Teens Doing Too Much?

Some teens today are doing so much, they stress themselves out to the point of, well, engaging in unhealthy behavior. Is this “new” though, or just something a lot of teens have done (and it’s simply now getting more attention)? The Washington Post has the story earlier this week.

It’s hard to say for certain whether teen over-scheduling is an increasing trend, since there are very few lifestyle surveys of teens across decades (the only data that could reliably answer such a question). However, one study mentioned near the end of the article (that’s always the place they put the dissenting data that calls into question the value of the entire article!), does provide some context:

In 2006, around the time that the pediatrics group issued its warning, psychologist Joseph L. Mahoney, then an associate professor at Yale, and two colleagues published a study debunking what they called “the over-scheduling myth.”

Based on an analysis of previous research, Mahoney’s team concluded that fewer than one in 10 youths could be described as over-scheduled and that 40 percent did not participate in any organized activities. Teenagers who did participate averaged fewer than 10 hours per week, Mahoney reported, while fewer than 6 percent devoted 20 hours or more to extracurricular activities. The researchers also challenged the notions that parental pressure was to blame for over-scheduling and that a lack of free time caused undue stress.

Anecdotally, we can all remember our own teenage years, and how some of our friends or people we knew seemed always to be doing something.

I fell somewhere in-between. I wasn’t a complete slacker, but I also didn’t join every club or after-school activity I could. I ensured I kept some time free, but even then, there were definitely times I felt overwhelmed by all the commitments I had made.

In the article, the writer notes how some teens drive themselves right into therapy with their packed schedules, and they do so to please their parents:

The toxic combination of perfectionism and over-scheduling can lead to excesses such as those seen by University of Pennsylvania adolescent medicine specialist Kenneth Ginsburg, author of the AAP recommendations. Ginsburg said his patients have included a teenager who had started studying for the SATs at age 11 and high school students whose parents told them they “didn’t need to bother to go to college” if they didn’t get into either Harvard or Yale, schools that last year reported record-low acceptance rates hovering around 8 percent.

Sometimes, he noted, teenagers who say they can’t imagine life without a packed schedule and profess to “love” hours of extracurricular activities are really afraid of disappointing their parents by opting out or scaling back.

The irony of this, however, is that most parents don’t really have a set agenda for their kids’ lives. (Some do, and those parents should stop trying to live their lives through their kids.) They just want their children to be happy. But somewhat mistakenly, some parents believe that they need — i.e., it is their responsibility as a parent — to try and expose their child to as many “opportunities” as possible. “Let’s sign up little Johnny for softball! Let’s sign him up for soccer! Oh, he enjoyed going to the show, maybe he wants to sing, and dance, and…” You get the picture.

There is a balance there that needs to be found. Sure, giving your children the opportunity to experience a wide range of activities is potentially beneficial. But don’t take it too far, because kids need to be kids first and foremost. They can always learn or discover a talent later on in life too — childhood isn’t the only time we learn activities.

Because what happens in many cases is that a child learns their parent always wants them to not just “do well,” but “exceed expectations,” to “excel” in everything they do. And as they become a teenager, that work ethic turns into a nightmare in trying to balance 3 or 4 social activites and hobbies with clubs and academic pressures, and sports, and friends, and still have time to enjoy life. Teens don’t need to excel. They need to find a place in life that feels right, to explore who they are, what they like, and what relationships are all about. A few activities helps a teen explore and enjoy the things they like to do, but too many and it can quickly feel like pressure they don’t need nor want.

So over-scheduling may be a problem for some youths, but by and large, most teens understand the need for some balance in their lives, even if they don’t always succeed in finding it.

Teens, know your limitations and learn to prioritize what’s most important to you (versus something you might be doing that you no longer enjoy or care for). Parents, don’t pressure your teens into doing stuff that you think they enjoy (but that they really don’t). Listen to them if they say to you, “Hey, I don’t think I’m going to go out this year for the team.” It doesn’t make them a quitter, it makes them a wise pragmatist who is beginning to find their way in the world.

Read the full article: Too-Busy Teens Feel Health Toll

Teens Doing Too Much?

Some teens today are doing so much, they stress themselves out to the point of, well, engaging in unhealthy behavior. Is this “new” though, or just something a lot of teens have done (and it’s simply now getting more attention)? The Washington Post has the story earlier this week.

