For our November Readers' Review: “Dinner at the Homesick Restaurant” by Anne Tyler. As we prepare for holiday gatherings, join Diane and her guests to discuss this master work from the author who has made an art of exploring family love and dysfunction.
Guest Host: Katty Kay
Anxiety disorders are the most common psychiatric illnesses affecting children and adults. Yet out of the estimated forty million American’s suffering from it, only about a third receives treatment. The latest in research, treatment and education of this illness, and how to distinguish a disorder from everyday anxiety.
- Dr. Blair Simpson Director of the Anxiety Disorders Clinic and of the OCD Research Program and Professor of Clinical Psychiatry at Columbia University.
- Dr. Elizabeth Phelps Lab Director of New York University's Department of Psychology
- Dr. Richard Nakamura Scientific Director of the National Institute of Mental Health (NIMH)
- Dr. Daniel Pine Chief, Section on Development and Affective Neuroscience and Chief of Emotion and Development Branch in the Mood and Anxiety Disorders Program of the National Institute of Mental Health Intramural Research Program.
- Dr. Jerrold Rosenbaum President of the Anxiety Disorders Association of America, Chief of Psychiatry at Massachusetts General Hospital, Professor of Psychiatry at Harvard Medical School
MS. KATTY KAYThanks for joining us. I'm Katty Kay of the BBC, sitting in for Diane Rehm. Diane is still sick, and we do hope she'll be back with us soon. Anxiety disorders are the most common form of psychiatric illnesses, yet just a third of the millions suffering from them get the help they need. Joining us to talk about the latest research and treatment of anxiety disorders in our studio, Dr. Richard Nakamura, scientific director of the National Institute of Mental Health, and Dr. Daniel Pine, a psychiatrist who directs the institute's Mood and Anxiety Disorders Research Program. Also joining us from WGBH in Boston, Dr. Jerrold Rosenbaum, he's president of the Anxiety Disorders Association of America. Gentlemen, thank you so much for joining me.
DR. DANIEL PINEPleasure to be here.
KAYThe phone number here is 1-800-433-8850. Our e-mail address is firstname.lastname@example.org. Of course, you can also find us on Twitter and Facebook. We would love to hear from you, and we will be opening the phones in just a while. Dr. Nakamura, if I could start with you, anxiety disorders, of course, covers a range of symptoms and problems. What exactly does it include?
DR. RICHARD NAKAMURAI'm going to pass that question over to our clinician, Dr. Pine.
PINESo there's really a range of different symptoms that people can manifest when they have an anxiety disorder, but all of them involve some level of fear or nervousness. So people can be afraid of specific things, like heights or spiders, or people can be nervous about certain situations, like being afraid of crowds or having to give a presentation at work. But the thing that binds them all together is the tendency to feel afraid, more afraid than most people are in that situation.
KAYSo whilst the situations might be different and the things that trigger an anxiety disorder might be very different, there is a common link between them all.
PINEThat's exactly right.
KAYHow do you identify, Dr. Nakamura, or make a difference between an anxiety disorder, which is a clinical condition, and what other people might suffer as everyday anxiety?
NAKAMURAWell, the key thing is, does it really cause an impairment? So about -- over a lifetime, about 20 percent of the public has a clinically significant anxiety disorder. However, there -- we also distinguish severe anxiety disorders in which people are highly impaired by the condition. And that's about 10 percent of the population experiences this over their lifetime. I should also point out that anxiety disorders, in general, tend to be chronic. This doesn't wax and wane like depression.
NAKAMURABut people tend to be relatively stable in them. So if you have a clinically significant or severe anxiety disorder, this is likely to affect you for your lifetime unless they're appropriately treated. So that figure of only 30 percent being treated is a very important one. It means that the vast majority of people walking around with clinically significant or even severely impairing anxiety disorders are not being treated.
KAYBut you're also suggesting that some people do get episodes of anxiety disorder during the course of their life.
NAKAMURAThere can be episodes of anxiety disorder triggered by trauma, for instance. And that is where actually the most interesting research going on right now is coming from, the idea of fear conditioning or anxiety disorders triggered by an event or by multiple events.
DR. JERROLD ROSENBAUMKatty, if I could just...
KAYYes, do. Yeah, go ahead, Dr. Rosenbaum.
ROSENBAUMSo one of the dilemmas in conveying the unique suffering of people with anxiety disorders is that the term anxiety -- in some ways similar to the use of the term depression -- has lay meanings that represent fairly universal experiences from time to time that we all have. And so sometimes if one has never actually experienced the level of distress, the immobilizing fear, the disabling anxiety that characterizes these disorders, people are unclear of really what we're talking about and why it's such a big deal.
