Anxiety, Depression, & Stress
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ANXIETY, DEPRESSION, & STRESS How Mental Health Effects Us and Our Students Larry Scott [email protected]
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Anxiety, Depression, & Stress. How Mental Health Effects Us and Our Students Larry Scott [email protected]. Agenda. Current State of Mental Health General Characteristics of Anxiety & Depression Depression Anxiety Self-Harm & Suicide Addiction - PowerPoint PPT Presentation
Transcript of Anxiety, Depression, & Stress
AgendaI. Current State of Mental HealthII. General Characteristics of Anxiety &
DepressionIII. DepressionIV. AnxietyV. Self-Harm & SuicideVI. AddictionVII. Mental Health Treatment/Intervention
Community Mental Health Crisis 47% of people killed by police, north of NYC, over a 5 year period suffered from a
mental illness or were emotionally disturbed
About 17% of U.S. prison population have mental illness; 3x the rate of the general public
8,000 inmates are cared for by NYS Office of Mental Health
56% of NYS prison population have a “mental health problem” including substance abuse; 5x the rate of general public
Law enforcement have become primary providers to those with serious mental illness
Cuts, consolidations, and closings in mental health continue
In 1955 the U.S. had 558,000 beds for mentally ill; today we have about 40,000
Mentally ill are more likely to be victims of crime, than criminals, and they are more likely to be harmed by police, than harm police
Poverty & Mental Health The number of poor in the entire Buffalo Niagara
metropolitan area grew from 120,861 in 1970 to 162,917 in 2011
52 percent – of this area’s poor reside in the suburbs
Mobile Safety-Net Team (John R. Oishei Foundation): Ken-Ton School District is the largest human service of 38
agencies Free/reduced lunch (#1):
27% in March of 2001 compared to 41% in March of 2013
Youth & Mental Health Question #4 CDC (2012): About 20% of American youth (aged 3 – 17) suffer from a mental health
disorder (ADHD, anxiety, depression, and conduct problems)
ADHD= 6.8% Conduct Problems= 3.5% Anxiety= 3% Depression= 2.1% Autism Spectrum Disorder= 1.1%
ADHD diagnosis has jumped 53% in past decade
Chronic health problems (i.e. asthma & diabetes) are associated with mental illness in adulthood
Question #3 $247 Billion is spent per year for mental health services from medical bills, special education,
and juvenile justice
Question #2 Suicide has become the 2nd leading cause of death among youth (aged 12-17) behind accidents
Emotion & Mood Everyone experiences varying emotion and mood, including
symptoms of anxiety and depression
Mood: sustained emotional state which impacts how we respond on a regular basis; becomes more of an internal state, independent of external circumstances
Emotion: short-term and more influenced by external factors
“Emotion is the weather, mood is the climate.” (C. Smith)
Mood exists across species; the more developed the species the more intensely mood exists independent of external events
Some manage the interaction of mood, personality, and stress well; for others it becomes damaging
Anxiety & Depression Anxiety & Depression often co-exist and influence each
Share a single set of genes, which are also involved in alcoholism
Depression: a response to loss; Anxiety: a response to future loss
Depression with high anxiety increases risk of suicide & complicates recovery
Intervention needed when anxiety and/or depression
interferes with a life function (i.e. work, school, family relationships/functioning….).
