An interview with Francis S. Lee, MD, PhD, Weill Cornell Medical College, BBRF Scientific Council Member, 2010 Independent Investigator 2005, 2002 Young Investigator
Dr. Francis Lee is the Mortimer D. Sackler Professor and Vice Chair for Research in the Department of Psychiatry at Weill Cornell Medical College, and an attending psychiatrist at NewYork-Presbyterian Hospital. He is also the Co-Research Director of the Youth Anxiety Center at NewYork-Presbyterian Hospital. His research focuses on leveraging molecular neuroscience tools to improve our understanding of anxiety disorders. His current research has centered on factors that influence the plasticity of the brain – its ability to change in response to experiences, both good and bad. Dr. Lee additionally sees patients with a focus on anxiety disorders.
Over 20 percent of adolescents have anxiety disorders. How does this compare with other mental health issues?
Anxiety disorders are the most common psychiatric disorder in children and adolescents. Studies differ, but most suggest between 15 percent and 30 percent of youth will have an anxiety disorder before age 18. This is more than other common childhood and adolescent conditions, such as ADHD (eight to 10 percent), or depression (10 to 20 percent). The prevalence of anxiety disorders in adults is around 30 percent, and the prevalence of depression in adults is about seven percent, schizophrenia is one percent, bipolar disorder is about three percent.
And yet you say that anxiety disorders are under-recognized and misdiagnosed in young people. Why?
Anxiety disorders are under-recognized because everyone, children and adults alike, experience anxiety. In children, for example, it is normal to be anxious before an exam or on the first day of school. Your child comes to you and says they are anxious. You yourself are anxious at times, so you don’t recognize the difference in degree. Your hope is that this is due to an adjustment to routine, for example going to a new school. You figure this will all go away on its own.
Anxiety is also frequently misdiagnosed because of the way it manifests sometimes as a bodily symptom, like a stomach ache. If a child has chronic stomach aches, they might refuse to go to school. This could be a tip off that there may be something more there.
Compared to the anxiety that any young person normally feels, how does anxiety in a young person with an anxiety disorder differ?
Feeling anxious about a few things some of the time, like giving a speech or taking a test, is in itself not a disorder. An anxiety disorder is a condition in which there is a significant distress and functional impairment. When a child’s severe distress or avoidance of anxiety-provoking situations gets in the way of the child’s day-to-day life, and/or the family’s daily life, then the anxiety has likely crossed a threshold that would warrant a professional assessment and intervention. An obvious warning sign would be if your son or daughter refuses to go to school. This is probably one of the most severe manifestations. Other warning signs would be if your child does not seem to spend much time outside his or her room, or does not seem to want to interact or be part of various activities. Anxiety is a normal emotion to have. It’s when it gets to an extreme level that you should start keeping track, like when you see your child avoiding things that other children are not avoiding, like going to parties, hanging out with friends, or joining school activities, clubs, or team sports.
Is avoidance the main symptom parents would see?
There are a panoply of symptoms. Anxiety is also associated with frequent worry or reassurance-seeking, chronic irritability, difficulty sleeping, and anxiety-related physical symptoms, which for some youth can progress to a panic attack (a brief period of intense fear and inability to act).
What should parents do if they think their child might have an anxiety disorder? Who should they consult first?
There are very good national organizations such as the Anxiety and Depression Association of America (ADAA), the Association for Behavioral and Cognitive Therapies, and the National Institute of Mental Health (NIMH), as well as our organization, the NewYork-Presbyterian Youth Anxiety Center, all of whose websites provide a very detailed description of each type of anxiety disorder, as well as information on the recommended evidence-based treatment options, and often links to well-trained providers in your geographic area. Looking at those websites should be step one. Step two would be to meet with your child’s primary care doctor, and get a referral to a psychologist or psychiatrist for an assessment.
If you start to have a sense that there seem to be greater levels of fear-related symptoms as well as avoidance behavior, then you want to see a professional to get a sense of whether the anxiety warrants a diagnosis and treatment.
What we have learned, from both clinical experience and from research, is that these disorders don’t go away on their own. They need to be treated.
Tell us about the different types of anxiety disorders and the different treatments for them.
The first anxiety disorders we tend to see in youth are separation anxiety disorder, a fear of being separated from one’s parents or safety figure, or a specific phobia, for example fear of the dark, heights, animals, insects, getting sick, etc. Many youth have these fears to a certain extent, but for some it becomes extreme, interfering with the child and family’s functioning.
In later childhood, generalized anxiety is characterized by frequent worry about many things, including school, friends, family members, world events, health, and safety. Obsessive compulsive disorder has specifically to do with intrusive, unwanted obsessive thoughts or urges that cause distress and anxiety, and associated compulsions, habits, or behaviors that temporarily relieve the anxiety but cause other impairments in daily life.
Social anxiety disorder is more common in adolescence and is focused more on anxiety symptoms related to social events, meeting new people, or public speaking. Panic disorder is typically not seen until later adolescence, but includes out-of-the-blue panic attacks and invokes fear and avoidance of situations that might cause a panic attack.
Is there a reason why anxiety peaks early in life?
Anxiety disorders seem to peak at two main times: during childhood (between five and seven years of age), and during adolescence.