ROSENBAUMThe reality is that, you know, we all are wired to experience fear quite appropriately, and by evolution for survival, it means we have fear circuitry. But for some individuals, it is on such a hair-trigger or is on so constantly or the level of alarm is so great that they really are unable to do the activities of daily living to enjoy a life, to participate in family activities or even to engage socially with other human beings. So the term anxiety being so commonly used often misleads people and can trivialize the level of distress that people with these disorders actually experience.
KAYI think that's so true. I think for people who do not suffer from this and who suffer some level, of course, of everyday stress or anxiety, they kind of think, well, I can't sleep at night sometimes, or I can't eat sometimes when I'm under stress. But they can't envisage what it's like to suffer from an extreme form of that kind of fear or that kind of phobia. One woman, who did recognize what it was like, Dr. Rosenbaum, was Jerilyn Ross. She was a pioneer in this field. She was somebody who was dedicated to bringing attention and treatment and research to anxiety disorders. I was just wondering if you could tell us a little bit about her.
ROSENBAUMOh, sure. Well, Jerilyn, who was the founding president of the Anxiety Disorders Association of America, was an individual who experienced one of the extreme forms of anxiety called panic. And it disabled her and made her unable to go out, experiencing agoraphobia, and her response was to try to learn everything she could about it and how to treat it. And this was really 30 years ago when treatments were in its infancy, and these disorders were even more stigmatized and taboo than they are today. And so she felt her experience and her story could be a vehicle for helping others.
ROSENBAUMAnd she dedicated her life to building this organization, the Anxiety Disorders Association of America, to -- as a forum where people who suffer these conditions could understand they're not alone -- in fact, they're among many millions -- to understand that these fears are irrational, and although impairing, that there was -- there were treatments, and really brought together clinicians, consumers or sufferers and scientists into an organization to try to combine, really, education facilitating of research and support for individuals who suffer from anxiety disorders, including phobias, panic disorder, panic attacks, social anxiety, post-traumatic stress, generalized anxiety disorder, and to create an organization that would both advocate and advance the cause of education and treatment.
KAYDanny Pine, how many of those anxieties that Jerilyn Ross was working so hard to identify and get treatment for and recognition for are found in children? Because what Dr. Nakamura was suggesting is that this is a lifelong condition, that if you have an anxiety disorder, you will have it for your life. Does that then suggest that it is necessarily, in an adult who has it, that it was necessarily present in that person as a child?
PINEI'll speak that in one second, but I think I want to just come back to Jerilyn for...
PINE...one more second because I think there is a very important lesson, particularly for children in the life that Jerilyn led that I think tells us something very important about what it means to have an anxiety disorder and how we might work to alleviate the burden. And that relates to the fact that there are -- there's a tremendous amount of stigma about mental illnesses, and at the time that Jerilyn was suffering, the stigma was even greater than it is right now.
PINEAnd it took a huge amount of courage for somebody like Jerilyn to stand up and say, I'm afflicted with this, and I'm not ashamed about it. And there are other people who are afflicted about it. And the thing that we all need to do is not hide from it but look at this problem and treat this problem like any other medical problem that we're confronted with. And that's really what Jerilyn did. And, you know, I think when we start thinking about children -- to come to back your question -- I think there is a tendency -- and it's a good tendency, by and large -- to want to be very protective, to want to be very protective towards our children, and that does relate to this issue of stigma.
PINEBecause there has been so much stigma and because there are not that many people who have the courage that Jerilyn had, people are particularly concerned about calling attention to the problem of anxiety in children. But just as you mentioned that the overwhelming majority of anxiety disorders that adults have actually have their roots in childhood, so the seeds of most chronic mental health problems -- and this is clearly true for anxiety disorders -- they start during childhood. So if we as a society really want to address the burden of mental illnesses, what we need to do is we need to confront the stigma. And we need to start thinking about, how can we do things to alleviate these problems very early in their course when they just begin to start to manifest in childhood?
ROSENBAUMI would add...
ROSENBAUM...to Danny's comment that as much as it is abundantly clear that the vulnerability to these disorders is, to an important extent, heritable and brain-based, and it is clear that they emerge early in life. But that -- whether these are genetic or otherwise biologically based, that is not destiny. And what we've seen -- and I know Danny would agree with this -- that however heritable, that if you intervene early with children who are suffering anxiety in the right way, which involves education of parents working with children, modeling coping behaviors, helping them through graduated exposure to feared situations, you can actually take children who look like they're destined for anxiety and change them. The brain is very plastic when you're young. It's very malleable, and it is possible to intervene early and change the course of someone's life through early recognition and intervention.