“Biopsychosocial” Model
Genetics
Environment
al
Neuropsychological
Personality
The Brain Brain Plasticity
Between approximately 10 to 18 months of age is a critical period of plasticity and shaping of the brain (right frontal lobe) for attachments & emotional regulation
Neglect/trauma during this time can shape “wiring” for attachments & emotional regulation which can continue into adulthood
Limbic System (hypothalamus, hippocampus, & thalamus) is involved in emotional regulation
Dopamine (pleasure neurotransmitter) likes novelty & enhances brain circuitry
Depression About 19 million Americans suffer chronic depression (over 2 million
are children)
About 15% will commit suicide
2.3 million suffer from Bipolar Disorder
Could be leading cause of death when considering its influence on suicide, substance abuse, heart disease, and other health issues
Anger & violence may be symptoms of depression, particularly in males (destructive, but short-term remedy)
Question #5 Leading cause of disability in U.S. for those over the age of 5 and leading cause
worldwide (WHO); costs tens of billions yearly in lost productivity
Depression Females are 2x more likely to suffer depression, a ratio consistent throughout Western
societies
Males synthesize serotonin 50% more rapidly than females
Rate of depression is about the same among working and non-working married females
Males are more likely to have ADHD, autism, and alcoholism
Closeted people and single people have a higher rate of depression
Question #6 Women who are pregnant or have just given birth are more likely than anyone else to suffer
depression, but least likely to commit suicide
Question #7 Poverty & parent depression are highest predictors of child depression
Question #8 GLBT are at increased risk for depression and anxiety problems. Suicide is the number 1 cause
of death for this group
Characteristics of Depression
Fewer social skills and close relationships Fewer social interactions Limited interest in activities Limited motivation and academic
achievement Irritability Limited energy Limited affect Worsened with the presence of learning
weaknesses Most challenging during adolescence
The Brain & Depression There are particular genes which predispose depression, but whether one
suffers depression is dependent on life events/experiences
These genes are involved in serotonin regulation in the brain
There are three possible gene combinations, one from each parent: short/short, short/long, and long/long
A short/short combination with multiple uncontrollable bad life events makes it about twice as likely to suffer from depression than long/long combination
Significant episodes of depression alter brain chemistry and structure
Decrease in serotonin receptors and rise in cortisol (stress hormone) are known to occur with depression
With each episode of depression there is an increased 10% risk depression will become chronic and inescapable
Depression & Poverty Many studies show that socioeconomic status is the number one
predictor of depression
Question #9 Those in poverty represent the highest rate of depression compared to any other
class in U.S.
Depression is so common in poor communities awareness that an internal problem exists is lacking; perceived the problems are only due to uncontrollable external factors
Poverty is highly associated with a learned helplessness & passivity
Rate among welfare recipients is about 3x higher
Question #10 85 – 95% of those with serious mental illness are unemployed
Depression & Poverty Quality mental health care is lacking
most among the poor
Investment in addressing mental health needs may be worthwhile, financially and socially
The cost of not treating mental illness, may far outweigh the cost of adequately treating it
Mothers with Depression Depressed mothers greatly influence the likelihood that a
child will suffer depression or other emotional / behavioral issues
Having a depressed mother is often more detrimental than a schizophrenic mother
With a depressed mother, signs of depression can be seen in infants, as early as 3 months
Children are often weepy, angry, & aggressive
If mother’s depression is treated early, children show improvement, reversal becomes more challenging with age
Mothers with Depression Five potential impacts on child’s emotional /
behavioral development (Sameroff, A.):
1. Genetics2. Empathetic mirroring: repeating back what they
experience3. Learned helplessness: giving up on connecting due
to lack of parent approval for emotional outreach4. Role-playing: taking on the illness role to avoid
unpleasant things as observed by parent5. Withdrawal: consequence of seeing no
pleasure/meaning in communication with unhappy parent
Children with Depression Anaclitic depression: occurs in second half of
the child’s first year when separated from too much from their mother
May develop in “failure to thrive” starting at age four or five; limited affect & don’t bond
At age five to six show extreme crankiness, irritability, poor sleeping, and poor eating
Low self-esteem, high anxiety, and bed-wetting become common problems
The Course of Depression Depressed children usually go on to be
depressed adults
The earlier the onset the more resistance to treatment
Occurs in many before puberty, but peaks in adolescence
Early/preventative intervention is critical
Why So Much Depression? Four possible theories of evolution:
1. Served an important purpose in pre-human times
2. The stresses of modern life are incompatible with the brains we have evolved.
3. It serves a useful function.
4. It is a secondary result of other characteristics.
Why So Much Depression? Self-Consciousness: high awareness of self, meta-
cognition, and awareness of competing cognitive functions (i.e. rational and emotional thinking) makes us unlike any other species
Humans have the slowest brain maturation and are most plastic at older ages
Humans exhibit significant capacity to regulate emotions
Linguistic-Evolutionary Model (Crow, Timothy) mental illness is on a continuous spectrum and is determined by difference in intensity of symptoms
Anxiety 10 – 20% Americans suffer from Anxiety Disorder About ½ of those with true anxiety disorders develop
major depression within 5 years Anxiety is often overlooked, misdiagnosed as ADHD, left
untreated, and sometimes worsened when misdiagnosed Anxiety is difficult to detect- internal, not easily observed Worsens with time if untreated Self-awareness Medication
Anxiety The opposite of peace and feeling safe
“Curse” of sensitivity & empathy: capacity for feeling deeply, including emotional pain can be hindering, but also beneficial
Often obsessive thinkers without compulsive tendencies
Anticipatory anxiety
Frightening/gruesome thoughts may be a diversion to facing and dealing with inner and external conflict
Characteristics of Anxiety Strong episodes of anxiousness and panicky feelings Racing heart and chest discomfort Dizziness or lightheadedness Feelings of bewilderment and unreality Inner nervousness Scary, uncontrollable thoughts Nausea, upset stomach, diarrhea Hot and cold flashes Numbness or strange aches and pains, muscle tension Feelings of depression and hopelessness Restless feelings, insomnia, sleeping too much Difficulty breathing Picking at self or objects Uncontrollable bouts of anger/crying Obsessive-compulsive tendencies Withdrawing
ANXIETY CYCLE
Control Anxiety
Anxiety Control
Panic Attacks Experiencing severe panic attacks can be debilitating
Often develop from life events where there is a loss of security or perceived loss of security
Most difficult factor- it is not volitional, feelings occur for absolutely no reason
About 1/3 of panic attacks related to depression occur during deep, dreamless sleep
Gives a sense that you have a serious medical condition
Panic AttacksCognitive Symptoms:
“I’m going to have a heart attack.” “I’m about to die.” “I can’t breathe properly. I’m going to
suffocate.” “I’m about to pass out.” “I’m going to lose control and go crazy.”
Panic Attack: Physical Symptoms
Hot / cold
flashes
Numbness /
tingling
Chest pain /
tightness
Trembling
Tight, tense
muscles
Pounding heart
Shortness of
breath
Nausea / dizzy
Feeling unreal or detached
Physiology of Anxiety/Panic Anxiety is one of the most basic emotions found in almost all
animal species
Is a response to danger or threat- perceived or real
It’s primary purpose is to protect us, not harm us
“Fight/Flight/Freeze” response
Sympathetic nervous system releases energy to respond to threat
Parasympathetic nervous system restores the body to normal function
Psycho-Physical Cycle of Fear
Physical Symptoms
FearPhysical
Symptoms
Fear
The Brain & Anxiety People with high anxiety lock onto worry and
can’t let go
Their brains are haunted with horrific scenarios that present as quite real and can’t be ignored
Norepinephrine and serotonin are neurotransmitters which play a role in anxiety
Locus coeruleus controls norepinephrine production & the lower bowel
The Brain & Trauma/Stress Early childhood trauma causes major changes to the brain’s hippocampus,
shrinking it & inhibiting new, long-term memories
A stress hormone, glucocorticoid, kills cells in the hippocampus
Depression, high stress, and childhood trauma all cause the release of glucocorticoid.
The longer someone is seriously depressed or under high stress the smaller their hippocampus.
Antidepressants have been found to increase stem cells that become new neurons in the hippocampus
It takes about 3-6 weeks on an antidepressant for new neurons to mature and connect with other neurons
Psychotherapy has been shown to decrease activation in prefrontal cortex (less blood flow) in patients who suffer from past trauma and/or panic attacks
OCD Obsessive-Compulsive Disorder (OCD) can be most
severe with frequent worrying about harm to self and/or loved ones
Excessive fear of health is common- with frequent scanning of body for symptoms & doctor visits
OCD often worsens with time, slowly shaping brain structures/functioning
Certain thoughts are persist even when it is known that they are meaningless
The Brain & OCD The brain of OCD does not move or transition easily. It
becomes “locked.”
