-anxiety disorder. What was left, presumably, were 62 young people who all functioned just fine, at least in the sense of never having suffered from social anxiety. Schwartz reviewed their brain images, and the difference between the cortical thickening in the high-reactive group and the low-reactives not only remained; it also became more pronounced. One explanation of this could be that a thicker cortex is protective in the anxiety-prone. He surmises that those 14 subjects who developed problems did so in part because their cortex was thinner, and the high-reactives who had avoided social anxiety had the thickest cortexes of all.

So what do these brain-anxious young people report about their state of mind? Anxiety, remember, can occur at three levels: brain, behavior and subjective experience. Were the ones whose brains looked anxious on the M.R.I. scans actually experiencing the sensation of being anxious?

This is a question the scientists struggle with, hampered as they are by peoples’ inability to report their own feelings accurately. Pine told me that his subjects often admit, after the fact, that they had been more afraid during the experiment than they said at the time — leaving him unsure what conclusions to draw. According to Kagan, the high-reactive temperament is characterized by a tendency to be supersensitive to your own body’s signals. Wouldn’t you expect, then, that anxiety-prone kids would have some insight into their own brains? Yet even in the high-risk subjects, objective brain state and subjective experience of anxiety still don’t always track.

It is also difficult to say whether high-reactive people are aware, more generally, that their brains are more tightly coiled than other people’s. “What people say about what they’re feeling is significant, but it is hardly the whole story,” Schwartz says. “Some of those kids probably do have a subjective awareness of their brain state; others who have equally large amygdala signals — depending on how they have adapted, how they’ve been brought up and supported — might have little awareness of it.” In some cases, he says, people might even have “reframed” certain physical sensations that could be considered symptoms of anxiety — like feeling jazzed up or having your pulse quicken — as “vaguely exhilarating or exciting.”

Studies like Pine’s and Schwartz’s might actually be revealing not an anxious brain at all but an experimental artifact, says the developmental psychologist Robert Plomin. Plomin, who runs a longitudinal twin study of genes and behavior at King’s College, London, agrees that anxiety does have a neurological fingerprint, but he worries about a disconnect between anxiety in the lab and anxiety as a quotidian experience. “Let’s say that in your real life you learn to manage your temperamental dispositions so you don’t freak out,” he said. “Let’s say you learn to take a deep breath, learn tricks to make yourself function better in life. But in the lab you’re not dealing with social situations you’ve learned to control. You’re just shown — boom! — some horrible picture of a bloody accident.” If your response to a brutal image is milliseconds faster than the response of someone who is more sanguine, Plomin asked, what does that really tell you about how your brain would respond in the real world to a worrisome situation?

To make the anxiety-provoking lab challenge more authentic and emotionally charged, Pine and his colleagues at the N.I.M.H., Eric Nelson and Amanda Guyer, concocted an elaborate experimental setup to persuade teenagers in a functional M.R.I. machine that their social status really is on the line: a fake Internet chat room. They created a set of potential chat-room partners for their subjects: smiley, fictitious teenagers, complete with sham MySpace pages. The setup was that the other kids would eventually tell the subjects in the scanner whether they did or did not want to chat with them. The scans were taken, then, while the subjects were lying still, awaiting the verdict. In a handful of pilot experiments, this has proved to be an emotionally significant challenge for teenagers with social anxiety. The anxious youngsters, while waiting to hear from one of the pretend teenagers they wanted to avoid, showed more reactivity in the amygdala and prefrontal cortex. Pine has conducted this same experiment on 40 of Fox’s longitudinal-study subjects and is currently analyzing the results.

Still, tracking the anxious mind, even with a more realistic experimental setup, means having the subject lie in an M.R.I. scanner, which is inherently not only artificial but also stressful. So Plomin’s point is interesting. Brain scans and other lab findings might reflect something deep and persistent going on in the anxious mind. But if you have learned to control your behavior, to structure your life so you can limit triggers and cope with your emotional skittishness, how much does it really matter?

THE BEHAVIORAL STRAND of the brain-behavior-experience triad is the one that seems most amenable to intervention, and scientists are now investigating how it is that two-thirds of those with a high-reactive temperament manage to avoid trouble. Many environmental factors no doubt come into play — some of them malleable, some less so. In Kagan’s first study, for instance, he found that birth order seemed relevant. Behaviorally inhibited children were much more likely to have older siblings: two-thirds of them did, compared with just one-third of the uninhibited children. Could having older siblings, he and his co-authors wondered, mean being teased and pushed, which becomes a source of chronic stress, which in turn amplifies a biological predisposition to inhibition? Kagan never replicated this finding, as intriguing as it was — which shows how difficult it can be to tease out which environmental factors are relevant, and which turn out to be incidental. Fox, meanwhile, noted that the high-reactive babies who went to day care when they were young were significantly less fearful at age 4 than were the high-reactives who stayed home with their mothers.

Attempts to see what kind of parenting works best with an anxiety-prone temperament leave almost as many questions asked as answered. Which is better for a fearful, high-strung child — a parent who coddles the child and says everything will be all right, or a parent who sets firm, strict limits and has no tolerance for skittishness? You could picture it as going either way, really. On the one hand, it might be good to shield children from the things that worry them. On the other hand, it might be better to urge them, maybe even force them, to confront the things they dread.

Scientists from both Kagan’s and Fox’s labs have looked at this question in a systematic way, and they have come up with two somewhat different findings. Both studies involved a series of home visits and hours of videotapes of mother-baby interactions. But one study, by Kagan’s graduate student Doreen Arcus in the early 1990s, found that what seemed to be best for high-reactive babies were mothers who set firm limits and did not rush too quickly to comfort them when they cried. And the other, by Fox’s postdoctoral fellow Amie Ashley Hane a decade later, found something slightly different: that the best fit for high-strung babies were sensitive mothers, who met their fearful children on their own terms and interacted with them in a way that was accepting and supportive without being intrusive. Sometimes, of course, there’s a fine line between firm and hardhearted, and a fine line between supportive and intrusive. This makes it especially tough to turn research findings like Arcus’s and Hane’s into clear guidance on how best to care for a fretful child.

The best outcome, however it happens, is to rear a child who learns to wrestle his demons on his own. Some children figure out themselves what works best. “Inner struggles pulled at me for years until I was able to just let go and calm myself,” wrote one of Kagan’s high-reactive study subjects in an essay, revealing a wisdom far beyond his 13 years. “For example, when I first heard about the anthrax in Washington, I began to have an upset stomach. I realized it was simply because of my anxiety that I was feeling sick. As soon as I realized that, the stomachache went away. Because I now understand my predisposition toward anxiety, I can talk myself out of simple fears.” There are many adults, anxious or not, who can’t control their own interior monologues as well as this boy can.

For the children who need help grappling with their fears, some psychologists try to intervene early, with programs that give worried children tools for quieting the scary thoughts in their heads. Kids are often taught the same skills that anxious adults are, a variation on cognitive behavior therapy, designed to stop the endless recursive loop of rumination, replacing it with a smart, rational interior voice. In a way, it’s teaching anxious people to do what non-anxious people do naturally.

“I joke a lot about my anxiety,” wrote a young woman named Brittany on the group blog We Worry, part of a thriving community of anxiety blogs. “And there are times I do find it funny. I can do this because there is that voice in my head that tells me what I’m worrying about is irrational. But then I worry about worrying about irrational things. It is a never-ending cycle.” She might laugh at herself, she wrote, but life can get “overwhelming to me sometimes. Things that don’t even register to most people are uphill battles for me.”

Even those with normal, run-of-the-mill fretfulness — not a clinical anxiety disorder like Brittany’s — struggle to outsmart their brooding. “I have a friend who’s a clinical psychologist, and we talk about this a lot — what people do on their own to make themselves less anxious,” said Engel of Williams College, who is writing a book about temperament called “Red Flags and Red Herrings.” Engel said she is by nature very anxious, as is the eldest of her three sons. “The way we deal with it is that we both get everything done in lots of time. We can’t stand the anxiety of a looming deadline; we’re so worried about being late that we do it five days early.” This is one way to alleviate anxiety, she said. “There are other things we could do. We could drink, we could procrastinate, we could pretend we don’t have the deadline. I guess we both happen to be lucky that our method is adaptive.”