KAYDr. Jerrold Rosenbaum, joining us from Harvard. Dr. Daniel Pine is in the studio with me, too. Dr. Richard Nakamura from the National Institute of Mental Health is also here. We'll have more on our discussion on anxiety disorders after this short break. We'll also be taking your calls and questions. The number is 1-800-433-8850.
KAYWelcome back. I'm Katty Kay of the BBC, sitting in for Diane Rehm. You've joined our conversation on anxiety disorders, the latest in research and treatment. I'm joined in the studio by Dr. Daniel Pine and Dr. Richard Nakamura. Dr. Jerrold Rosenbaum joins us on the phone from Harvard. And before we get back to you, gentlemen, we also have joining us by phone from her office, Dr. Blair Simpson of the Anxiety Disorders Clinic at Columbia University. Dr. Simpson, thank you so much for joining me.
DR. BLAIR SIMPSONThank you for having me.
KAYDr. Simpson, your area of expertise in the very broad field that is anxiety disorders is OCD, obsessive-compulsive disorder. Can you explain what that means for our listeners?
SIMPSONYes. So OCD is one of the anxiety disorders that we haven't mentioned yet. And OCD is characterized by symptoms like obsessions, which are intrusive thoughts or fears that generate anxiety and distress. But it also is characterized by rituals or compulsive behaviors, things that people feel like they have to do over and over again. And just to pick up a theme that you had already discussed -- look, most people have funny little thoughts from time to time, and many of us have habits. That isn't OCD. OCD is people who have these obsessions and compulsions more than an hour a day, often hours and hours a day, and they're really distressed and not able to function as a result.
KAYAnd do we know what causes it?
SIMPSONIn a simple answer, no. What we do know is that all of our behavior in the end is caused by the brain, and so if I have abnormal behavior, then that's caused by my brain, too. And there is data to suggest -- or are data to suggest that people with OCD have abnormal functioning in certain parts of their brain, and the thinking is that maybe that leads to the symptoms. But that's not the same thing as how your brain got to be abnormal in the first place. And that's a different question, which is, so how did my brain get this way?
SIMPSONAnd that's picking up what Dr. Rosenbaum said, is that's a complicated -- that's a -- it's a series of things, including maybe your genetic vulnerability, maybe what happens to you in early life, maybe your development and maybe a contribution of your environment, either to protect you or not to protect you.
KAYIf we're not clear on what causes OCD, are we any clearer on what appropriate treatment there is?
SIMPSONYes. There, it's very clear, and that's good. We have two main treatments for OCD. One is with a class of medications called serotonin reuptake inhibitors. Sometimes there's a specific form of them called the selective serotonin reuptake inhibitors. Those are medications like fluoxetine or paroxetine. We know in many clinical trials they've been shown to help, over giving someone a sugar pill, and can be very well tolerated. The other important treatment for OCD is a very specific type of cognitive behavioral therapy called exposure and response prevention.
SIMPSONAnd that involves really creating a hierarchy of what people fear with OCD and then starting to expose them to those fears in a very specific way while helping them not to give in to their rituals -- again, an incredibly effective treatment in people who can do it. So we definitely have effective treatments. The problem is they don't work for everybody, and there are many different reasons for that. But that's why there's a lot of research ongoing about, really, what causes OCD. And how can we improve our current treatments? And how can we get the treatments we know work out to the people who are suffering?
KAYDr. Simpson, I have a very good friend whose child has been diagnosed with OCD. How common is it in children? And is the treatment the same as it is in adults?
SIMPSONNo, it's -- you know, it's very tragic. OCD, half the cases start by age 19 -- a quarter of the cases of the disorder. I don't even mean symptoms now. I mean of the disorder start by age 14. OCD is not the most prevalent or common of the anxiety disorders. It's about twice as common as schizophrenia, 1 to 2 percent. But it is -- it starts early, and it's very chronic. And the majority of the cases are moderate to severe. So I think it's our most disabling anxiety disorder because kids get it, and then they get off track 'cause the symptoms are generally not mild. That's the bad news.
SIMPSONThe good news is these same treatments that we know work in adults also work in children. We usually start with cognitive behavioral therapy in children. Again, it can be very effective. The problem with cognitive behavioral therapy, though, is you need a skilled therapist, and you need to engage in the treatment. It doesn't work on you. You have to actually change what you do in your everyday life to actually see the benefits.
