Anxiety Everywhere: Grappling With a Pervasive Symptom
The Carlat Child Psychiatry Report, Volume 10, Number 1, January 2019
Moira Rynn, MD
Chair for the Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine, Durham, NC.
Dr. Rynn has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CCPR: Can you tell us a little about your background?
Dr. Rynn: I’ve been doing clinical research examining new medications for children with anxiety disorders. My passion is working with children who have failed first-line, evidence-based treatments. How do we help these children? What are our options? I look at new treatments or changing the intensity of treatments. We do have good treatments available—it’s just that they don’t work 100% for everybody.
CCPR: Tell us about your take on anxiety.
Dr. Rynn: For us to advance the field beyond the treatments that we have available, we need to think about these illnesses in a different way, understanding more of their biology and expression depending on the environment in which they occur. Children don’t present with just one anxiety or anxiety-related disorder; it’s often more than one. The brain does not recognize our DSM-5 criteria. The circuits that are involved overlap across those disorders, and the environmental interaction brings forth what you see in the child. Under Tom Insel’s leadership, NIMH put forth a multilevel analysis approach, the Research Diagnostic Criteria (RDoC), to examine the range of symptoms—from genomics to circuits and behaviors. It is important to think about core symptoms that can be very problematic for children or adults, cutting across different disorders.
CCPR: Child psychiatrists see patients who report anxiety as a symptom and then typically look for specific diagnoses and then appropriate treatments for these diagnoses. Why is it important to also look at anxiety as a symptom that cuts across diagnostic categories vs differentiating it into specific DSM diagnoses?
Dr. Rynn: Anxiety presents as a core symptom across disorders—mood disorders, disruptive behaviors, and autism, to name a few. Anxiety affects nearly everyone we treat. So, while we need to treat the definable disorders, we also need to figure out how to treat anxiety as a part of these other conditions or situations.
CCPR: How do we address anxiety in all these circumstances?
Dr. Rynn: You need a good assessment that examines all contributors to the symptoms, such as environmental reasons for anxiety; the relationship between anxiety and other problems, for instance anxiety in ADHD when a child is unable to complete homework; and the presence of definable anxiety disorders for which we have defined treatments.
CCPR: And we treat those definable anxiety disorders as we would usually do?
Dr. Rynn: It may depend on the specific child and circumstances, but yes, I would consider applying the usual treatments, as they may have the best chance of helping the anxiety aspect of the situation.
CCPR: We often find in our practices that the parents of the patient have strong or even differing views on medication vs therapy (as well as the patient depending on age). Can you speak to this? How do you decide to go with medication or therapy?
Dr. Rynn: You have to be willing to meet the patient and the parents in their thinking. If they are not comfortable with your recommendations and they come in with their own experiences, that will inform their thoughts about treatment. It is not uncommon for parents to have an anxiety disorder themselves, or for an extended family member or acquaintance to have one: an aunt, uncle, friend, teacher, coach, or clergy member. So keep in mind that a range of people give input to families and children about treatment.
CCPR: How do you speak with parents, knowing there might be this type of preconceived input surrounding treatment?
Dr. Rynn: I like talking to parents about the literature. We know a lot about outcomes if you elect to use a medication vs cognitive behavioral therapy (CBT) vs a combination of these treatments. I want the parents and children to feel empowered to consider their treatment options.
CCPR: Are there any particular studies that you refer to?
Dr. Rynn: The most well-known study—a great accomplishment for the field and NIMH—is the Child/Adolescent Anxiety Multimodal Study (CAMS) study (Walkup JT et al, N Engl J Med 2008;359(26):2753–2766). This was a large, multisite study of 488 children and adolescents that focused on the triad anxiety disorders and mild OCD. We compared sertraline alone (as a representative SSRI, nothing specific about sertraline), CBT alone, and the combination of sertraline and CBT. The study showed we have three efficacious treatments that all separated from placebo. The one caveat is that the medication arm was the only blinded arm—it’s difficult to blind CBT—so to help, independent evaluators were utilized who did not know which research treatment was assigned to the child or family.
CCPR: Was there any difference among the treatment arms?
Dr. Rynn: Those patients who received combined medication treatment with the CBT had the greatest improvement. Some experts in the field have interpreted this to say that you should begin with combined treatment.
CCPR: Do you think combined treatment is the way to go every time, if possible?
Dr. Rynn: In my experience, some families come in and say doing talk therapy is not right for them. Or the child says, “I’m not ready for that, but my anxiety is really problematic. I need something I can just take that will help me.” And so, it is a reasonable choice to start with medication, depending on the clinical context of what is happening for the child. Other families are not comfortable with medication as the first step and want to try CBT. And still other families are dealing with severe symptoms, and for them the combination is the best approach.