This kind of adapting might have something to do with intelligence, says Steven Pinker, a psychologist at Harvard and author of “The Blank Slate: The Modern Denial of Human Nature.” He says he believes, based on pure conjecture, that people with higher intelligence are better at overcoming their anxious temperament and more likely to “see their own worry list as a problem to be solved, minimizing unnecessary anxiety while still being anxious enough to get things done.” At least one study lends support to Pinker’s impression. In a 2004 article called “Can Worriers Be Winners?” two British scientists gave personality questionnaires to a group of financial services managers and found that those who reported themselves as scoring high on anxiety traits, like being nervous about performing well on the job, turned out to be better employees, but only if their worrying was accompanied by high cognitive ability.

Fox said that what distinguishes the high-reactives who learn to adapt from those who don’t often comes down to something simple, like finding one or two supportive friends — or, like Mary and her ballet, finding something they’re good at and can feel self-confident about. But there could be some physiological differences between the adapters and the nonadapters, too. Baby 19, for instance, ran into some problems as she grew up. At a year old, she was one of the most fearful children in Kagan’s study, and she had an episode of depression in middle school and a diagnosis of social anxiety disorder as a teenager. While these could have been related to any of a number of environmental factors, including a broken home, they could be related too to something curious that turned up in the brain scan Schwartz did on Baby 19 when she was 18 years old.

When Baby 19 was in the functional M.R.I. scanner and shown a series of unfamiliar faces, Schwartz said, her amygdala was highly reactive — about three times as much as that of a typical low-reactor. This was what Schwartz expected in someone with her temperament and psychiatric history. More surprising, though, was how her prefrontal cortex appeared on the structural M.R.I. scan. Rather than the thickened cortex that so many young adults with her temperament had, Baby 19’s was relatively thin.

“This is the brain area implicated in emotional regulation,” Schwartz told me. Could it be that in her case, her thin cortex was unable to regulate excessive activity in the amygdala, leading to more problems than someone with a thicker cortex would encounter? “At the level of an individual, it’s always a bit dangerous to draw conclusions,” he said. “In fact, it’s pretty much impossible. But maybe one thing that affects outcome is whether the genes that contribute to these two areas, the amygdala and the cortex, travel together or separately.” Maybe a high-reactive person with a jumpy amygdala can manage to avoid the behavioral and subjective experience of anxiety because of a strong cortex that can quiet the overactive brain. But in Baby 19’s case, the jumpy amygdala might instead have been accompanied by a cortex less able to mount an inhibitory response. “Maybe when those things occur together,” Schwartz said, “your outcome is that you have a little bit more trouble.”

LOOKING AT THE neurology of anxiety raises the inevitable question of why a trait that causes so much mental anguish would have evolved in the first place. For the species as a whole, it is most likely an advantage to have some group members who are hypervigilant and who see everything as a threat, always ready to sound an alarm and leap into action. For the individual, though, being inhibited can mean having fewer mating opportunities, not to mention the psychic burden, wearing yourself ragged with a brain that’s always on high alert.

In the modern world, the anxious temperament does offer certain benefits: caution, introspection, the capacity to work alone. These can be adaptive qualities. Kagan has observed that the high-reactives in his sample tend to avoid the traditional hazards of adolescence. Because they are more restrained than their wilder peers, he says, high-reactive kids are less likely to experiment with drugs, to get pregnant or to drive recklessly. They grow up to be the Felix Ungers of the world, he says, clearing a safe, neat path for the Oscar Madisons.

People with a high-reactive temperament — as long as it doesn’t show itself as a clinical disorder — are generally conscientious and almost obsessively well-prepared. Worriers are likely to be the most thorough workers and the most attentive friends. Someone who worries about being late will plan to get to places early. Someone anxious about giving a public lecture will work harder to prepare for it. Test-taking anxiety can lead to better studying; fear of traveling can lead to careful mapping of transit routes.

Kagan told me that in the 40 years he worked at Harvard, he hired at least 200 research assistants, “and I always looked for high-reactives. They’re compulsive, they don’t make errors, they’re careful when they’re coding data.” He said he would bet that when the United States sends people up in space, the steely, brave astronauts were low-reactive as infants, and the mission-control people down on the ground, doing the detail work that keeps the craft aloft, were high-reactive.

An anxious temperament might serve a more exalted function too. “Our culture has this illusion that anxiety is toxic,” Kagan said. But without inner-directed people who prefer solitude, where would we get the writers and artists and scientists and computer programmers who make society hum? Kagan likes to point out that T. S. Eliot suffered from anxiety, and that biographies indicate that he was a typical high-reactive baby. “That line ‘I will show you fear in a handful of dust’ — he couldn’t have written that without feeling the tension and dysphoria he did,” Kagan said.

These are overgeneralizations, of course. And they’re easy to shoot down with exceptions. But all the exceptions mean, really, is that the link between neurology and behavior is complicated. There may well be hundreds of different temperaments, and these studies have investigated only two — the most stable and most amenable to measurement, but still just two. If it were as simple as saying that a high-reactive infant will become a behaviorally inhibited child who will become an anxious adult, all the scientific work on temperament would amount to little more than charting horoscopes.

The predictive power of an anxiety-prone temperament, such as it is, essentially works in just one direction: not by predicting what these children will become but by predicting what they will not. In the longitudinal studies of anxiety, all you can say with confidence is that the high-reactive infants will not grow up to be exuberant, outgoing, bubbly or bold. Still, while a Sylvia Plath almost certainly won’t grow up to be a Bill Clinton, she can either grow up to be anxious and suicidal, or simply a poet. Temperament is important, but life intervenes.

As for Baby 19, she has not yet gone against type, and odds are she never will. She is in college and doing pretty well, Kagan told me. But her temperament still comes through in her personality. Kagan said Baby 19 tends to be “dour” and “melancholy.” And she is still, and probably always will be, a worrier.

Robin Marantz Henig is a contributing writer. Her last article for the magazine was about the federal effort to diagnose mysterious diseases.

An anxiety disorder case study

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Case Study: Overcoming Anxiety – Success Stories

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Anxiety is a formidable adversary in the everyday life of many people in the UK. According to statistics, around 6% of people are diagnosed with generalised anxiety disorder (GAD) every week and, in total, more than 8 million people experience an anxiety disorder. Characterised by excessive apprehension, worry and fear, anxiety comes in many forms. Generalised anxiety disorder is a persistent and excessive worry about everyday events. Social anxiety disorder , however, focuses on overwhelming fears of social situations. There are also several other disorders with anxiety-based symptoms. These include panic disorder, specific phobias , obsessive-compulsive disorder ( OCD ), post-traumatic stress disorder ( PTSD ), selective mutism and separation anxiety disorder. In this article, we’ll explore three case studies on people with different anxiety problems and how they overcame them. 

Case Study 1: Overcoming Social Anxiety

Meet Sarah*, a 28-year-old professional who, for years, grappled with the debilitating effects of social anxiety disorder. Sarah’s anxiety manifested itself in a fear of social interactions. Since this problem crept up over time, Sarah didn’t realise how much of a problem she had until her early 20s when she left university and began working in her professional field. Ultimately, Sarah recognised she had a problem that others didn’t seem to have, and it left her isolated and hindered in both her personal life and professional sphere. 

Sarah’s social anxiety manifested itself in her avoidance of social events and gatherings. In work meetings she couldn’t avoid, she would feel sick, lightheaded and extremely nervous. She chose not to socialise with her colleagues and found it difficult to maintain friendships with more outgoing people. The most profound symptom for Sarah was her intense fear of being scrutinised and criticised. These intense emotions took their toll on her self-esteem. Recognising the need for change, Sarah began to explore her feelings and sought help.

Sarah knew there was no quick fix. Anxiety was something she’d lived with her entire life and she’d managed to mask her issues quite well. Her transformation began with her seeking the guidance of a mental health professional. After speaking initially with her GP, Sarah began a course of cognitive-behavioural therapy ( CBT ) where she gained valuable insights into the irrational thought patterns that were fuelling her anxiety. CBT equipped her with practical tools to challenge and reframe her thoughts. Gradually, these tools helped her to diminish the power anxiety held over her in specific situations. 