KAYDr. Blair Simpson, joining us from Columbia University, thank you so much, Dr. Simpson, for joining the program.
KAYDr. Nakamura, picking up there on what Dr. Simpson was talking about, particularly in terms of what we know about the causes. You've done work on brain scans, looking at anxiety disorders. What does it show us? What do they show? What's the latest in the research now showing us on what causes anxiety disorders?
NAKAMURAWell, I'd like to focus on plasticity because the brain, we now know, is highly plastic. And when we focus on the brain, we can begin to see what are the connections between different areas that one -- are started by fear conditioning. So we'll hear later from Dr. Phelps that the amygdala is the key to the development of fears and fear conditioning. We also know that other structures can influence how much fear is expressed by the amygdala. So right now, we know that because the brain is plastic and because the environment changes the brain, we can influence the degree with which fear is shown. Now, we will also hear that this fear is very, very strong and very tight connection.
NAKAMURAAnd -- but medication on the one hand and behavioral conditioning on the other hand can loosen that. This is a very new result and allows us to both develop new treatments -- I'm not going to take all of Liz Phelps' story, so I'll let her go on with it.
KAYWell, let's bring Dr. Elizabeth Phelps into the conversation. She joins us now by phone from New York University. She is the lab director of NYU's department of psychology, and I believe we have Dr. Phelps on the phone. Dr. Phelps, thank you so much for joining the conversation.
DR. ELIZABETH PHELPSThanks for having me.
KAYDo tell us a little bit more about the research that your lab has been doing. Dr. Nakamura was starting to tell us some of it there.
PHELPSMy research recently has -- a lot of it has focused on how we -- not how we get fears, but how we get rid of fears. So there are a number of techniques we can use to diminish our fear responses. And I'd say in the first 20 years or so, or 15 years of studying fear in the brain, we were very concerned with how you learn fears. But we've really shifted our focus to how, now, you get rid of fears, which is much more relevant to anxiety disorders. And so we look at a range of different techniques.
PHELPSWe look at having experiences now that diminish your fear response because you've learned that something that was dangerous is now safe. We've looked at using your thoughts to try to diminish your emotional responses by interpreting the situation differently. We've looked at how a sense of control over the situation might diminish your fear response. And the work that's gotten probably the most attention is looking at how we might actually be able to rewrite fears in our brains so that we actually aren't inhibiting them. We're -- we no longer have the fears.
KAYDr. Phelps, does that kind of treatment work best with people who have an anxiety disorder that is caused by an external traumatic event happening to them? Or is it different for people who have -- in whom this is more of a genetic condition? Or is that -- am I making a false distinction?
PHELPSWell, I wish I could answer that question because that's what we want to know. The truth is, all the work we've done so far, it -- with these, especially these techniques for sort of rewriting or erasing fears have been in normal humans. We're just discovering how this works, so there haven't been -- we haven't even been able to extend it to any type of anxiety disorder effectively 'cause we don't quite understand the specifics well enough at this point to do that.
KAYSo we understand how to get rid of some of the fears, but we don't understand what might have caused those fears? And that complicates the treatment -- am I understanding you correctly?
PHELPSNo. What we don't understand -- we don't understand the techniques quite well enough to know what's going to be most effective in what circumstance. And so we're really -- right now, the research I'm doing is very basic research, mostly on normal human subjects, where we create fears in the laboratory. We then try to diminish those fears, and we're trying to understand specifically, how do these techniques work? Once we have that information, we will do a better job at saying when they might work for one anxiety disorder or another.
KAYAnd has your research in the lab, to the extent that it has been tried on patients, how successful has it been?
PHELPSI would say the little bit of work that's been done with patients has been mixed. And I think that's because we don't have enough good information about, you know, what we're actually manipulating when we go from the laboratory -- the simple laboratory experiment to the complex situations that are linked to anxiety disorders.
KAYDr. Phelps, I have with me in the studio, Dr. Danny Pine, he's from the National Institute for Mental Health. He has a question for you.
PINEWell, actually, I was going to pick up on some of the things that Liz was saying, in that I think it's important for listeners to realize what a difficult problem it is, in all the mental illnesses, to try to understand this complex relationship between how the brain works and how patients function. And the thing to note about the anxiety disorders -- and it really follows directly from the kind of work that Liz is discussing right now -- is that we have a very important foothold in the anxiety disorders.