CCPR: Is the choice that straightforward?
Dr. Rynn: There are a lot of nuances in regard to the family and presentation of symptoms that come into the clinical decision-making.
CCPR: Let’s talk specifics with treatment as usual. In what circumstances do you recommend starting with both medication and therapy together?
Dr. Rynn: In those cases, I look at what’s going on in the child’s life: Is he not going to school at all? Having terrible sleep problems? There might be weight loss and a concern about comorbid depressive symptoms. Is she having thoughts that life’s not worth living? I educate the family, explaining that it can take 6–8 weeks to see improvement with CBT and, given the severity of symptoms, strongly recommending that we start with the medication and the CBT together. In the CAMS study, we start seeing a difference in medication in about 4 weeks. CBT response onset is later. For a child with moderate to severe symptoms, it is important to educate the parents and the child about all the treatment options. However, just to be clear, CBT does have efficacy with treating moderate to severe levels of anxiety symptoms, although the child and family need to be able to fully engage in the treatment and access a professional trained to provide it.
CCPR: What about side effects of medication? Any thoughts on that?
Dr. Rynn: The CAMS trial was such a large sampling that it gave us an opportunity to look at safety issues. Evaluating the adverse events across the different treatment arms, there is a suggestion that we need to be more cautious in the 12-and-under set as they might experience some activation, more irritability, and/or sleep difficulties. It’s something to be considered and monitored. I think what’s important is to give parents the information so that they, along with the child, can make decisions about where they want to take their next steps for treatment.
CCPR: Let’s talk about CBT. How effective do you think it is?
Dr. Rynn: That was an important finding in the CAMS study: CBT is a therapy you can use with a child who has moderate to severe anxiety. It just depends on what the other additional symptoms are in terms of risk issues. If the child is able to engage in the treatment, CBT can be quite beneficial.
CCPR: How does OCD fit into this?
Dr. Rynn: When I talk about anxiety disorders, I’m referring to generalized anxiety disorders, social anxiety disorder, separation anxiety disorder, etc. With the DSM-5, OCD has been placed under a different category, which is interesting. That is informed more by thinking about the neurocircuitry, and that’s important, but in terms of available treatment for OCD and this triad of anxiety disorders, it can be comorbid in children and adolescents. So my first few steps of treatment apply both for OCD and the other childhood anxiety disorders.
CCPR: For OCD, beyond going higher on the SSRIs, I think a lot of us would try another SSRI. We’ll go high on the doses; maybe we’ll add a neuroleptic. Do you have your own general algorithm for therapy and for medications?
Dr. Rynn: I start treatment with SSRIs or CBT exposure and response prevention as the first two kinds of treatment. John March and his group led an important study called the Pediatric OCD Treatment Study (POTS) (March J et al, JAMA 2004;292(16):1969–1976). It actually showed a similar pattern of differentiation from placebo with medication alone, CBT, and the combination of medication and CBT, with all doing really well. Combination treatment had an advantage over the others; however, when you look at excellent responder status—those who really, really did well—you see that CBT alone achieved that along with combination, but not medication. Medication with excellent responder status didn’t differentiate from the placebo.
CCPR: What about the family? How do they fit into the process?
Dr. Rynn: It’s so important to get a comprehensive evaluation, including family history of anxiety and other difficulties, as well as family dynamics and stressors, attachment issues, and possible maltreatment, so that the parents and child can understand what the issues are. There can be a decrease in symptoms just based on that, educating parents and helping them change some of their responses and some of the other things that they’re doing.
CCPR: Can you talk more about that?
Dr. Rynn: Parents care for their children, and they of course mean well. They want to decrease their child’s distress, but sometimes they’re doing things that continue to enable the anxiety. They might be inadvertently making things worse by allowing the child to continue to avoid the things that are causing anxiety. Parents may just need more guidance. We need a more systematic way of getting that information out for children and families, and I’m very excited about another arm of the federal funding option: It’s called PCORI, the Patient-Centered Outcomes Research Institute. They recently had requests for applications about treatments for children with anxiety disorders and to examine more closely the evidence-based treatments that we have in the real-world setting. There have been several announcements, and there will be studies funded on this. So that, I think, will help the field.
CCPR: Thank you for your time, Dr. Rynn.
Editor’s note: Access to good CBT is another issue. There are online CBT programs for OCD and anxiety disorders that have been shown to be helpful for adults, although often people do not follow through and use them enough to be of benefit. The literature is limited about the efficacy of online CBT treatment for children and adolescents.