At the same time, Sarah engaged in exposure therapy. This therapeutic approach introduced her gradually to situations that ordinarily would cause her immense fear. However, this systematic desensitisation process was done in a controlled and supportive environment, which allowed her to confront her anxieties gradually. Over time, Sarah was able to build up her resilience and confidence in these situations.

Beyond therapy and with the advice of an online support group, Sarah adopted mindfulness practices. She incorporated meditation and deep breathing into her daily routine. These mindfulness practice techniques became invaluable to her and helped her stay present and manage anxious thoughts during social interactions.

Sarah also took it upon herself to make lifestyle changes to promote good mental wellbeing. She began exercising routinely rather than sporadically as she had done before and noticed improvements in mood and a reduction in stress. 

Through consistent effort, Sarah emerged triumphant over her social anxiety. Today, she is able to deal with social situations much more easily than before. She can handle new situations well, both professionally and personally, while acknowledging that she’ll always have a tendency to feel anxious and will need to continue practising techniques that she now knows work.

Sarah’s story underscores the effectiveness of tailored therapeutic interventions and lifestyle adjustments. Sarah remained committed and open-minded about the route she was taking. Though she chose not to try medication, she recognised that this was available to her if her chosen pathway didn’t have the desired effects she was looking for. Her journey serves as an inspiration for others dealing with similar struggles who are perhaps fearful of turning to medication.  

Case Study 2: Triumphing Over Panic Attacks

Alex,* a 35-year-old plumber from Barnsley in South Yorkshire, struggled with the debilitating impact of frequent panic attacks for a number of years. Alex’s initial experiences with panic attacks occurred suddenly and intensely. He had recently undergone a series of major life changes, including a job promotion that came with increased responsibilities and higher expectations. Though he was excited and enthusiastic about the professional growth, the added pressure triggered heightened stress levels. Simultaneously, there were changes in his personal life. He’d just become a father for the first time and his child had had to spend several weeks in the NICU. 

The combination of stressors, both professional and personal, created a perfect storm for anxiety. The pressure to excel in a new job while adapting to fatherhood and an ill baby became overwhelming for Alex. The first panic attack occurred just after a particularly stressful work meeting during which his wife, who was at the NICU with their baby, had called his mobile several times. After the initial panic attack, a cycle of anxiety and panic attacks began.

Alex’s initial experiences of panic attacks were characterised by sudden and intense episodes of fear, shortness of breath and dizziness. These attacks had a huge impact on various aspects of Alex’s life, causing disruptions in his work life and personal relationships. 

Recognising the severity of the situation and needing to be strong for his wife and baby, Alex took the crucial step of seeking professional help. Alex was diagnosed with panic disorder, after which he began a course of treatment. Alex began cognitive-behavioural therapy as well as medication. 

Alex’s therapist worked with him to develop coping strategies that empowered him to overcome the triggers to his panic attacks. His anti-anxiety medication and antidepressants helped Alex in the initial stages of treating his disorder to alleviate the frequency and intensity of his panic attacks. 

On a personal level, Alex began ensuring he looked after himself through sufficient sleep, regular exercise and a healthier diet. Over time, Alex was able to come off his medication and, with continuing techniques learned in CBT, began living a life free from panic attacks once again. 

Case Study 3: Mastering Generalised Anxiety

Chris’s*experiences with GAD were characterised by a constant state of worry and apprehension about various aspects of his life, from school performances to personal relationships. The generalised nature of the anxiety made it difficult for him to understand specific triggers, which led to a pervasive sense of unease and heightened stress levels. 

After opening up to his parents, Chris saw his GP who offered him support through CBT. He also had support from his sixth-form college. 

Chris’s CBT therapist helped him to see and challenge the maladaptive thought patterns he had. Through a series of structured sessions, Chris learned to identify and reframe irrational thoughts to gain a more balanced perspective on perceived threats. CBT provided Chris with practical tools and coping strategies that empowered him to manage situations that caused him anxiety.

At college, Chris joined a mindfulness group to learn techniques like meditation and relaxation. This helped him to reduce how often he wound up ruminating on future uncertainties. After committing to therapy and working hard to manage his anxiety, Chris became much more resilient. 

Chris’s journey highlights the effectiveness of evidence-based interventions like CBT and mindfulness techniques in managing GAD. By addressing both the cognitive and emotional aspects of the disorder, people with GAD can form adaptive coping mechanisms to regain control over their lives. 

Common Themes and Strategies

As we explore the diverse narratives of triumph over anxiety, several common themes emerge. Key among these is the importance of seeking support. Be it friends, family or mental health professionals, it is one of the most important principles that contribute to successful recovery.

Recognition and acknowledgement

In each case study, the individuals were all the first people to recognise and acknowledge that things weren’t right. This critical self-awareness marked the initial step to seeking help and initiating recovery. Acknowledging that things weren’t right allowed them to confront their issues and consider the possibility of—and hope for—positive change.

Professional guidance

All three individuals in our case studies recognised the importance of seeking professional help. Mental health professionals played an important role in their recoveries, providing tailored interventions like CBT and medication. Therapeutic relationships provide a safe space for exploration, understanding and the development of coping strategies. 

Holistic approaches

A holistic approach to mental wellbeing in addition to professional interventions was key here too. Lifestyle changes like mindfulness practice, regular exercise and healthy diets were integral to their improvement. 

Support systems

The support of friends and family is important too. Whether it was Sarah navigating social situations, Alex overcoming panic attacks or Chris managing his generalised anxiety at college, the presence of a supportive network was important. Open communication, understanding and empathy from loved ones create an environment that is conducive to recovery.

Coping mechanisms

Developing coping mechanisms was also integral to all three people’s recoveries. Each individual engaged in techniques tailored to their specific anxiety disorders. Exposure therapy can help with some phobias and social anxiety, whereas CBT can work with all forms of anxiety.

Persistence and commitment

Persistence and commitment are required to overcome anxiety, which is what makes this condition so tricky to manage. It’s a journey that takes a long time and there may be many bumps in the road on the way.

The Role of Resilience

One recurring theme stands out in all three case studies: resilience. Resilience is often defined as the ability to bounce back from adversity. Building resilience plays a huge role in any person’s journey to overcoming an anxiety disorder. It’s important to know that setbacks will happen and that this is natural and inevitable.

Navigating setbacks

Whether it’s facing initial discomfort or experiencing a panic attack after treatment has started, setbacks are an important part of the recovery process. Resilience means continuing to try despite the setback. 

Learning and growth

Resilience enables you to see and approach a setback as an opportunity for learning and growth. Setbacks are not indicative of failure; they represent moments of refinement. They allow individuals to refine their coping mechanisms and build emotional strength.

Celebrating progress

Resilience isn’t just about getting through a tough time; it’s about celebrating progress. Recognising and acknowledging achievements, whether this is overcoming a fear or working well with coping strategies, reinforces the process.

Inspiring Others

The power of real-life success stories shows others who are about to start their journey or who have just started, that it is possible to get better. Sharing success stories is a beacon of hope for others. What’s more, openness is key to breaking the stigma that surrounds mental health. It shows that anxiety disorders can affect anyone, and that seeking help is not a sign of weakness but a courageous step towards a better future.

Real-life stories make the journey more tangible for individuals currently struggling with anxiety. Knowing that others have walked similar paths and come through the other side is positive. It instils a sense of optimism and motivation. Success stories also help to validate experiences. They make individuals feel less alone and isolated, showing that their conditions are legitimate and worthy of space. 

Ultimately, case studies like Sarah’s, Alex’s and Chris’s serve as catalysts. They highlight the transformations that are possible, thus motivating individuals to take the first steps themselves. 

Key Takeaways:

• Professional support matters: seeking professional help is a crucial step in the recovery process. Therapies like CBT and medication play a pivotal role.
• See the problem holistically: approach your mental wellbeing from a holistic perspective. Make lifestyle changes and seek social support.
• See resilience as a pillar: resilience is a key factor in recovery. Acknowledge setbacks, learn from them, and celebrate progress.
• Success is possible: through commitment, resilience and a combination of strategies, triumph over anxiety is an achievable reality.

*names have been changed

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About the author

Louise Woffindin

Louise is a writer and translator from Sheffield. Before turning to writing, she worked as a secondary school language teacher. Outside of work, she is a keen runner and also enjoys reading and walking her dog Chaos.