PINEAnd that's because the relationship between how the brain works and how fearful people are looks very similar to the relationship between how the brain works and how fearful animals are. And in other areas of medicine -- in cardiology and in cancer -- having that foothold, being able to study in animals something that looks very similar in people is a very important first step. And we're still struggling in things like schizophrenia and things like depression to make that first step. The important thing about the work that Liz has done is that it makes that first step.
PINEIt shows that we can ask questions about people that are meaningful in terms of what we understand about animals and to the extent that people's brain behave in the way that we would expect, based on what we know about animals. That creates a huge amount of excitement for new treatments, so that's really why this work is so important. It generates a whole host of ideas about new treatments that have everybody -- the basic scientists, the clinicians and the patients and people like Jerilyn Ross -- have them tremendously excited because we can see a new age when better treatments are going to emerge.
KAYOkay. Dr. Elizabeth Phelps, joining us from NYU's Department of Psychology, thank you so much for joining the program, Dr. Phelps.
PHELPSThanks for having me.
NAKAMURAMay I make a...
KAYI'm Katty Kay of the BBC. You're listening to "The Diane Rehm Show." And if you'd like to join us, do call 1-800-433-8850. You can also send us an e-mail to email@example.com. We will be opening the phones in just a moment. Dr. Nakamura, you wanted to jump in.
NAKAMURAYes. You asked the question about -- related to vulnerability, to anxiety disorders. I'd like -- just like to make the point that it's clear, both from human heredity and from animals studies in which the genetics are manipulated, that you can vary in the amount of vulnerability you have to anxiety disorders and so that a small event can trigger an anxiety disorder in someone who's very vulnerable. Whereas, for someone who is very resilient, it may take a lot of traumatic trauma in order to develop this.
KAYAnd, Dr. Rosenbaum, I was going to ask you that question. How -- you know, if you take somebody, for example, who has been in an extremely stressful situation -- and there have been several incidents in the news just in the last couple of weeks. You've had miners stuck underground for three months in Chile. You've had a couple kidnapped by Somali pirates who were kept for a year. Later on in the program, we're going to have Salman Rushdie on the show, who spent a decade of his life with a death threat hanging over his head. How can we -- what can we learn from how different people respond to different traumatic situations, about whether it's the situation that causes the anxiety disorder, why some people are more resilient in those circumstances than others?
ROSENBAUMI will say that's a wonderful question because the distribution of qualities that underpin resilience and vulnerability are complex but widely distributed. And some people are obviously born and develop with greater resilience and tolerate extremes of stress in extreme environments and do quite well, while others, often with minimal provocation and sometimes even with optimal environments, react with marked distress. And reflecting back on what Danny and Elizabeth said about animals, it's remarkable how evolution has conserved the fear response and, indeed, extremes of the fear response.
ROSENBAUMAnd we think about one in six human infants are born with a profile that predisposes them to fearful responses to otherwise benign situations, that they have excessive arousal, and even early in life, manifest anxiety at stimuli that other toddlers and children find pleasurable, react to strangers and novel situations with fear. And if that's about one in six children, it's remarkable how consistent that is across other species, from fish to mice to dogs to monkeys. And what's interesting about that is it's not just -- it doesn't seem to be just a distribution. There does seem to be a group that's maybe categorically different, and maybe it's about one in six. And they may be genetically prepared to react with excessive distress and arousal.
ROSENBAUMAnd the question is, why would evolution do that to us? And it may be that some of those traits have value. You know, guppies who are aggressive and bold tend to mate more but are often eaten faster because they don't flee predators. Whereas, inhibited guppies have fewer offspring, but they live longer. And it may be that having some of our human population as sentinels in our threatening environment may have had some evolutionarily valuable property, so, well -- so going back -- so there is a bias towards resiliency and vulnerability. That's quite clear. But I also want to emphasize again that we can build resiliency through a variety of techniques and interventions. And we can obviously also do the opposite through damaging environments and development and extremes of trauma and take someone who may not have otherwise been destined to be fearful and create that.
KAYDanny Pine, if we took that group of Chilean miners who were stuck underground for so long, and we looked at the ones who, in five years time, were still suffering from fear and anxiety disorders because of that, would we have been able to look back at their early life and see something that might tell us that person would have suffered this and the other person wouldn't?
PINESo we do have clues. For a lot of the reasons that you've heard many of the other speakers mention, it's very hard to predict what's going to happen to one traumatized individual from another. So people come to a situation with differences already related to how fearful they might be -- related to what Jerry was just talking about -- but then we also know there's a great deal of what we call plasticity. These functions change. And so the thing that many people want to know -- and maybe it's something we can talk about in a minute -- is what can people do to minimize their chance of having an adverse effect?