It’s hard to say for certain whether teen over-scheduling is an increasing trend, since there are very few lifestyle surveys of teens across decades (the only data that could reliably answer such a question). However, one study mentioned near the end of the article (that’s always the place they put the dissenting data that calls into question the value of the entire article!), does provide some context:

In 2006, around the time that the pediatrics group issued its warning, psychologist Joseph L. Mahoney, then an associate professor at Yale, and two colleagues published a study debunking what they called “the over-scheduling myth.”

Based on an analysis of previous research, Mahoney’s team concluded that fewer than one in 10 youths could be described as over-scheduled and that 40 percent did not participate in any organized activities. Teenagers who did participate averaged fewer than 10 hours per week, Mahoney reported, while fewer than 6 percent devoted 20 hours or more to extracurricular activities. The researchers also challenged the notions that parental pressure was to blame for over-scheduling and that a lack of free time caused undue stress.

Anecdotally, we can all remember our own teenage years, and how some of our friends or people we knew seemed always to be doing something.

I fell somewhere in-between. I wasn’t a complete slacker, but I also didn’t join every club or after-school activity I could. I ensured I kept some time free, but even then, there were definitely times I felt overwhelmed by all the commitments I had made.

In the article, the writer notes how some teens drive themselves right into therapy with their packed schedules, and they do so to please their parents:

The toxic combination of perfectionism and over-scheduling can lead to excesses such as those seen by University of Pennsylvania adolescent medicine specialist Kenneth Ginsburg, author of the AAP recommendations. Ginsburg said his patients have included a teenager who had started studying for the SATs at age 11 and high school students whose parents told them they “didn’t need to bother to go to college” if they didn’t get into either Harvard or Yale, schools that last year reported record-low acceptance rates hovering around 8 percent.

Sometimes, he noted, teenagers who say they can’t imagine life without a packed schedule and profess to “love” hours of extracurricular activities are really afraid of disappointing their parents by opting out or scaling back.

The irony of this, however, is that most parents don’t really have a set agenda for their kids’ lives. (Some do, and those parents should stop trying to live their lives through their kids.) They just want their children to be happy. But somewhat mistakenly, some parents believe that they need — i.e., it is their responsibility as a parent — to try and expose their child to as many “opportunities” as possible. “Let’s sign up little Johnny for softball! Let’s sign him up for soccer! Oh, he enjoyed going to the show, maybe he wants to sing, and dance, and…” You get the picture.

There is a balance there that needs to be found. Sure, giving your children the opportunity to experience a wide range of activities is potentially beneficial. But don’t take it too far, because kids need to be kids first and foremost. They can always learn or discover a talent later on in life too — childhood isn’t the only time we learn activities.

Because what happens in many cases is that a child learns their parent always wants them to not just “do well,” but “exceed expectations,” to “excel” in everything they do. And as they become a teenager, that work ethic turns into a nightmare in trying to balance 3 or 4 social activites and hobbies with clubs and academic pressures, and sports, and friends, and still have time to enjoy life. Teens don’t need to excel. They need to find a place in life that feels right, to explore who they are, what they like, and what relationships are all about. A few activities helps a teen explore and enjoy the things they like to do, but too many and it can quickly feel like pressure they don’t need nor want.

So over-scheduling may be a problem for some youths, but by and large, most teens understand the need for some balance in their lives, even if they don’t always succeed in finding it.

Teens, know your limitations and learn to prioritize what’s most important to you (versus something you might be doing that you no longer enjoy or care for). Parents, don’t pressure your teens into doing stuff that you think they enjoy (but that they really don’t). Listen to them if they say to you, “Hey, I don’t think I’m going to go out this year for the team.” It doesn’t make them a quitter, it makes them a wise pragmatist who is beginning to find their way in the world.

Read the full article: Too-Busy Teens Feel Health Toll

“Oh No, Multitasking!?”: Handling the Job Search (with an Anxiety Disorder)

“The ideal candidate will be skilled at multitasking and working in a fast-paced environment.”

Well, that’s more than enough to scare away the anxiety-disordered job-seeker, isn’t it?

Finding a job is tough. Finding a job that’s a good fit for someone who has an anxiety disorder is even more difficult. How is it possible? It’s not like you can openly profess your panic disorder or anxious tendencies to the hiring manager and hope for an understanding nod. So, how can you realistically navigate the job-search process and find a job that works for you?

I’ve spent the past five years trying to hold my anxiety and panic tendencies at bay. I’m doing well these days, and I owe a wide round of thanks to cognitive behavioral therapy, biofeedback, and lifestyle changes. I eat well, (try to) exercise regularly, and I do one thing at a time.

Yes, just one….thing. At. A. Time.