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Case report: From anxiety disorders to psychosis, a continuum in transitional age youth?

1 Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium

2 Child and Adolescent Psychiatry Department, Queen Fabiola Children's University Hospital, Brussels, Belgium

3 Child and Adolescent Team, Mental Health Service at Université Libre de Bruxelles, Brussels, Belgium

Simone Marchini

4 Child and Adolescent Psychiatry Department, Erasme Hospital, Brussels, Belgium

Hélène Nicolis

Véronique delvenne, associated data.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Introduction

To date, among individuals meeting ultra-high risk criteria for psychosis, the relationship between the presence of anxiety disorders and the risk of psychotic transition raises several unanswered questions.

Case description

This case report describes the clinical progression of a 17-year-old male initially presenting anxious symptoms meeting the DSM-V criteria for panic disorder. The patient also reported social withdraw, mild depressive symptoms, insomnia and fatigue. Over a 6 month period, a gradual onset of subthreshold psychotic symptoms suggested a prodromal phase of a psychotic disorder.

Diagnostic assessment and therapeutic intervention

A detailed assessment of UHR criteria for psychosis was performed. The overall level of social and occupational functioning was assessed by the SOFAS, which showed a 35% drop over a 12 months period. The CAARMS, has also been administered. The patient met the diagnostic criteria for UHR, APS group. The care plan included psychiatric follow-up, pharmacologic treatment, individual psychological follow-up and individual and familial psychoeducation. Over a 6 months period, the patient did not experienced a first psychotic episode and presented a partial improvement of psychotic symptoms.

The DSM-V categorical approach does not seem to adapt well to early clinical presentations in transitional age youth. A transdiagnostic and dimensional approach allows to better identify at-risk patients of psychiatric disorders and implement early intervention strategies.

As the onset of most psychiatric disorders typically occurs during late adolescence and early adulthood, transitional age youth (TAY) are an at-risk population in terms of mental health ( 1 ). Early intervention in mental health is crucial, as it seems promising in modifying long-term outcomes and reducing illness severity ( 2 ).

Recent research recognizes that current categorical frameworks for classification and treatment in psychiatry are inadequate, particularly in TAY. Trans-diagnostic clinical staging models have gained prominence, by allowing a multidimensional assessment and taking into account a continuum of illness ( 3 ).

Categorical diagnosis such as anxiety and schizophrenia have been considered as completely distinct entities for years, even if the comorbidity between them has long been recognized. Regarding schizophrenia, the initial diagnosis frequently occurs at the time of the first psychotic episode. However, the diagnosis is often preceded by a prodromal phase where several symptoms gradually emerge. Early symptoms may be non-specific and include anxiety, as well as depressed mood, social withdrawal and academic difficulties. Non-specific symptoms may be followed by the basic symptoms, subtle subclinical disturbances in cognition, perception, language, emotional reactivity and stress tolerance. Later, these abnormalities become more pronounced and subthreshold positive symptoms of psychosis also emerge ( 4 ). The broad range of symptoms present in these early stages of schizophrenia include a wide variety of anxiety symptoms and comorbid entities are often present ( 5 ). Thus, the identification of anxiety symptoms seems to be an essential step in the assessment of a potential prodromal phase, in particular, when evaluating a patient also presenting impaired cognitive or social functioning. Recent epidemiological studies also show that anxiety disorders, such as social anxiety disorder, panic disorder and obsessive-compulsive disorder, are more common among people diagnosed with psychotic disorders compared to the general population ( 6 ).

Current research establishes a new paradigm for schizophrenia prodrome, which is currently considered a flexible entity where symptoms can completely disappear, persist or progress in several possible directions. The term ultra-high risk (UHR) for psychosis has therefore been used to designate individuals who potentially present prodromal symptoms and may benefit from early intervention strategies ( 7 ). Most evidence-based recommendations for UHR point out cognitive-behavioral therapy (CBT) as the most efficacious intervention, improving social functioning, allowing reduction of psychotic symptomatology and preventing or delaying transition to psychosis. Studies on the benefit/ risk balance of antipsychotic medication were not conclusive and existing clinical guidelines do not recommend systematic antipsychotic use ( 8 , 9 ).

To date, among UHR individuals, the relationship between the onset of anxiety symptoms and the risk of psychotic transition raises several unanswered questions and remains a topic of scientific interest. This case report presents the clinical situation of a 17-year-old adolescent complaining with anxious symptoms meeting the DSM-V criteria for panic disorder [300.01 (F41.0)]. The progressive emergence of prodromal symptoms, possibly suggesting a psychotic disorder, led to reflexions about anxiety disorders and psychosis as comorbid conditions or manifestations of the same clinical entity. The authors propose to include some considerations about the clinical and epistemological complexity of these categorical diagnoses. A trans-diagnostic dimensional approach is preferable in order to comprehensively assess the ever-changing clinical presentation and to provide appropriate care.

We describe the clinical case of a white Caucasian 17-year-old male adolescent referred to an outpatient child and adolescent mental health service in the Brussels urban area, Belgium, after an initial psychological assessment in a private outpatient clinic. At the time of the first psychiatric assessment, the patient was the main requester of the consultation. He presented, for about 3 months, panic attacks, characterized mainly by trembling, palpitations, a sensation of shortness of breath and a fear of losing control, without a trigger factor. These episodes, which had increased in frequency and intensity since their onset, were accompanied by a persistent worry of further panic attacks and an increase in social withdrawal that had been gradually increase in intensity over about 3 years. This posture described by the patient as voluntary self-isolation and avoidance of interactions with peers and family, was not associated with fear or anxiety related to social interactions. The patient also reported mild depressive symptoms, a sleep disorder characterized by initial insomnia, and fatigue.

Early childhood development was described as normal by parents and there was no history of perinatal complications. The patient received speech therapy, from age 3 to, for speech delay (first words at 24-months old) and articulation disorders. He took his first steps at around 12 months of age. Social interactions with peers were spontaneous during childhood and early adolescence. Regarding scholar functioning, no learning difficulties had ever been reported and he was attending, at the time of the first consultation, the last year of secondary school.

Prior to the onset of symptoms, there were no known family stressors or any significant life events, apart from the emigration of the family, from another European country, 7 years later, for professional reasons. Family psychiatric history was also not relevant.

His medical history included a primary spontaneous pneumothorax at the age of 16. He was admitted to hospital for 1 week and a chest tube was inserted, without complications. Physical examination (including cardiovascular screening) was normal, with a body mass index of 19 kg/m 2 . All laboratory results (blood and urine tests) were within normal limits. There was no history of alcohol, tobacco or drug use and he had not been on any medications.

Intelligence quotient (IQ) was assessed using the Wechsler Intelligence Scale for Adults, 4 th Edition ( 10 ) and revealed a very superior IQ (140, percentile >99).

At the time of the first psychiatric assessment, Beck Depression Inventory II (BDI-II), was administered to measure the severity of depressive symptoms ( 11 , 12 ). The patient scored for “mild depression” (score: 19). The Panic Disorder Severity Scale (PDSS), was also administered ( 13 , 14 ). This self-report scale, assessing the severity of panic attacks and panic disorder symptoms, revealed a moderate intensity of symptoms (score: 12). Initial assessment outcomes are described in Table 1 . The patient met the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) criteria for panic disorder [300.01 (F41.0)] ( 15 ).

Initial assessment results.

BDI-II, Beck Depression Inventory, second version; IQ, Intelligence Quotient; PDSS, Panic Disorder Severity Scale; PRI, Perceptual Reasoning Index; PSI, Processing Speed Index; VCI, Verbal Comprehension Index; WAIS-IV, Wechsler Adult Intelligence Scale, fourth edition; WMI, Working Memory Index.

Pharmacologic and psychotherapeutic treatment options were discussed with the patient and parents ( 16 ). Since the patient was not motivated to start CBT, a selective serotonergic reuptake inhibitor, Sertraline 50 mg per day, was initiated, with a substantial improvement of anxiety and depressive symptoms, over a 3 months period. No unexpected side effects were described.

