January/February 2008

Freeing Your Child from Anxiety, Tamar Chansky, Ph.D., (paperback, 308 pages) Broadway Books, 2004. The subtitle of this book is “powerful, practical strategies to overcome your child’s fears, phobias and worries,” and that is an accurate assessment of this excellent resource.  Her approach is summarized on page 9, “Remember the goal: it’s not to talk your children out of their fears, it’s to teach them how to talk themselves through their fears.  Don’t remove the hurdle, but teach them how to jump over it.” I’ll talk more about what she has to offer in the article below.

Treating Generalized Anxiety Disorder: Evidence-Based Strategies, Tools, and Techniques, Jayne Rygh and William Sanderson, (paperback, 210 pages) Guilford, 2004. We are in need of good treatment guides for GAD.  Fortunately, we have this one now.  The book is published in an 8 ½ X 11 format, with 26 reproducible handouts for clients. This is designed as a therapist’s manual, in the best sense of the word.  Clear, highly organized and step-wise.  Structures are provided for each of the three targeted areas: cognitive, physiological and behavioral. Cognitive gets the most attention, with about 12 different protocols.  For those new to the treatment of GAD, client responses on two forms—the Worry Episode Log and the Rational Response Form—will give you ample material to work with over several sessions.  I certainly hope that others, like Tom Borkovic, will grace us with a manual for their innovative approaches to GAD.  In the meantime, nothing competes with this one.

Training Event:
Winning the Anxiety Game

Brief Strategic Treatment for the Anxiety Disorders

I'll be offering a 5-day training on Cape Cod this summer. I'll teach from 9 to noon each morning. We'll cover:

• Principles and Goals for Brief Strategic Treatment
• The Anxiety Disorder Game and Second-Order Change
• Provocative Treatment of Panic Disorder and Social Anxiety
• Obsessive-Compulsive Disorder
• Worry and Generalized Anxiety Disorder

Self-Help Update:
Talking to Kids about Anxiety

I want to share some of the helpful viewpoints and principles Dr. Tamar Chansky conveys in her book Freeing Your Child from Anxiety. It is clear that her goal is to empower kids, not “fix” them or “treat” them. 

Her “master plan for anxiety” (page 85), involves these steps:

1. Empathize with what your child is feeling
2. Relabel the problem as the worry brain
3. Rewire and resist: act with your smarts, not your fears
4. Get the body on board – turn off the alarms
5. Refocus on what you want to do
6. Reinforce your child’s efforts at fighting

Education is empowerment.  The more anxious children can comprehend what is happening to them, the better they can develop coping skills. On page 62 she explains,  “An easy way to remember the order of the brain train is to work your way down the body – head (thoughts) to stomach (feelings) to toes (do your feet run away or stay?).” Then on page 63 she begins to drive a wedge between worries and actions by teaching the client to hesitate instead of jumping to conclusions. “Remember that you have two hands.  How about the worry goes in one hand, and the calm thoughts go in the other?  That should be easy to remember – when you go into a situation, just remember to take both hands!”

On page 68 she is continuing to coach this perspective with the concept of second reaction and by externalizing and personifying worry. “Feeling scared doesn’t mean you are in danger.  Go for your second reaction – think about the probability and realize that what you’re warned about is no more probable now than it was before you thought it.  Use good, smart thinking to boss back the worry brain, and teach it a lesson about how things work.”  She defines that “boss back” voice as the one inside you that tells people you can’t be bossed around, the same voice you use when a younger sibling is trying to mess with you. By page 80 she is introducing systematic desensitization. “When emotions compete, you win too.  It’s a process called reciprocal inhibition.  Feeling mad, relaxed or goofy inhibits your ability to feel scared.  Basically, you can’t be in two places at once emotionally.”

As she addresses the individual phobias and fears, she gives great tips for exposure exercises. 