I’d never fully realized how much of a serial multi-tasker I was until I began practicing mindfulness meditation in graduate school. I would sit on a chair in my quiet living room in an attempt to “tune in” to the moment and stop thinking about what needed to be done, but a constant stream of to-do lists would cloud my mind. Finish my persuasion paper by seven o’clock. Don’t forget to do the dishes tonight. Call my boss back before the end of the day. Call maintenance about the leak in my ceiling. What smells funny in here? Find the source. Speaking of sources, I need more references for my persuasion paper. Figure out how to reset my office voicemail. Oh no, I have an exam next week! What time am I supposed to meet with that prospective student?

With practice, I was able to ditch the habit of thinking about (and doing!) twenty things at once. I learned to do the dishes while thinking exclusively about the dishes. I discovered that banging out the rough draft of a ten-page paper in one sitting was, surprisingly, less stressful than writing a tiny bit at a time and leaving Microsoft Word open on my desktop for the (few) moments during which I felt inspired. I found out that I study better for exams if I’ve already completed reading my weekly dose of peer-reviewed journal articles. I began doing one thing at a time. I became focused. My mental clarity improved and my stress level receded below the levee.

And now, I’m a proud graduate. Like the rest of my classmates, I’m looking for a job. And yes, they all seem to require a love of multitasking as a prerequisite! If you’re anything like me, the thought scares you. But, the phrase is everywhere, and most jobs require multitasking to some degree. These lines are taken directly from the last three job listings I’ve viewed on major career-search Web sites:

“Candidates should enjoy multitasking and possess a strong desire to succeed.”

“Must be able to multi-task several projects at a time.”

“Candidate needs to multi-task between handling email, telephone, and projects as assigned.”

Yikes.

It’s a bit intimidating, but I’m determined to push on and find a job that isn’t going to stress me to pieces. Here’s some tips for handling the job search process if you, like me, are hoping to keep your anxiety and stress levels in check:

1. Don’t outright ignore the job listings that include words and phrases such as “multi-tasking”, “meeting tight deadlines”, and “stressful environment”. You can never be sure if the company representative who wrote the job listing is writing about what the position is like on the absolute worst day or on a standard day at the office. Send in an application if the job meets your needs and skills; worry about the semantics later.

2. If you’re contacted for an interview, prepare yourself with a list of questions to ask your potential employer. Many employers like to see a candidate ask questions about the position, so throw in a few neutrally-worded questions about the office culture, deadline structure or project timelines, or the position’s daily goals. However, be careful to avoid direct questions about job pressures. Some commonly recommended questions include the following:

• What would a typical first assignment be?
• How much travel is normally expected?
• What are some examples of the short and long-term goals of the project or position?
• What qualities are you looking for in the ideal candidate?

Asking questions can help you to feel out if the position truly is too stressful for you to handle, and it demonstrates to your potential employer that you have an interest in the position.

3. If you are presented with a job offer, weigh the pros and cons carefully. Consider the following questions: What will the job do for your anxiety and stress level? Will the job produce positive or negative stress for you? What types of coping skills can you use (or must you develop) in order to handle the pressures of the job? Would refusing the job offer be a step toward unhealthy avoidance of an anxiety trigger or would it be a healthy way of managing your lifestyle?

4. If you choose to accept the job, keep your physical and mental stress levels in check. Making small changes in the way you organize your desk, computer files, or office can have a profound difference on your sense of well-being. If you are required to multi-task, do your best to complete one activity before starting another. For example, if you are responsible for checking email and answering phones at the same time, don’t look at your inbox while you’re on a phone call. If you’re assigned two projects to be completed by the end of the business day, try dedicating your morning to one and your afternoon to the other (instead of hastily trying to complete both at one time!) When you turn your attention to one task at a time, your quality of work will likely increase as well. Finally, utilize all breaks that are given to you to get out of your workspace and into a more relaxing environment (the break room or the outdoors, for example). Only use your break time for errands if you absolutely must. Breaks are meant for relaxation and rejuvenation!

Debate over NBC’s “The Baby Borrowers” Rages On

A new NBC reality show is proving to be as controversial as its British counterpart, with criticism from psychologists, child developmentalists, and related organizations pouring in long before the first episode aired two weeks ago.

The main premise of “The Baby Borrowers”, which airs Wednesdays at 8:00 PM, is simple: showing inexperienced teenagers the realities of raising children through, well, reality. NBC’s website for the “intriguing new social experiment” describes the process like this:

“The Baby Borrowers”…[is] based on the hit British program that asks five diverse teenage couples — ages 18-20 — to fast-track to adulthood by setting up a home, getting a job and becoming caring parents first to babies, toddlers, pre-teens and their pets, teenagers and senior citizens — all over the course of three weeks.