Approximately 6 months after starting antidepressant treatment, parents reported a more pronounced decrease in social functioning, despite continued pharmacologic treatment and complete remission of panic attacks. In particular, parents observed a global decrease in social interactions, including family interactions, and the onset of clinophilia. The patient additionally reported aboulia and concentration problems related to school but only a slight drop in school results was observed at this stage. Besides, the patient reported, for the first time, having, for about 4 months, subthreshold psychotic symptoms, such as suspiciousness ideas, visual distortions, and subjective changes in speech, such as thought blockage and intrusive thoughts. These recent symptoms caused a significant distress and fear to “go crazy”.

Figure 1 shows a timeline of psychiatric symptoms and pharmacologic treatment.

Simplified timeline of psychiatric symptoms and pharmacologic treatment.

Diagnostic assessment, therapeutic intervention

Further clinical evaluation was performed and included a detailed assessment of UHR criteria for psychosis as showed in Table 2 . The 16-item Version of the Prodromal Questionnaire (PQ-16), a routine screening tool for UHR of developing psychosis ( 17 ) was administered and showed a total score of 11 points (above the distress threshold of 6 or more points). The overall level of psychosocial functioning was assessed by the Social and Occupational Functioning Assessment Scale (SOFAS) ( 18 ), showing a sustained 35% drop in SOFAS score over a 12 months period. The Comprehensive Assessment of at Risk Mental States (CAARMS), was also administered. The CAARMS is a semi-structured assessment tool used by mental health professionals to identify help-seeking youth who are at UHR of psychosis and to identify the onset of the first episode of psychosis ( 19 ). Patient presented subthreshold intensity and frequency scores on non-bizarre ideas subtest and perceptual abnormalities subtest. Based on both SOFAS and CAARMS scores, the patient met the diagnostic criteria for UHR, attenuated psychosis group (APS). He did not met the diagnostic criteria for brief, limited intermittent psychotic symptoms (BLIPS), neither trait vulnerability criteria ( 20 ). Based on presenting clinical features and the clinical staging model of mental disorders, the patient was assigned a stage 1b ( 21 ).

UHR for psychosis assessment results.

APS, Attenuated Psychotic Syndrome; CAARMS, Comprehensive Assessment of At Risk Mental States; PQ-16, Prodromal Questionnaire, 16-item; SOFAS, Social and Occupational Functioning Assessment Scale; UHR, Ultra-High Risk for Psychosis.

In line with recent recommendations for UHR patients ( 8 , 9 ), information about the diagnosis and early intervention strategies was provided and an individualized and multidisciplinary care plan was proposed. The patient still refused CBT and the follow-up included regular psychiatric monitorisation and supportive therapy, every 2–4 weeks. In order to better manage comorbid symptoms, sertraline was increased to 100 mg per day. Antipsychotic treatment was not initiated since the patient did not present severe and/ progressive UHR symptomatology ( 9 ). Both individual and family psychoeducational approaches were started even if evidence in UHR patient is still lacking and they focused on enhancing the understating of psychotic and non-psychotic symptoms, psychoeducation about the nature of anxiety and stress, engagement in treatment and increase adherence to treatment.

Over a 6 months period after the diagnosis and about a year after the onset of APS, a partial improvement of APS was observed by the clinician and the patient. The patient did not experienced a first psychotic episode over the same period.

During the initial psychiatric evaluation and the psychiatric follow-up, even if the patient was seeking care, he had a hard time in the therapeutic alliance and in explaining the symptoms, because of fear of stigmatization and of being diagnosed with a serious chronic disease. He also presented some difficulties in understanding the implications of the diagnosis and the therapeutic objectives, and in accepting the therapeutic strategies (CBT and pharmacological treatment). Both individual and family psychoeducational sessions were, according to the patient, unproductive at first, because he presented lack of motivation, but after that period, essential in order to finally understand available treatments and reduce stress and anxiety.

CARE case report guidelines were followed in the redaction of all sections the manuscript ( Table 3 ).

CARE case report guidelines.

n/a, non-applicable.

Psychiatric clinical cases are often characterized by interactions and overlaps between different diagnostic entities. Initially, this clinical case met the DSM-V criteria for panic disorder. However, the evolution of the disease has raised questions regarding a possible schizophrenia prodrome. Non-specific negative symptoms, including sleep disturbances, depressed mood, fatigue and social withdrawal were already present at the time of initial clinical presentation. Still, it was the gradual onset of positive symptoms, the attenuated psychotic symptoms, in particularly persecutory ideas and visual perceptual abnormalities, that suggested a prodromal phase of a psychotic disorder.

The DSM-V categorical approach, usually applied in clinical practice and research, is based on a list of signs and symptoms drawing a clear line between normality and psychopathology, according to a defined threshold ( 15 ). This approach is being increasingly criticized by scientific community for multiple reasons such as the excessive comorbidity between syndromes and the lack of emphasis on developmental, social, cultural and environmental context. Dimensional approaches seem to better adapt to TAY psychopathology, often characterized by early clinical presentations which include non-specific or subthreshold intensity/frequency symptoms and by the high incidence of comorbid disorders ( 22 ). In recent years, trans-diagnostic clinical staging models have gained importance, by allowing a multidimensional assessment while considering illness as a dynamic continuum from its absence to its most extreme expression ( 3 ). This broader strategy to identify at-risk patients may ultimately permit to recognize early stages of severe mental disorders, offering new management strategies tailored to patient's clinical stage, preventing the onset and/or progression of mental disorders ( 23 ). More specifically, with regard to psychotic disorders, UHR criteria represents a milestone in early detection and intervention field. The prodromal phase, previously described retrospectively, is now approached as a prospective phase. Moreover, UHR individual have a high risk to develop psychotic disorders but this pathway is neither inevitable nor the only diagnostic possibility ( 2 ). Recent scientific efforts permitted to develop clinical criteria and tools to identify UHR individuals, including the SOFAS and the CAAMS. The use of these standardized instruments can be extremely helpful to enable an early transdiagnostic approach but also to complement differential diagnosis evaluations.

More studies are needed to better identify risk and protective factors involved in transition from UHR to first episode of psychosis and schizophrenia. In this particular situation, authors questioned whether these two clinical entities are comorbid disorders or dimensional manifestations of a same disorder and whether the presence of an anxiety disorder could increase the risk of psychotic transition in UHR individuals. Prospective studies conducted in UHR individuals have found high prevalence of psychiatric comorbidities, in particular depressive (between 31 and 34%) and anxiety disorders (between 28 and 39%) ( 24 , 25 ). A study on 509 UHR individuals revealed that comorbid anxiety and depressive disorders do not appear to have an effect on the risk of psychotic transition ( 26 ). Conversely, a recent study showed that, in individuals presenting psychotic experiences, non-psychotic comorbidity increases the risk of psychotic transition ( 27 ). Furthermore, in adolescents and young adults, the presence of psychotic symptoms is frequent in depressive and anxiety disorders ( 28 ).

There is still limited knowledge of the mechanisms involved in the simultaneous presence of psychotic and anxiety symptoms, including if the treatment of anxiety disorders could decrease the frequency and intensity of subthreshold psychotic symptoms and the risk of psychotic transition. Additionally, in TAY, it is particularly important to take into account developmental, social, cultural and environmental contexts. According to cohort studies, individuals who develop schizophrenia in adulthood often show developmental abnormalities in early childhood, such as speech and motor disorders and social adjustment difficulties ( 29 ). However, there are many common risk factors between psychotic and anxiety symptoms ( 30 ). Nevertheless, the knowledge of identified risk factors may provide additional clues and guide diagnostic reasoning.

Individualized and multidisciplinary assessment and management, according to the clinical stage, should be offered to the patient and the family, ideally in a specialized center. However, to date, in Brussels, Belgium, there is no service or program specifically design to UHR patients, despite scientific evidence showing the role of these structures in reducing the risk of psychotic transition and reducing the duration of untreated psychosis, compared to conventional services ( 31 ). There is, therefore, a substantial difficulty in access to current treatment strategies. Antipsychotic medication prescription to UHR patients is not recommended in clinical practice guidelines based on the current evidence. Nevertheless, pharmacological treatment of comorbidities (principally depressive and anxiety disorders) and CBT seem to decline the rate of psychotic transition ( 32 ).