KAYDr. Daniel Pine in the studio with me for my conversation on anxiety disorders. We will be taking your calls and opening the phones just after this short break. 1-800-433-8850 is the phone number.
KAYWelcome back. I'm Katty Kay of the BBC, sitting in for Diane Rehm. You've joined our conversation on anxiety disorders. I'm joined here in the studio by Dr. Daniel Pine. He's a psychiatrist who directs the research program on mood and anxiety disorders of children and adolescents at the National Institute of Mental Health. Dr. Richard Nakamura, scientific director of the National Institute of Mental Health, is also here. Dr. Jerrold Rosenbaum, president of the Anxiety Disorders Association of America and chief of psychiatry at Mass General Hospital, is also joining us on the line from Harvard. We will be going to the phones now and taking your calls. So let's go to Don in Louisville, Ky. Don, you've joined "The Diane Rehm Show."
DONThank you for taking my call.
KAYYou're very welcome.
DONMy family and I -- my wife and I and my son -- youngest son, who was 13 at the time, last year we spent an inordinate amount of time dealing with anxiety disorder with him and panic attacks, and what I want to bring up is the inability of the school systems to be able to handle this. You know, they handle special education children. But when it comes to this, they kind of write it off as -- you know, well, just suck it up, and he'll get better. So we dealt with it for the whole school year -- his whole seventh grade -- and finally got to the end of the year with a lot of therapy and medical treatment.
DONAnd then this year, we chose to send him to a private school where there were smaller class sizes. And they were able to handle this sort of thing 'cause they have children that have different disorders and so forth that they can handle. I was just interested in letting the panel know that and hear what their comments are about the schools dealing with panic disorder and the fact that it's -- a lot of people think it's -- you know, a lot of our friends said that he was being bullied at school, and that's why he's having these panic attacks and so forth. So...
KAYWell, Don, thank you very much for calling into the panel and sharing your story with me -- us. That must have been a very difficult time for you. Dr. Pine.
DONYes. Yes, it was.
PINEIt -- so I also want to thank Don because I think it's very helpful and informative to hear the particulars of his story. So one thing it brings up again is the huge stigma of mental illnesses, again, particularly in kids. And it takes a great deal of courage for parents such as Don to come forward and tell their story. And I think it's very helpful, both in giving other parents guideposts and lessons, but also in pointing out things in our society that we need to focus on. And one of the particular focuses that we need to think about, again, that Don brings up, is whose responsibility ultimately is it to identify and take care of mental health problems in kids?
PINEAnd I think society at large is really struggling with that, and I think the questions that Don is raising about the schools reflect those struggles. So I think there are some people who do believe that schools have an obligation to do whatever they can to look after the emotional needs of our children, and there are other people who think that school is really the place to focus on education. And I think Don's story highlights some of the tensions that that creates, but as he shows us, the problem cannot be ignored. It cannot be avoided. And I think by trying to address some of the stigma, we're going to be able to have a more open, informed conversation.
KAYAnd, Danny, would say that for a child in that position, attending a school -- as Don said, he's now -- his child is going to a private school where there are other children with disorders. Does that help?
PINESo there really is no one-size-fits-all answer because mental health problems in kids are so variable. The one thing we do know is that schools need to be flexible in terms of meeting the many different kinds of needs that different kids have. And it's in situations where schools can be flexible and work with individual kids that kids tend to prosper best when they have special needs.
KAYOkay. Let's go to Julie Ann Bolton (sp?) who joins us on the phone. Julie, thank you for joining "The Diane Rehm Show."
JULIE ANN BOLTONHi. Thanks for taking my call.
BOLTONI'm a primary care physician, and I just see so much really significant anxiety and some people resistant to treatment. But hand in hand with that, I see a lot of different kinds of substance abuse, addictions -- there's just so much alcoholism that just -- it's like a -- it's just an epidemic. So I wondered if the panel could speak to substance abuse and kind of self-medication along with addiction...
KAYAnd, Julie, you're ask...
BOLTON...and along with anxiety.
KAYSo you're asking whether there is a relationship between the two, you mean.
BOLTONYeah, is there a relationship? And are people looking at that? And -- I mean, just, you know, all of this, you're emphasizing kids a lot, which is great. And I'm seeing some real kids at risk 'cause I see them -- you know, a drink will come them down. A good joint will calm them down. And, you know, they start hanging around with the wrong crowd 'cause they're not fitting in. They're self-medicating, and then some of the medications are problematic, some of the benzodiazepines. I see some psychiatrists and other doctors using that in adolescence, and that seems problematic as well.