As the social experiment begins, the five young volunteer couples are asked to literally grow up overnight when they are each given a home in a quiet cul-de-sac outside Boise, Idaho and attend pre-natal classes as each “mother” wears a simulated “empathy” belly to prepare them for the arrival of their “baby.”

When a real baby (all aged six-11 months old) appears at their door — courtesy of five pairs of real volunteer parents (some of whom were teen parents themselves) who entrust their infants to one of the couples — the nervous, fumbling teens are in for three long, arduous days that make chilling out a distant memory. They must stick to rigid routines, handle the feeding chores, diaper duty and crying jags that might be shared by baby and teens — all the while under 24-hour supervision by nannies and the real parents who are stationed next door, watching via monitor, and able to step in at any time. Plus, one teen from each of the couples must start a job, ranging from working in a local vet’s office to a lumberyard, leaving the other alone as caregiver for the day.

Multiple advocacy groups, such as The Natural Child Project, Zero to Three, and the American Academy of Child and Adolescent Psychiatry, have issued statements calling for the removal of the show (follow the previous links to read them), on the grounds that separating babies and toddlers from their parents for three days is too traumatic and could damage healthy parent-child attachment. Furthermore, opponents of the show argue, parents who “loan” their children to “The Baby Borrowers” are not acting responsibly because they have no way of knowing whether their child’s teenage “parents” will be competent caregivers or not. (The “hit British program” was criticized for the same reasons, by the way.)

NBC has responded with this message board, on which some of the parents discuss their positive experiences with the show and entertain questions from curious viewers. One parent, Chet Nichols, describes the surprisingly lengthy and thorough-sounding evaluation process he and his family had to go through before their acceptance to the show:

“After making the decision to move forward, we were informed of the process of not only selecting the teens, but us (the actual parents) as well. We were informed that the teen couples, the parents and the children would have to all undergo a psychological evaluation, as well as a thorough background check. This included a very long, in depth psychological test, as well as the children having to go under psychological observation away from the parents. We were informed that all the houses would be professionally baby proofed, there would be a nanny watching the babies 24 hours a day who could only intervene if the safety and/or welfare of our children was being compromised, and that a psychologist would be watching what was going on as well. We were also informed that we could intervene at any time and remove our children at any time without any repercussions or breach of contract. Once we had a full disclosure of all the precautions that were put in place, we agreed to allow both of our youngest children, Etta age 6 months and Benjamin age 2 years old, to participate.”

Bill and Julie, who give no last name on the message board, feel that “people don’t actually care who we are, they just want to complain about us and judge without actually knowing who we are and why we participated. But the question keeps being asked without a real answer. Who would let someone “borrow” their baby?”

From what I read, the main goal of parents who submitted commentary to the NBC message board was to encourage would-be teen parents to think twice before having children; several of the “Baby Borrower” parents say they were teen parents themselves and want to warn others against making the same mistakes.

That’s all well and good, but it does seem ridiculous to me that the parents and NBC would willfully ignore and claim to know better than the experts on child development who have repeatedly raised concerns about the adverse effects “The Baby Borrowers” might be having on its youngest participants. It could certainly be worse — remember CBS’ slightly creepy “Kid Nation”? — but I’m still not comfortable with the way “The Baby Borrowers” works. As Zero to Three’s press statement points out, “Legitimate social experiments are not conducted on national television or on reality shows.”

I realize many of you have been discussing “The Baby Borrowers” already in the NeuroTalk communities, so, what do you think? If you have children, would you volunteer them for such a project? Are the concerns of such organizations as AACAP, Zero to Three, and the Natural Child Project valid? Or, as NBC and the participating parents would have us believe, are these professionals just big old wet blankets who don’t know a good teen birth control initiative when they see one?

Debate over NBC’s “The Baby Borrowers” Rages On

A new NBC reality show is proving to be as controversial as its British counterpart, with criticism from psychologists, child developmentalists, and related organizations pouring in long before the first episode aired two weeks ago.

The main premise of “The Baby Borrowers”, which airs Wednesdays at 8:00 PM, is simple: showing inexperienced teenagers the realities of raising children through, well, reality. NBC’s website for the “intriguing new social experiment” describes the process like this:

“The Baby Borrowers”…[is] based on the hit British program that asks five diverse teenage couples — ages 18-20 — to fast-track to adulthood by setting up a home, getting a job and becoming caring parents first to babies, toddlers, pre-teens and their pets, teenagers and senior citizens — all over the course of three weeks.