In conclusion, this case report illustrates frequent difficulties on psychiatric clinical practice, particularly in transition age youth. In UHR individuals, psychiatric comorbidities, including anxiety disorders, are common and may be responsible for additional distress. The DSM-V categorical approach does not seem to adapt well to TAY psychopathology, often characterized by early clinical presentations, non-specific and/or subthreshold symptoms. A transdiagnostic and dimensional approach could better identify at-risk patients of psychiatric disorders and allow a personalized targeted-care.

Data availability statement

Ethics statement.

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.

Author contributions

JR and SM contributed to the manuscript draft and research on the topic. JR was responsible for the psychiatric assessment and follow-up of the patient. HN provided clinical advice to JR. HN and VD reviewed the case report and article as senior authors. All authors approved the submitted version.

This study is part of the University Chair Psychiatry in Transition in a World in Transition (Université Libre de Bruxelles, Brussels, Belgium), supported by the Julie Renson Fund, the Queen Fabiola Fund and the King Baudouin Foundation. Apart from the financial contribution in research activities, the funding institutions have no role in data collection, diagnostic assessment, or therapeutic strategies.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Very early family-based intervention for anxiety: two case studies with toddlers

Author affiliations

Aude Henin 1 2

Stephanie J Rapoport 1

Timothy E Wilens 3 4

Alice S Carter 5

Anxiety disorders represent the most common category of psychiatric disorder in children and adolescents and contribute to distress, impairment and dysfunction. Anxiety disorders or their temperamental precursors are often evident in early childhood, and anxiety can impair functioning, even during preschool age and in toddlerhood. A growing number of investigators have shown that anxiety in preschoolers can be treated efficaciously using cognitive–behavioural therapy (CBT) administered either by training the parents to apply CBT strategies with their children or through direct intervention with parents and children. To date, most investigators have drawn the line at offering direct CBT to children under the age of 4. However, since toddlers can also present with impairing symptoms, and since behaviour strategies can be applied in older preschoolers with poor language ability successfully, it ought to be possible to apply CBT for anxiety to younger children as well. We therefore present two cases of very young children with impairing anxiety (ages 26 and 35 months) and illustrate the combination of parent-only and parent–child CBT sessions that comprised their treatment. The treatment was well tolerated by parents and children and showed promise for reducing anxiety symptoms and improving coping skills.

• Introduction

Anxiety disorders affect as many as 30% of children and adolescents and contribute to social and academic dysfunction. These disorders or their temperamental precursors 1 are often evident in early childhood, with 10% of children ages 2–5 already exhibiting anxiety disorders. 2 Anxiety symptoms in toddlerhood 3 and preschool age 4 show moderate persistence and map on to the corresponding Diagnostic and Statistic Manual anxiety disorders. 5 6 Well-meaning parents, particularly those with anxiety disorders themselves, may respond to a child’s distress around separating from parents or being around unfamiliar children by decreasing the child’s exposure to these situations, for example, by not having the child start preschool or by not leaving the child with a childcare provider to go to work or socialise. In the short term, such responses may impair concurrent family function, strain the parent–child relationship, and reduce the child’s opportunity for increased autonomy, learning and social development. 7 These avoidant strategies may initiate a trajectory where the child takes part in fewer and fewer activities, leading to social and academic dysfunction. 8

Members of our research team began championing the idea of early intervention with young anxious children over two decades ago, with the aim of teaching children and their parents cognitive–behavioural strategies to manage anxiety before their symptoms became too debilitating. 8 Although cognitive–behavioural therapy (CBT) has since emerged as the psychosocial treatment of choice for treating and preventing anxiety, 9 10 at that time, most protocols that had been empirically tested were aimed at children ages 7 through early adolescence, with only a few enrolling children as young as age 6. 11 We developed and tested a parent–child CBT intervention (called ‘Being Brave’) and reported efficacy in children as young as 4 years. 12 13 The treatment involved teaching parents about fostering adaptive coping and implementing graduated exposures to feared situations, and modelling how to teach children basic coping skills and conduct exposures with reinforcement. In parallel, a growing number of investigators confirmed that anxiety in preschoolers could be treated efficaciously using CBT administered either by training parents to apply CBT strategies with their children or through direct intervention with children. 14 15 Early family-based intervention using cognitive–behavioural strategies was shown to reduce rates of later anxiety and to attenuate the onset of depression in adolescence in girls. 16

The question remains as to whether early intervention can be extended even younger. With few exceptions, 17 18 most investigators do not offer direct CBT for anxiety to children under age 3 or 4, 15 and none to our knowledge have treated anxiety disorders with CBT in children under age 2.7. 15 However, we reasoned that since toddlers can also present with impairing symptoms, and since behaviour strategies can be feasibly applied even in preschoolers with poor language ability, 19 it ought to be possible to apply family-based CBT for anxiety to toddlers as well. We therefore present two cases of anxious children, ages 26 and 35 months, treated with parent and child CBT.

Recruitment

Parents of children ages 21–35 months were recruited for a pilot intervention study (a maximum of three cases) using advertisements to the community. To be included, children had to be rated by a parent as above a standard deviation on the Early Childhood Behavior Questionnaire Fear or Shyness Scale 20 and could not have global developmental delays, autism spectrum disorder or a primary psychiatric disorder other than anxiety.

Children were evaluated for behavioural inhibition using a 45 min observational protocol. 21 Parents completed a structured diagnostic interview about the child (Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime) that has been used with parents of children as young as 2 years; 22 23 an adapted Coping Questionnaire, 24 in which parents assessed the child’s ability to cope with their six most feared situations; and questionnaires assessing child symptoms (Child Behavior Checklist 1-1/2-5 (CBCL), 25 subscales from the Infant Toddler Social Emotional Assessment (ITSEA) 26 ), family function (Family Life Impairment Scale 27 ) and parental stress (Depression Anxiety Stress Scale 28 ). These assessments were repeated following the intervention, with the exception of the behavioural observation for the child initially rated ‘not inhibited’. The clinician rated the global severity of the child’s anxiety on a 7-point severity scale (Clinician Global Impression of Anxiety 29 ) at baseline and rated global severity and improvement of anxiety postintervention. Participant engagement in session and adherence to between-session assignments were rated by the clinician at each visit, and parents completed a post-treatment questionnaire rating the intervention.

Children were treated by the first author, a licensed child psychologist, using the ‘Being Brave’ programme. 13 It includes six parent-only sessions, eight or more parent–child sessions and a final parent-only session on relapse prevention. An accompanying parent workbook reinforces the information presented. Parent-only sessions focus on factors maintaining anxiety; monitoring the child’s anxious responses and their antecedents and consequences; restructuring parents’ anxious thoughts; identifying helpful/unhelpful responses to child anxiety; modelling adaptive coping; playing with the child in a non-directive way; protecting the child from danger rather than anxiety; using praise to reinforce adaptive coping; and planning and implementing graduated exposure. Child–parent sessions teach the child basic coping skills; and focus on planning, rehearsing and performing exposure exercises, often introduced as games, with immediate reinforcement. All parent–child sessions were preserved from the original protocol, but two sessions teaching the child about the CBT model, relaxation and coping plans were omitted, as were two sessions in which the (older) child does a summary project and celebrates gains. Up to six child–parent sessions focusing on exposure practice were included.

In the cases that follow, identifying details are disguised to protect participants’ privacy. Parents of both children provided written consent for the publication of de-identified case reports.

Background information

‘J’ was a 35-month-old girl, the third of three children of married parents. She had congenital medical problems requiring multiple surgeries, and she continued to undergo regular follow-up procedures. J met the criteria for separation anxiety disorder with marked severity, mild social phobia and mild specific phobia. Although she was able to attend her familiar day care if handed directly to a teacher and attend a gymnastics class with a friend while her mother waited in the hall, J showed great distress if apart from her mother at home. If her mother left her sight (eg, to use the bathroom), J would sob, cry and try to open the door to get in. If her mother went out and left her with a family member, J would fuss, cry and try to come along, and would continually ask to video-call her, so her mother would cut her outings short. J also had fears of doctors’ visits, of riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was afraid to take part in gymnastics performances.

J also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say ‘ow, ow’ if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties.