KAYOkay. Dr. Nakamura, do you want to take that?
NAKAMURAThere are -- one, it's very clear that substance abuse and mental health problems go together. A very high proportion of those with mental health problems do abuse substances of various content. It does look like self-medication. I would say that in general, our society has a very hard time dealing with those with mental illnesses, mental disorders and substance use disorders. They try and see physicians often, often do not get sent to psychiatrists.
NAKAMURAMany of these kids end up, because of their substance use disorders, ending up being treated in jails. Our jails seem to house the highest proportion of those with mental illnesses. So our society in general, not just schools and not just medicine, seems to be having a hard time in trying to figure out what to do with these individuals. What science is telling us now is that treatment works and that the more people we can get into treatment, the fewer problems we're going to have in our society.
KAYI want to read an e-mail that's come into us from Claudette who writes to us -- actually on Facebook. "There is some evidence that psychodynamic, not just cognitive behavioral treatment, can be quite effective in the treatment of panic disorder. What does the panel think about this treatment?" Dr. Rosenbaum.
ROSENBAUMWell, there haven't -- has been at least one controlled study that used a short form of a traditional psychotherapy -- psychodynamic psychotherapy -- that did show positive outcome, and so it's good to have additional tools. I think the evidence is much, much stronger and deeper for other forms of psychotherapy. But I think in as much as psychodynamically-informed therapies are more widespread and traditional, it's reassuring that they can be helpful.
KAYWe also have an e-mail that comes to us from Rebecca who writes to us on our website. "I have suffered from an anxiety disorder most of my life. As a teenager, I had several panic attacks which were so frightening mainly because I had no idea what they were. All I knew was that I felt horrible. My heart was pounding all the time. Then I learned transcendental meditation. It changed my life. I have now been practicing TM for almost 40 years, twice a day every day. There is no more healthful way to make a life better." Dr. Rosenbaum.
ROSENBAUMSo there is interesting evidence -- actually brain imaging evidence that those who use meditation regularly show some changes in their brain in the regions of their prefrontal cortex that actually look associated in other situations with resiliency and ability to extinguish fear. So it's possible that for some individuals, meditation techniques will enhance resiliency, decrease their overall level of arousal and stress and help with that contributor to anxiety suffering.
KAYDr. Nakamura, you were talking earlier about the plasticity of the brain. Is that an area where the brain can be molded?
NAKAMURAIt's very clear that if you can engage the executive function of the brain -- that is the frontal parts of the brain, the frontal lobes -- you can control a lot of these sources of anxiety. You can extinguish fear. The trouble is trying to get that frontal lobe engaged. Sometimes the fear is so overwhelming that the frontal lobes shut down. A key thing within therapy is to try and re-engage that circuit. Meditation and other forms can help.
PINEAnd I think Dr. Nakamura is giving a broader, general lesson -- as is Dr. Rosenbaum -- that when people are anxious, one of the things that tends to happen is you tend to avoid things. And this idea of engaging, that Richard was just talking about, is a very important one for people who are having problems with anxiety to consider. Because while the first reflex might be to shy away from the things that we're afraid of, it's really by engaging in our fears, by actively confronting them and by tolerating feeling fearful sometimes that we know that people are most able to be resilient and to overcome the problems that they're having.
KAYLet's go to Karen in Plainfield, N.H. Karen, thank you for joining "The Diane Rehm Show."
KARENHi, Katty, great program today. Thank you. I wanted to comment on the stigma issue. I have a 10-year-old daughter with severe anxiety disorder, and we've done a combination of talk therapy starting when she was four. And then we ended up adding in medications -- she's on Prozac -- when she was six, and she's doing really well. And we call her medicine her worry medicine. And she's very comfortable telling people if they ask her why she takes medicine that it's her worry medicine, and she takes it to help her with her worries. And I think we -- as parents of kids with anxiety and other mental health issues -- need to help our kids normalize to the extent possible these disorders. And I think if we can do that, I'm really hopeful that we can start to get away from the stigma associated with these disorders...
KAREN...at least among the next generation.
KAYKaren, would you mind telling us a little bit more about your daughter's symptoms and particularly what you noticed when she was just four? 'Cause that's very young.