As the social experiment begins, the five young volunteer couples are asked to literally grow up overnight when they are each given a home in a quiet cul-de-sac outside Boise, Idaho and attend pre-natal classes as each “mother” wears a simulated “empathy” belly to prepare them for the arrival of their “baby.”

When a real baby (all aged six-11 months old) appears at their door — courtesy of five pairs of real volunteer parents (some of whom were teen parents themselves) who entrust their infants to one of the couples — the nervous, fumbling teens are in for three long, arduous days that make chilling out a distant memory. They must stick to rigid routines, handle the feeding chores, diaper duty and crying jags that might be shared by baby and teens — all the while under 24-hour supervision by nannies and the real parents who are stationed next door, watching via monitor, and able to step in at any time. Plus, one teen from each of the couples must start a job, ranging from working in a local vet’s office to a lumberyard, leaving the other alone as caregiver for the day.

Multiple advocacy groups, such as The Natural Child Project, Zero to Three, and the American Academy of Child and Adolescent Psychiatry, have issued statements calling for the removal of the show (follow the previous links to read them), on the grounds that separating babies and toddlers from their parents for three days is too traumatic and could damage healthy parent-child attachment. Furthermore, opponents of the show argue, parents who “loan” their children to “The Baby Borrowers” are not acting responsibly because they have no way of knowing whether their child’s teenage “parents” will be competent caregivers or not. (The “hit British program” was criticized for the same reasons, by the way.)

NBC has responded with this message board, on which some of the parents discuss their positive experiences with the show and entertain questions from curious viewers. One parent, Chet Nichols, describes the surprisingly lengthy and thorough-sounding evaluation process he and his family had to go through before their acceptance to the show:

“After making the decision to move forward, we were informed of the process of not only selecting the teens, but us (the actual parents) as well. We were informed that the teen couples, the parents and the children would have to all undergo a psychological evaluation, as well as a thorough background check. This included a very long, in depth psychological test, as well as the children having to go under psychological observation away from the parents. We were informed that all the houses would be professionally baby proofed, there would be a nanny watching the babies 24 hours a day who could only intervene if the safety and/or welfare of our children was being compromised, and that a psychologist would be watching what was going on as well. We were also informed that we could intervene at any time and remove our children at any time without any repercussions or breach of contract. Once we had a full disclosure of all the precautions that were put in place, we agreed to allow both of our youngest children, Etta age 6 months and Benjamin age 2 years old, to participate.”

Bill and Julie, who give no last name on the message board, feel that “people don’t actually care who we are, they just want to complain about us and judge without actually knowing who we are and why we participated. But the question keeps being asked without a real answer. Who would let someone “borrow” their baby?”

From what I read, the main goal of parents who submitted commentary to the NBC message board was to encourage would-be teen parents to think twice before having children; several of the “Baby Borrower” parents say they were teen parents themselves and want to warn others against making the same mistakes.

That’s all well and good, but it does seem ridiculous to me that the parents and NBC would willfully ignore and claim to know better than the experts on child development who have repeatedly raised concerns about the adverse effects “The Baby Borrowers” might be having on its youngest participants. It could certainly be worse — remember CBS’ slightly creepy “Kid Nation”? — but I’m still not comfortable with the way “The Baby Borrowers” works. As Zero to Three’s press statement points out, “Legitimate social experiments are not conducted on national television or on reality shows.”

I realize many of you have been discussing “The Baby Borrowers” already in the NeuroTalk communities, so, what do you think? If you have children, would you volunteer them for such a project? Are the concerns of such organizations as AACAP, Zero to Three, and the Natural Child Project valid? Or, as NBC and the participating parents would have us believe, are these professionals just big old wet blankets who don’t know a good teen birth control initiative when they see one?

Running in Place to Conquer Your Anxiety?

In this blog post a few days ago, John mentioned an April 2008 literature review by researchers at Boston University who wanted to explore the efficacy of Cognitive-Behavioral Therapy (CBT) in treating anxiety. The authors of the review concluded that CBT, a short-term treatment technique, is generally effective for anxiety orders.

In a related article from the June 2008 BUforward Alumni e-newsletter, a study taking place at the University’s Center for Anxiety and Related Disorders is discussed in more detail. Associate Professor of Psychology Donna Pincus is currently conducting a five-year, NIMH-funded study looking at the effectiveness of intensive, short-term CBT on adolescent patients with severe anxiety problems such as agoraphobia and panic disorder.