‘K’ was a 26-month-old boy, the only child of married parents. He met the criteria for moderate separation anxiety disorder. Although able to go to a day care he had been attending since infancy, he showed distress at drop-off particularly at the start of each week, crying for 15 min. He feared being apart from his mother in the house: he could not tolerate his mother leaving the room even to change clothes and would cry if his mother left the playroom while K played with his father. He would get distressed if his father took him on outings without his mother. He could not be dropped off at a childcare centre at his parents’ gym, leading to their avoiding exercise. He slept in his own crib, rocked to sleep by a parent, but would wake in a panic (alert but distressed) two to three times per month, crying for over an hour until his parents took him into their bed. K also was very particular about where objects were placed in the playroom and would fuss if they were put in the wrong place. He got anxious about deviations in routine (eg, taking a different path on a walk) and had trouble throwing things away (eg, used Band-Aids).

Intervention Feasibility and Outcomes

To demonstrate feasibility, the application of the treatment protocol with both participants is summarised in table 1 . Both participants completed the treatment, in 11 and 10 sessions, respectively. For each, session engagement was rated ‘moderately’ or ‘completely engaged’ at all but one session, and homework adherence was rated as ‘moderate work’ to ‘did everything assigned’ at all but one session.

The quantitative results of the treatment are presented in table 2 . Both children were rated by the clinician as having shown ‘much improvement’ (Clinician Global Impression of Anxiety-Improvement 1 or 2), and both showed changes in quantitative measures of anxiety and family function. In both families, parents rated their satisfaction with the treatment as ‘extremely satisfied’, and felt that they would ‘definitely’ recommend the intervention to a friend. They rated all strategies introduced in the intervention as ‘very-’ or ‘moderately helpful’ and rated the change in their ability to help their child handle anxiety as ‘moderately-’ to ‘very much improved’.

These pilot cases demonstrate the feasibility and acceptability of parent–child CBT for toddlers with anxiety disorders. The two participating families completed the treatment protocol and were consistently engaged with in-session exercises and adherent to between-session skills practice. The cases demonstrate that basic coping skills and exposure practice can be conducted with toddlers.

Although efficacy cannot be determined from uncontrolled case studies, the cases did show promising preliminary results. Both children showed a decrease in number of anxiety disorders, both were rated by the clinician (and parents) as either ‘moderately-’ or ‘much improved’ in their overall anxiety, and both showed increases in their parent-rated ability to cope with their most feared situations. Participant 2 improved on all symptom measures as well. Most significantly, his ITSEA general anxiety, separation distress, inhibition to novelty, negative emotionality, compliance and social relatedness scores and his CBCL total score, internalising score and somatic complaints scale score normalised from clinical to non-clinical range. Participant 1 had a more complicated clinical presentation, and whereas her diagnoses and coping scores improved, her parent-rated symptom scores were more mixed, perhaps related to medical problems which impacted sleep. Beyond changes in the children’s behaviour, family life impairment was reduced for both families, and parental stress was decreased out of clinical range for participant 1. Notably, both children also showed gains in areas of competence, including prosocial peer relations and mastery motivation.

This work extends previous research demonstrating that very young children experience impairing levels of anxiety that are amenable to CBT. Previous studies have found that CBT is as efficacious with older preschool-age children with anxiety disorders as it is with school-aged youth, 14 15 with approximately two-thirds of treated youth demonstrating clinically significant improvement. There is increasing recognition that anxiety disorders start early in childhood, and that there are significant advantages to intervening proximally to their onset, before anxiety symptoms crystallise and impairment accumulates. For example, one study of 1375 consecutive referrals (mean age 10.7) to a paediatric psychopharmacology clinic found that the median age of onset of a child’s first anxiety disorder was 4 years. 30 Children seeking treatment for anxiety often present in middle childhood, for symptoms which began much earlier, exposing the child and family to undue stress for years. By teaching parents and very young children skills to manage anxiety, we hope to give families important tools to navigate the developmental transitions inherent in this age range, and to help children develop a sense of mastery during a critical developmental period. Of course, a larger controlled trial is needed to further evaluate this intervention and its efficacy over time.

Assessing and treating toddlers require a developmentally informed approach. Anxiety and other symptoms may present differently in younger children, and because of limited language and cognitive abstraction capabilities toddlers are not as able to describe their fears and worries. Because some forms of anxiety (eg, separation anxiety, stranger anxiety) are normative, determination of clinically significant levels of anxiety requires an understanding of typical development in toddlerhood and the ability to conduct a detailed assessment with parents and the child using measures normed for this age group (such as the ITSEA and CBCL 1-1/2-5). Similarly, implementing CBT with toddlers and preschoolers requires age-appropriate modifications of empirically supported techniques. The adaptations we used included increased parental involvement in planning exposures, decreased focus on child cognitive restructuring (beyond framing the practice as ‘being brave’ and redirecting the child’s attention to rewarding aspects of the situation), and adaptations to exposure exercises to maximise child participation and motivation (practising at times when the child was rested and not irritable, incorporation of games and reinforcers, and allowing the child maximal choice about when/how to carry out the exposure). The cases we presented demonstrate that existing interventions can be effectively adapted and implemented with children as young as 2 years of age. By sharing the information gleaned from our research, we hope to inform providers who may be less familiar with treating children in this age range and increase their confidence in intervening with very young children.

Dina Hirshfeld-Becker earned her undergraduate degree from Harvard and her doctorate in clinical psychology from Boston University, and completed post-doctoral training at Massachusetts General Hospital. Dr Hirshfeld-Becker is currently co-founder and co-director of the Child Cognitive Behavioral Therapy (CBT) Program in the Department of Psychiatry at MGH and an associate professor of psychology in the Department of Psychiatry at Harvard Medical School. The Child CBT Program offers short-term empirically supported CBT with youths ages 3-24, research in novel treatment adaptations, and clinical training in CBT, including on-line training courses. She pioneered the development and empirical evaluation of one of the first manualized cognitive-behavioral intervention protocols for anxiety in 4- to 7-year-old children, the “Being Brave” program, and has been exploring its use with children with autism spectrum disorder and with younger toddlers and their parents. Dr Hirshfeld-Becker has published numerous articles, reviews, and chapters. Her main research interests include the etiology, development, and treatment of childhood psychiatric disorders, particularly anxiety disorders, and in the study of early risk factors for these disorders.

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Securing adolescent health and well-being today is vital for the health of future generations - WHO

Increased investment is urgently needed to address evolving health risks and meet the mental and sexual and reproductive health needs for the nearly 1.3 billion adolescents (aged 10-19 years) globally, according to a new scientific publication released by the World Health Organization (WHO).  Adolescence is a unique and critical stage of human development, involving major physical, emotional, and social transitions, and is a pivotal window for laying long-term foundations for good health.

“Promoting and protecting the health and rights of young people is essential to building a better future for our world,” said Dr Tedros Adhanom Ghebreyesus, Director-General of WHO. “Conversely, failing to address the health threats that adolescents face – some longstanding, some emerging – will not only have serious and life-threatening consequences for young people themselves, but will create spiraling economic costs for societies. That makes investing in services and programmes for adolescent health both a moral imperative and an economic no-brainer.”

The publication was launched at an event on the margins of the United Nations’ Summit of the Future . It highlights a number of troubling trends in adolescent health observed over the last decade, pointing to the urgent need for action.

At least 1 in 7 adolescents globally now suffer from a mental disorder, for instance, with particularly high rates of depression and anxiety.  Anaemia among adolescent girls remains prevalent, at levels similar to those in 2010, while close to 1 in 10 adolescents are obese.  Sexually transmitted infections (STIs) including syphilis, chlamydia, trichomoniasis, and genital herpes that commonly occur among youth are rising, and if left untreated, can have lifelong implications for health.  

Meanwhile violence, including bullying, affects millions of young people worldwide each year, with devastating impacts on their physical and mental health.

Concerningly, attempts to roll-back adolescents’ access to sexual and reproductive health care and comprehensive sexuality education have escalated amidst a growing backlash against gender equality and human rights. Restrictive age of consent policies are limiting their access to STI and HIV services. Such measures can marginalize young people, reduce health-seeking behaviour, and lead to lasting negative health impacts.

The study emphasizes other broader fundamental challenges to the future of adolescents including climate change, conflict, and inequality.