There is definitely a cohort of patients who have anxiety disorders in childhood, which corresponds to when they have to leave the house and go to school. This environmental change seems to trigger these symptoms. The second wave of anxiety in early- to mid-adolescence is harder to understand. There is still great debate amongst psychiatrists and epidemiologists whether there is a second wave, or whether these adolescents have had low levels of anxiety all along throughout childhood, and it is only now finally getting to the attention of a care provider. As I said, there is a significant under-diagnosis of this disorder.
If the child has had symptoms during childhood, his or her chances of also being diagnosed with depression and substance use disorders during adolescence also increase. This is one of the main reasons why diagnosing and treating anxiety early is so important. If not treated, these disorders build upon themselves. If parents notice a significant level of anxiety, irritability, or even a persistent stomach ache, or some other type of symptom, they should not ignore it.
If an anxiety disorder is allowed to linger for, say, five years from onset, not only do the symptoms get worse, but you then have a child who has a very limited world, in which they have been avoiding things. At that point, you’re starting treatment at a different point than you might have five years earlier and it’s more difficult to treat.
Does anxiety disorder run in families?
Just as with many other psychiatric disorders, there is high heritability. But heritability is difficult to explain, because it’s not like getting a diagnosis of Huntington’s disease, where there is a genetic test and if you have the gene, you have the illness. Heritability for anxiety disorders, like any psychiatric disorder, just means that there is a higher chance of having an anxiety disorder if it runs in your family. Parents who have anxiety themselves may also model or reinforce anxious or avoidant coping with their children, which can send an unhelpful message to a child who is genetically predisposed to anxiety.
Can factors in the environment, such as trauma, trigger anxiety disorders?
When you try to do a natural history intake [asking patients and their family members] of what environmental factors or other circumstances caused or contributed to the disorder, it’s very difficult to pin down [the cause]. There is a biological component, including genetics, which we don’t understand, which obviously interacts with the environment. There is nothing that suggests there is something in the environment itself that causes an anxiety disorder. There is no direct correspondence with, for example, the way the child was reared — except for significant trauma. But in such a case, that anxiety disorder when diagnosed is referred to as post-traumatic stress disorder, since it is the result of an earlier trauma or chronic acute stress.
What are the therapeutic options?
All of these anxiety disorders are amenable to the same type of therapy, called cognitive behavioral therapy (CBT). The patient meets with a therapist, usually on a weekly basis, and gets exposed in a controlled environment to things that make them anxious. The point of the treatment is to ensure that adolescents will be able to confront their anxieties and work through them using adaptive coping strategies. The goal is to experience the anxiety and learn that the feeling can be tolerated and managed, and will likely get better the more the adolescent confronts the experience instead of avoiding it. Thus, therapy may consist of going to a nearby Starbucks, or some other public place, and interacting with strangers, or touching something “germy,” speaking in public, or purposely practicing another feared experience.
This is why it’s so helpful to see a professional, because there are certain things that they do that may seem a little bit counterintuitive – like having a socially anxious person go into a crowded place where they have to interact. But this is ultimately the bedrock of this kind of behavioral treatment. These treatments usually last 12 to 16 weeks. This will not only help the child in the moment, but also help them equip themselves on how they can manage their own anxiety going forward, post-treatment.
Medication within the serotonin reuptake inhibitor class, such as fluoxetine [Prozac] is an additional option. Usually, one follows a stepped-care model, where you start with psychotherapy, and consider adding medication depending on the severity of symptoms.
What role do parents play in treatment?
The family plays a significant role. Parents have to stay actively involved in the various behavioral measures taken during the treatment, not only during the therapy hour, but also outside the therapy.
So, for example, if the child refuses to go to school, the parent has to make sure their child goes to school. The normal impulse is to not subject your child to stressful scenarios. Therapists discuss with parents ways to push their child to confront their anxiety, and not enable avoidance behavior. Avoidance behavior leads to overdependence on parents. Therapy tries to place the responsibility of growing independence back on the adolescent.
Working with a skilled therapist will always involve not only the parent but also siblings, on how to deal with a situation where one person in the family seems to take up more attention.
When someone who has had anxiety symptoms early in life goes to high school or begins college, what can a parent expect?
If you have an anxiety disorder or depression before the age of 18, we know exactly what to do: you go to a pediatrician, who then refers you to a psychologist or psychiatrist who specializes in children and adolescents. When you turn 18, it’s unclear whom you should see. The young adult has outgrown pediatric care, but is not the typical patient seen in the adult mental health care system. This change occurs when youth are transitioning to college, or another post-high school experience. So, you might have been in a very protected environment at home, possibly seeing a therapist, and then when you go to college, you jump into a new context, possibly hundreds of miles away, with none of the same support systems in place. It’s estimated that over 20 percent of the adolescents who are going to college have a diagnosable anxiety disorder, and the mental health services at colleges are usually not equipped to handle the large number of cases.
If my child is going off to college, what kind of support network can I create?
Start by having a fairly long discussion with their current mental health care team. It might be possible to maintain continuity of care with their current provider through Skype or other tele-health methods. Also find out what services are available in the college and the city your child is going to.