Patients don’t get any medication during the therapy; “interoceptive exposure” (placing people in the same situations that cause them to panic) is more than enough. Pincus explains:

“In order to overcome anxiety, adolescents have to actually experience the physical sensations that are caused by panic… The first time it’s scary — terrifying, even. But by the second or third time, habituation occurs. By allowing patients to experience sensations of panic in a controlled setting, they learn that it takes only a few minutes for those sensations to dissipate, because our bodies like to stay at homeostasis… And once a patient stops responding to the sensations with fear, the sensations go away.”

Sixteen-year-old study participant Lindsey Lanouette suffered from panic attacks and anxiety before participating in Pincus’ cutting-edge program:

“…Lindsay…appeared to have it all. Tall and lithe, with long blonde hair and striking blue eyes, she had lots of friends, got along well with her parents and sister, earned good grades, and played varsity soccer.

But sometimes, while wandering the aisles of a shopping mall or eating in a dimly lit restaurant, things would start to go wrong. She’d become dizzy, her heart would race, and before long, she could barely breathe. “It just felt as if the walls were closing in,” the Falmouth, Massachusetts, teenager recalls, “and I couldn’t do anything to stop it. Sometimes I thought I was dying.”

During the eight-day treatment series at Boston University, in order to induce panic attacks in a controlled environment, clinicians had her

“…[Shake] her head from side to side to induce dizziness, [run] in place to make her heart race, [breathe] through a cocktail straw to make her feel light-headed, and [stare] at a bright light to cause disorientation.”

Although a session of interoceptive exposure therapy like Lanouette’s certainly sounds unorthodox, the approach appears to be working so far. Pincus claims “very positive” results in one-year follow-ups with former patients and “significant decreases in both the number of weekly panic attacks they are experiencing and the severity of their panic from pretreatment to post-treatment.” Of course, it’s too early in the game to draw any firm conclusions from Pincus’ work just yet, but it’ll be interesting to see what she comes up with when her five-year research period is done and the statistics have been calculated.

Help! I’m Anxious about My Anxiety Management Class!

I took a seat at a large conference table in the university’s counseling center. I looked around nervously. I kept my hands in my lap, fingers (figuratively) crossed, hoping that I wouldn’t recognize a single face that walked through the door and into the Anxiety and Stress Management Class that I’d signed up for. It was a six-week class that I’d discovered via a flier posted on a bulletin board outside of my second home, the university library. As I sat and waited, my heartbeat felt large and uncomfortable. No doubt, I was anxious.

I was a first-semester graduate student at the time, trying to keep up with the 200+ pages I needed to read each week for my classes. It was just too much reading. (I hadn’t yet fully realized the fine art of skimming and scanning.) Theories would blend together and famous philosophers like Hume and Locke would inch their way into my dreams, uninvited. Even during the waking hours, I couldn’t relax. I’d try to zone out by watching a sitcom; instead, I’d find myself thinking about how little I know about designing research studies — and I needed to know for that exam on Monday! — and I’d only end up flustered and feeling unproductive when the credits rolled by. I couldn’t keep my anxiety level in check. Not even through the traditional notion of relaxing — sitting on the couch, remote control in hand, pleasant faces and canned laughter on the screen. Nope. Didn’t work.

I held my breath as a handful of fellow students began filtering into the conference room. “He looks unfamiliar,” I thought, as I eyed up the other anxious twenty-somethings walking through the door. “And that girl looks friendly…maybe. Wait, maybe not.”

I had been nervous enough while walking up the stairs to the Counseling Center, and I’d tried to hide my face in an issue of the school’s weekly newspaper while I was in the Center’s waiting room, eight long minutes early. This was almost too much for my anxiety-ridden self. I never had a problem with social anxiety before — my anxieties have always been a result of workload issues — but I suddenly felt like I’d had a new diagnosis. I just didn’t want anyone else to know that I was having a problem. I was excited for the content of the class, which advertised cognitive and behavioral techniques that promised to get me through my first semester, but not for the company. Sitting in that conference room, I felt stigmatized. It was like I had a banner flying over my head that read “Yes, I do have a problem with anxiety!” There was no going back.

Students continued to walk in. “Oh no, I’ve seen him before. Somewhere in the library, maybe? A student worker at the circulation desk?” I couldn’t remember. My heart felt like it was vibrating.