KARENYeah, well, I actually -- looking back on it, I noticed it when she was born, literally. I mean, she was my second child, and in the hospital -- I was in the hospital for three nights -- she would not go to sleep. And finally one of the nurses said to me, you know, why don't you put her next to you? And that immediately helped, and so it was this -- throughout her infancy and then as she became a toddler, severe sort of attachment issues. And then when she was three -- she was in preschool -- she actually developed selective mutism, where she literally did not say a word at school for two years. And so that's when we started the talk therapy, and we got her to the point -- when she transitioned from preschool to kindergarten, we got her to the point where she could speak in school and be a relatively normal student in school.
KARENAnd -- but after about six months of that, it was still so problematic at home that we turned to the medication. I would say that we were resistant to putting her on the medication, but I'm so glad that we did. And she's continued needing occasional talk therapy, and we've even had her in a group therapy with other kids with anxiety disorders. So we continue to do, you know, whatever it is that she needs and try to give her as many tools as we can because I do suspect -- as has been, you know, said earlier in the show -- that this is probably a lifelong battle that she's going to have with this disorder.
KAYWell, Karen, again thank you very much for calling into the program and for sharing that with us. I'm Katty Kay. You're listening to "The Diane Rehm Show." And if you'd like to call us, do ring. The number is 1-800-433-8850, and we'll be taking calls and questions during the program. Dr. Pine, I wanted you to pick up on what Karen was talking about there 'cause four seems -- the symptoms that she recognized, saying that she recognized this from birth, anxiety symptoms. How common is that?
PINEWell, you know, there are a couple of things to take away from Karen's message. One is that it is relatively common to see in kids, high signs of anxiety, and sometimes they go on to being clinically impairing and significant. And I think it's actually incredibly illustrative for your listeners to hear the story that Karen just told because that is, for a child with a relatively serious problem, that is a pretty typical story. And it sounds like Karen has been amazing in getting for her child what she needs, and that's an important lesson to hear. However, for every child like that, that we are worried about, that ultimately does not do well, there are an equal number of children who overcome their fears and who do not have the problems that Karen was just describing.
PINEAnd how to sort out those differences is something that we don't really understand, and, again -- back to this idea of stigma, what Karen started her call with -- it's really through the courage of patients who are willing to stand up and say that this is just like any other medical problem. And we need to face it, and we need to deal with it -- the way that Karen just did. That ultimately we're going to figure out how can we predict which child to be really concerned about and which child we can say, well, this problem is going to be transient.
KAYDr. Rosenbaum, there is in the D.C. area tomorrow, a symposium being held by the Anxiety Disorders Association of America. It's called Bridging Science, Treatment and Public Education of Anxiety Disorders. Could you tell us a little bit more about that?
ROSENBAUMYes. It's actually sponsored by Richard's organization, National Institute of Mental Health, and it's a symposium that is in honor of the life and work of Jerilyn Ross, whom we referred to earlier. The director of the National Institute of Mental Health, Tom Insel, will be moderating. And a number of distinguished researchers will be presenting -- Ron Kessler, who's done a lot of work in terms of the epidemiology and prevalence and burden of anxiety disorders in society, Elizabeth Phelps, who we heard from earlier, will talk about the biology of changing fears. Danny Pine will be talking about developmental neuroscience, how the research in anxiety really is leading the way in our understanding of the brain and developing psychiatric symptoms. And Kerry Ressler from Emory will be talking about new scientific approaches to understanding fear and fear-related disorders. So it's going to be a quite spectacular symposium. It's actually open to the public as well.
KAYAnd you can all find a link to that symposium and to the Anxiety Disorders Association. It's on our website at drshow.org. Just log on. You can find out all about the association and about that symposium as well. Dr. Jerrold Rosenbaum, joining us from WGBH in Boston, president of the Anxiety Disorders Association of America, Dr. Daniel Pine, director of the research program on mood and anxiety disorders of children and adolescents at the National Institute of Mental Health, Dr. Richard Nakamura, scientific director of the National Institute of Mental Health, thank you all so much for joining me for this fascinating conversation.
ROSENBAUMIt's been a pleasure.
KAYI'm Katty Kay of the BBC. I've been sitting in for Diane Rehm. Thank you all so much for listening.
ANNOUNCER"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Susan Nabors, Denise Couture and Monique Nazareth. The engineer is Tobey Schreiner. Dorie Anisman answers the phones. Visit drshow.org for audio archives, transcripts, podcasts and CD sales. Call 202-885-1200 for more information. Our e-mail address is firstname.lastname@example.org, and we're on Facebook and Twitter. This program comes to you from American University in Washington. This is NPR.
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