The authors also highlight that gains are possible with the right investment and support.  For example, adolescent HIV infections have declined, due to coordinated and persistent efforts in this area. Adolescent pregnancy and harmful practices such as female genital mutilation and early marriage have reduced. In addition, many positive trends in health outcomes are linked to more time in school, especially for girls; since 2000, the number of secondary-school-age children out of school decreased by nearly 30%.

Against this backdrop, the findings make a strong case for investing in adolescent health and well-being, with attention to foundational elements including education, healthcare, and nutrition.  The authors call for enacting and implementing laws and policies that protect adolescent health and rights, for health systems and services to be more responsive to adolescents’ unique needs, and for the prioritization of youth engagement and empowerment across research, programming, and policymaking.

“Adolescents are powerful and incredibly creative forces for good when they are able to shape the agenda for their well-being and their future,” said Rajat Khosla, Executive Director of the Partnership for Maternal, Newborn and Child Health (PMNCH), which co-hosted the event where the publication as launched. “Leaders must listen to what young people want and ensure they are active partners and decision-makers. They are critical for the world’s future social, economic, and political stability, and if given the platform they need, they can help make a better and healthier world possible for everyone.”

Earlier this year, world leaders committed to accelerate efforts to improve maternal and child health , including adolescent health, at the World Health Assembly.  Implementing these commitments, as well as those reflected in the UN’s Pact for the Future, will be critical to protecting and promoting the health and well-being of current and future generations.

Notes for editors 

The publication was released at a high-level event convened on the margins of the UN General Assembly. It was hosted by the Governments of Chile, Colombia, and Ireland along with the UN’s Human Reproduction Programme, PMNCH and WHO in collaboration with: FP2030, Guttmacher, International Association for Adolescent Health (IAAH), Johns Hopkins Bloomberg School of Public Health (JHUSPH), Plan International, UNESCO, UNFPA, Women Deliver, and YieldHub.  

The Summit of the Future takes place on September 22 and 23, 2024, seeking new consensus around how the international system can evolve to better meet the needs of current and future generations. 

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Adolescent health

What Young People Want

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Global Accelerated Action for the Health of Adolescent (AA-HA!)

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Evidence-Based Herbal and Nutritional Treatments for Anxiety in Psychiatric Disorders

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• David Camfield 0 ,
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Department of psychiatry faculty of medicine, the university of melbourne, melbourne, australia.

• Focuses on the current state of the art in research into herbal and nutritional treatments for anxiety disorders
• Provides evidence-based information on the efficacy of individual treatments
• Written and edited by world-renowned researchers with specific expertise in human psychopharmacology and the use of herbal medicines

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This book presents the current clinical evidence on the efficacy of herbal and nutritional treatments for anxiety that is experienced in association with psychiatric disorders, and explains how health professionals can apply this knowledge to the benefit of patients presenting with a wide range of symptoms, including comorbid mood disorders. All chapters are written by world-leading researchers who draw on the findings of human clinical trials to provide uncompromising assessments of individual treatments, including herbal anxiolytics with sedative actions, adaptogens, cognitive anxiolytics, and nutraceuticals. Traditional treatments requiring further study – including the plant-based psychotropic Ayahuasca and other phytotherapies of potential value in the treatment of anxiety – are also reviewed. In the closing chapters, a series of helpful case studies are provided by mental health clinicians in order to illustrate how herbal and nutritional treatments can best be integrated intoan overall treatment plan for individuals with a range of comorbid diagnoses. Mental health professionals, researchers, and general readers will find that the book provides an excellent review of current scientific knowledge gained from the study of herbal and nutritional treatments, together with important clinical recommendations for their use in patients experiencing clinically significant levels of anxiety.

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• Alternative medicine
• Biological psychiatry
• Complementary medicine
• Herbal medicine
• Human Psychopharmacology
• psychopharmacology
• pharmacotherapy

Table of contents (11 chapters)

Front matter, the need for evidence-based herbal and nutritional anxiety treatments in psychiatry.

• David A. Camfield, Erica McIntyre, Jerome Sarris

Clinical Evidence in Support of Herbal and Nutritional Treatments for Anxiety

Herbal anxiolytics with sedative actions.

• Jerome Sarris, Erica McIntyre
• Naomi L. Perry, David A. Camfield

Cognitive Anxiolytics

• Genevieve Z. Steiner, Danielle C. Mathersul

Nutritional-Based Nutraceuticals in the Treatment of Anxiety

• David A. Camfield

Treatments for Comorbid Anxiety and Mood Disorders

• Jerome Sarris, David Mischoulon

Traditional Treatments in Need of Further Study

The therapeutic potential of ayahuasca.

• Michael A. Coe, Dennis J. McKenna

Potential Herbal Anxiolytics

• Erica McIntyre, David A. Camfield, Jerome Sarris

Clinical Perspectives and Case Studies

Integrative treatments for masked anxiety and ptsd in highly sensitive patients.

• Patricia L. Gerbarg, Richard P. Brown

SAMe in the Treatment of Refractory Depression with Comorbid Anxiety: A Case Study in a High Histamine Patient

• Rachel Arthur

A Complex Case of Undiagnosed Generalised Anxiety Disorder with Episodic Panic Attacks

• Jane Hutchens

Back Matter

Editors and affiliations.

David Camfield

Erica McIntyre

Jerome Sarris

About the editors

Dr David A Camfield holds the position of Vice Chancellor’s Postdoctoral Research Fellow at the University of Wollongong (AUS), where he is conducting depression and anxiety research in association with the School of Psychology, Centre for Health Initiatives and the Illawarra Health and Medical Research Institute. He is also affiliated with the Centre for Human Psychopharmacology, Swinburne University of Technology (AUS), where he has previously been involved in human clinical trials for nutraceuticals which target cognitive function and mood. He has published 37 peer-reviewed journal articles and completed work on 9 book chapters. He has also served as a guest editor with Evidence-based Complementary and Alternative Medicine journal. His research interests involve nutraceutical treatments for psychiatric disorders, clinical psychology, biological psychiatry and affective neuroscience. Dr Camfield is currently studying for a Masters in Clinical Psychology, with a view to applying integrative treatment approaches in the treatment of depression, anxiety and obsessive compulsive disorder.

Erica McIntyre is a Research Associate and lecturer in the School of Psychology at Charles Sturt University, and submitted her PhD thesis in 2016. She previously worked as a Western herbalist with a special interest in mental health. Erica is a Fellow of the ARCCIM International Naturopathy Research Leadership Program at the Faculty of Health, University of Technology Sydney. Her research interest is in health behaviour, mental health, herbal medicine effectiveness and research translation. She has published 9 peer-reviewed journal articles and 3 book chapters. She is an Associate Editor of the Australian Journal of Herbal Medicine, and Scientific Program Chair for the International Conference on Herbal Medicine. She was previously Vice President of the National Herbalists Association of Australia, and was awarded Fellow of the NHAA in 2015.

Dr Jerome Sarris is a Senior Research Fellow, and Head of the ARCADIA mental health research group at the Professorial Unit, Department of Psychiatry, University of Melbourne. He has previously worked as a Naturopath and Acupuncturist before a career as an academic specialising in mental health research. His research interest is primarily in the study of nutrients and psychotropic plant-based medicines (nutraceuticals) to treat mood and anxiety disorders, and in lifestyle medicine and integrative medical approaches for enhancing mental health. He has published 82 peer-reviewed journal articles and completed work on 24 books and book chapters. He serves on the editorial board of notable integrative medicine journals. He has also been awarded the National Herbalists Association of Australia Notable Contribution to Research Award.

Bibliographic Information

Book Title : Evidence-Based Herbal and Nutritional Treatments for Anxiety in Psychiatric Disorders

Editors : David Camfield, Erica McIntyre, Jerome Sarris

DOI : https://doi.org/10.1007/978-3-319-42307-4

Publisher : Springer Cham

eBook Packages : Medicine , Medicine (R0)

Copyright Information : Springer International Publishing Switzerland 2017

Hardcover ISBN : 978-3-319-42305-0 Published: 16 December 2016

Softcover ISBN : 978-3-319-82550-2 Published: 04 July 2018

eBook ISBN : 978-3-319-42307-4 Published: 29 November 2016

Edition Number : 1

Number of Pages : XIV, 208

Topics : Psychopharmacology , Clinical Psychology , Complementary & Alternative Medicine , Pharmacotherapy

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