One of my professors would open each evening class by asking our class where we fell on the 1-to-10 “How ready are you to quit this program?” scale. That week, I was running on a 9.5…only because I was scared to admit the truth and give myself a 10. I had already been dressing my own academic grave and calling around for quotes on health insurance. Meanwhile, my classmates had all reported scores of 5 or below for that week. How could they be keeping their heads so level while I’m slowly cracking up from the pressure? How could they sit and watch television in the evening, or read a book for pleasure, or go for a walk knowing that there was a major amount of work to be done?

The halfway point of the semester was upon us, and the same professor with that brilliant scale idea had described the next seven weeks as a “downhill train ride” with no brakes. Oh, and the train was full of explosives. And there was a baby tied to the tracks ahead. (I’m not kidding; he actually said that!) How could the rest of my cohort sleep at night? Everyone knew that grad school wasn’t a walk in the park, but honestly? Explosive downhill trains to terror & babies tied to the tracks? I didn’t understand how everyone else projected such an A-OK, hunky-dory, we’ll-get-through-this image.

How Effective is Cognitive Behavioral Therapy (CBT) for Anxiety?

Cognitive behavioral therapy (CBT) is probably the most well-known and most-practiced form of modern psychotherapy. Even therapists who don’t identify themselves as a CBT therapist likely uses at least a handful of CBT techniques in their practice. And while much of CBT’s popularity is centered around its use for depression and related mood disorders, it’s also useful for many other disorders, including anxiety.

But to-date, there has been no systematic review of the efficacy of cognitive-behavioral therapy in randomized placebo-controlled research trials for anxiety. Until now.

In April, researchers from Boston University conducted an extensive literature review on CBT studies that reviewed the efficacy of CBT versus a placebo for anxiety disorders. Out of an original 1,165 studies identified, they found 27 that met their inclusion criteria.

They found support for the use of CBT in anxiety disorders. Specifically, the severity of anxiety symptoms was decreased for people who took CBT over placebo, and the effect of this decrease was most significant for people with obsessive-compulsive disorder and acute stress disorder. The smallest effect size the researchers found was for the use of CBT in panic disorder.

The researchers also noted that while they did find CBT effective for many anxiety disorders, there is considerable room for improvement for future research in this area. CBT is not a cure-all, but when wielded by an experienced therapist, it can provide helpful, beneficial results for most people suffering from an anxiety disorder.

Reference

Hofmann SG & Smits JA. (2008). Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry, 69(4), 621-32.

Exposure Therapy for Acute Stress Disorder

Before someone is diagnosed with posttraumatic stress disorder (PTSD), they are often diagnosed with a disorder called acute stress disorder. Why? Because PTSD is considered more of a longer-term, even chronic, disorder, while acute stress disorder occurs more immediately and generally doesn’t last as long, especially if it’s treated. Left untreated, acute stress disorder often turns into posttraumatic stress disorder.

So what kinds of treatments are most helpful with acute stress disorder (ASD)?

There are no medications approved for the treatment of ASD (although a medication may be prescribed for associated anxiety or depressive symptoms). So treatment usually is a type of psychotherapy.

Two types of psychotherapy often prescribed for ASD are either exposure therapy or trauma-focused cognitive restructuring. In the former, patients are taught and practice clinical relaxation and imagery techniques and, when mastered, gradually “exposed” to components related to the original trauma. This exposure is done either for real (in vivo) or via imagery techniques, depending upon the level of trauma and, in consultation with the patient, the therapist’s experience and preference. Cognitive restructuring, on the other hand, doesn’t expose people to the original trauma, but instead helps the person examine and deconstruct their negative, irrational thoughts surrounding the trauma. These thoughts often lead to negative emotions, such as anxiety, so the thinking goes that by dealing with them, one can deal with the anxiety and traumatic feelings.

Recent research has looked into which of these two techniques results in better outcomes for people. A randomized controlled clinical trial of people (non-military) who experienced trauma and who met the diagnostic criteria for ASD (N = 90) were seen at an outpatient clinic. Patients were randomly assigned to receive 5 weekly 90-minute sessions of either imaginal and in vivo exposure (n = 30), or cognitive restructuring (n = 30), or assessment at baseline and after 6 weeks (the wait-list control group; n = 30).

The researchers examined through clinical interviews and patient self-report measures to see whether they improved after treatment. They also assessed whether the person would meet the criteria for a PTSD diagnosis.

The results indicated that at the end of treatment, significantly fewer patients in the exposure group had PTSD than those in the cognitive restructuring or control groups. At a 6 month follow-up, patients who underwent exposure therapy were also more likely to not meet diagnostic criteria for PTSD and to achieve full remission of their acute stress disorder symptoms than the other two groups.