• Fear of lightning: use a strobe light or flashlights turned on and off
• Blood, injection, injury fears: create blood with ketchup or water with food coloring
• Fear of the dark: read or have a snack by flashlight
• Separation anxiety: “Have your child draw an independence thermometer.  Color in the thermometer in units of minutes or hours that your child is able to be apart from you, and plan a special celebration when your child reaches the top.”  (page 195)

She certainly has adopted the strategic approach when she teaches the child to manipulate the symptoms instead for trying to extinguish them:

• OCD bad thoughts: “turn intrusive images of hurting people into cartoons, with little mice squeaking the scary thoughts, thus demoting them.” (page 214) 
• throat-clearing tic: learn to take a slow deep breath, or a swallow, or chew gum.
• lip-licking tic: picture his mouth as a baseball diamond… “instead of rounding all the bases, teach his tongue to go just to the corner of his mouth and back to ‘first base…’” (page 231)

Professional Update: 
Can Medication Enhance Memory?
The D-cycloserine studies

In behavior therapy, one central approach is to encourage extinction of a conditioned fear by repeatedly pairing the feared stimulus with either relaxation or some other response that is counter to the fear. The tuberculosis antibiotic D-cycloserine (DCS) is currently under study as an enhancer to that learning process. DCS boosts glutamate signaling by acting on the glycine site of the N-methyl-D-aspartate (NMDA) receptor. It is possible that this may reorder connections between perception and the fear response.  A few early studies indicate that, at least at the beginning of behavioral treatment, it might serve a helpful function.

In one study 32 patients with OCD were randomized either to receive 125 mg of DCS or placebo 2 hours before each of 10 sessions of behavioral therapy. The sessions involved hierarchical exposure to feared stimuli. Once distress was reduced by 50%, the next stimulus was introduced. By the fourth session, DCS subjects reported significantly greater reduction in distress than the placebo group. By the end of treatment, those differences disappeared. At the end of treatment and 3 months later, both groups had equivalent reductions in OCD symptoms. This implies that DCS may augment treatment in the early phase by showing patients a greater payoff to their efforts.  A second important finding was that only 6% of DCS recipients dropped out, versus 35% of the placebo recipients. Here is another sign that DCS may help exposure therapy seem more palatable for patients who are leery of starting or continuing behavior therapy. If DCS motivates patients to remain in therapy until it becomes effective, then perhaps it can aid in turning the tide in the consistently moderate dropout rate for behavior therapy in most of the anxiety disorders.

Two studies show the benefits of DCS in very short treatment interventions (2-5 sessions). The first looked at whether the short-term treatment with a smaller dose (50 mg) of DCS would enhance the effectiveness of exposure therapy for social anxiety disorder (SAD). Twenty-seven participants received 5 exposure therapy sessions delivered in either an individual or group therapy format. One hour prior to each session, participants received single doses of DCS or placebo. Those receiving DCS in addition to exposure therapy reported significantly less social anxiety compared with those taking placebo, and controlled effect sizes were in the medium to large range.

In the second study, 28 patients with acrophobia (fear of heights) were treated with two sessions of virtual reality exposure to heights within a virtual glass elevator. Single doses of placebo or DCS were taken prior to each session. Patients receiving DCS had significantly more improvement than patients receiving placebo within the virtual environment (1 week after treatment and 3 months later) as well as on general measures of the real-world acrophobia symptoms (avoidance of, anxiety about, and attitude toward heights, and self-exposures to real-world heights). The improvement was evident early in the treatment and was maintained at 3 months.

Resources

Ressler KJ, Rothbaum BO, Tannenbaum L, et al. Cognitive enhancers as adjuncts to psychotherapy use of D-cycloserine in phobic individuals to facilitate extinction of fear. Arch Gen Psychiatry 2004; 61:1136-1144.

Hofmann SG; Meuret AE; Smits JA; Simon NM; Pollack MH; Eisenmenger K; Shiekh M; Otto MW. Augmentation of exposure therapy with D-cycloserine for social anxiety disorder. Arch Gen Psychiatry. 2006; 63(3):298-304. 

Pull, CB. Combined pharmacotherapy and cognitive-behavioural therapy for anxiety disorders. Curr Opin Psychiatry 2007; 20(1):30-35,

Kushner MG et al. D-cycloserine augmented exposure therapy for obsessive-compulsive disorder. Biol Psychiatry 2007 Oct 15; 62:835.

Krystal JH. Neuroplasticity as a target for the pharmacotherapy of psychiatric disorders: New opportunities for synergy with psychotherapy. Biol Psychiatry 2007, Oct 15; 62:8