On assessments of PTSD, depression, and anxiety, exposure treatment resulted in markedly larger effect sizes at the end of treatment and the 6 month follow-up than cognitive restructuring.

The researchers concluded that exposure-based therapy leads to greater reduction in subsequent PTSD symptoms in patients with ASD when compared with cognitive restructuring. They said, “Exposure should be used in early intervention for people who are at high risk for developing PTSD.”

There aren’t too many randomized controlled clinical trials of this nature for psychotherapy techniques, and fewer still that show such a clear differentiation between treatment options. Basically the researchers found that cognitive restructuring-focused therapy was little better than the control group. What the researchers found that works is exposure therapy, and that’s the treatment people should look for if they are diagnosed with an acute stress disorder.

Reference

Bryant RA, Mastrodomenico J, Felmingham KL, Hopwood S, Kenny L, Kandris E, Cahill C, Creamer M. (2008). Treatment of acute stress disorder: a randomized controlled trial. Arch Gen Psychiatry, 65(6), 659-67.

Are Diagnoses Too Inclusive?

Christopher Lane has an excellent article in yesterday’s The Boston Globe about the murky line between normal shyness and something called social anxiety disorder (also known as social phobia). The article examines the difficulty in telling “normal behavior” from something that’s diagnosable as a mental disorder, and rightfully picks on this disorder as a prime example of the blurred line. But first Lane drives a dagger into what passes for science on social anxiety disorder:

The Society of Nuclear Medicine has been touting a new study that suggests we’re one step closer to solving the riddle of social anxiety disorder. Researchers believe the origins of the disorder are biological. […]

Once you start calling fear of criticism a psychiatric disorder, it’s easy to ignore the countless social and psychological factors that cause stress and anxiety. Yet the justification for calling the disorder biological turned out to be modest at best. MRI scans of five women and seven men who met the criteria for social anxiety disorder suggested that minor fluctuations of dopamine and serotonin “may play a role in the neurobiology of social anxiety disorder.”

That’s a bit like saying, “Exercise will increase your heart rate” or “Caffeine is a stimulant.” Microscopic fluctuations of dopamine and serotonin impact the brain all the time, helping determine our moods. It’s a stretch to predict the health of 15 million Americans from a brief focus on only a dozen of them.

Indeed. Researchers get excited when they seem some correlation within their data, but then almost universally over-extend and generalize the meaning of that correlation and data.

Much of these types of studies that purport to find some sort of brain chemical link for a specific disorder have amounted to very little in changing the way most disorders are diagnosed and treated.

But the larger point Lane makes in the article is about the fuzzy lines between the diagnostic criteria for many mental disorders, and what most of us would consider normal behavior. He picks on social anxiety disorder, and rightfully so, because it is one of the most useless diagnoses in the entire diagnostic manual.

What he glosses over, though, is that for a person to meet the diagnosis of social anxiety disorder, he or she must meet a total of 8 different criteria. Some criteria he doesn’t mention in his article are things like:

• The person recognizes that the fear is excessive or unreasonable.
• The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
• The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
• In individuals under age 18 years, the duration is at least 6 months (so much for the senior prom example in the article).

I highlighted some of the words. These are the words trained mental health professionals look for when diagnosing someone with this particular disorder. If you’re just experiencing a few butterflies in your stomach before making an annual presentation to your boss, that’s not social anxiety disorder.

I agree with Lane’s overall theme that perhaps professionals (and especially health professionals like family physicians with little specific mental health training) are over-diagnosing many mental disorders these days due to inexact diagnostic criteria. But I also believe overdiagnosis is also happening because of a simple lack of adherence to the criteria that do exist.

Shyness, as Lane reminds us, is not a mental disorder, and social anxiety disorder is not the same as being shy or having a personality that favors shyness. Shyness is just a normal, everyday trait that some people have — and it’s perfectly okay.

But the problem of overdiagnosis, like Lane believes, is a real one and must be addressed:

To restore public and professional confidence in the manual, the organization needs to raise, not lower, its diagnostic thresholds and delete every reference in the manual to mild or routine suffering, so that it’s possible once more to distinguish between the chronically ill and the worried well.

I concur. We must do a better job with the validity of this diagnostic system in its next revision, and seek to continually improve upon our abilities to reliably diagnose these disorders. Because suggesting someone is “ill” and in need of treatment when they are perfectly healthy helps no one.

Read the full article: Shyness or social anxiety?

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