3 major areas are hyperactive in those who suffer from OCD:
1. Orbital frontal cortex: the more obsessive the more activity in this area
2. Cingulate gyrus: seems to play a role in triggering the sense of impending dread which then activates physiological responses (pain in stomach, pounding heart, etc…)
3. Caudate nucleus: plays a role in transitioning our thoughts
OCD can be inherited, but infections can swell the caudate nucleus leading to OCD symptoms
The Brain & OCD Dr. Jeffery Schwartz (Brain Lock) and his research have
discovered much about the brain’s role in OCD
Uses a form of psychotherapy to restructure the brain with a success rate of about 80% when combined with an antidepressant medication
The 3 major parts of the brain which are hyperactive & “locked” begin to function normally and separately, relieving the brain lock
Uses 2 major methods:1. Identify & accept that an obsessive worry is a symptom of OCD & not
something else (i.e. chronic disease)2. Focus on something desirable & pleasurable (about 30 minute intervals)
when faced with the obsessive thoughts
The Brain & OCD With obsessions & compulsions the more you do it, the
more desire to do it; the less you do it, the less you desire to do it
Intensive therapy which compels patients to think or do something pleasurable triggers dopamine release, rewarding new brain activity and growth of healthy neural circuitry and connections
One needs to be distracted and “change the channel” for a period of time when experiencing obsessions & compulsions
Anxious feelings will remain for some time (may initially increase) but by changing behavior & how one responds, brain restructuring can occur & with time anxiety will reduce
Suicide
The man who kills a man, kills a man. The man who
kill himself kills all men. As far as he is concerned, he
wipes out the world.G.K. Chesteron
Suicide Depression is not always the primary reason or only reason; often
committed after coming out of a depression or long after recovery
Suicide is more a response to anxiety and a tortured mind, rather than a solution to depression and purposeless mind
Question #12 Prior attempt to commit suicide is highest predictor of suicide
Although suicide can coincide with depression, it should be viewed independently just like substance abuse
Many unknowns
There is a significant difference between wanting to die and wanting to kill yourself
Suicide Statistics:
Most often on Mondays, between late morning & noon, and spring
Evidence suggests that the best-intentioned prevention programs introduce the idea to a vulnerable population & increase the rate
Suicide rate for age group of 10 – 14 increased by 120% between the early 80’s to the mid-90’s; 85% use aggressive means (guns, hanging, and poisoning)
Question #13 U.S. is the only country where guns are the primary means of suicide; more
Americans are kill themselves with guns than murder with guns, yearly
10 states with lax gun-control laws have a suicide rate 2x that of states with the strongest gun-control laws
Self-Harm Deliberate Self-Harm (DSH) has been on rise since 1980’s
Question #11 Average age of onset is about 13
Eating disorder & substance abuse are commonly associated
Females are 3x more likely than males
Reasons from an Inpatient Population: 53% to stop bad feelings 34% to feel something even if it was pain 32% to punish themselves 31% to relieve feeling numb or empty 14% to get help or attention out of desperation
Self-Harm Definitions Stereotypic Harm: includes behaviors like
head-banging/hitting self associated with mental retardation and severe autism
Major mutilation: involves a great deal of tissue damage associated with psychosis
Superficial/moderate mutilation : most common and usually includes skin cutting & burning
Self-Harm & Suicide Differentiation
Self-harm: intentional, non-life threatening bodily harm or disfigurement while in a state of distress
Suicidal behavior: act of self-inflicted, self-intended cessation of life
Question #14 Less than 1% kill selves from cutting
Self-harm is usually life sustaining act associated with the following: Impulsive- thought about for less than an hour Relieve inexpressible feelings Body alienation “Life preserver” rather than exit strategy May become angry if described as suicidal
Indirect Self-Harm Substance abuse
Eating disorder
Physical risk taking
High risk sexual behavior
Unauthorized discontinuation of medication
Suicide Reasons?4 Broad Types of Suicide:
1. Impulsive: sudden act triggered by specific external event without much thought
2. Revenge: poor awareness that death is the end
3. Faulty logic: death is the only escape from unbearable problems
4. Reasonable/logical: as a result of physical illness, mental instability, or change in life circumstances- do not wish to experience pain of life which outweighs remaining pleasure
The Brain & Suicide Low levels of serotonin in brain areas
associated with inhibition and freedom to act impulsively on emotion (similar to impulsive murders/arsonists)
Excessive number of serotonin receptors (possible brain compensating)
Stress reduces serotonin making the combination of stressful events and depression high risk for suicide
Dialectal Behavior Therapy A cognitive-behavioral treatment empirically
supported to treat self-harm in patients with Borderline Personality Disorder
Views self-harm behavior as a combination of dysfunction in emotional regulation in the brain & invalidating social environment, causing confusion of self, impulsivity, emotional instability, & interpersonal problems
Provides a comprehensive structure for treatment providers in dealing with a complex behavior
Addiction
Mental Illness
Substance Abuse
Addiction Alcohol is appealing for reducing anxiety short-term, but often
worsens depression
Alcohol decreases serotonin
Self-medication is common with alcohol and marijuana
Long-term use can alter brain structure and chemistry
Dopamine plays a role in addiction, requiring the need for more
It is typically thought that addiction should be addressed first, then the mental illness, but role of mental illness should not be ignored
Addiction Regular marijuana use mimics symptoms of depression
Marijuana may have short-term relief of anxiety and agitated-depression
Cocaine: 15% of those who try it become addicted, but for those 15% it is highly addictive and associated high risk of depression
Cocaine produces immediate gratification, acting on multiple neurotransmitters (serotonin, dopamine, and norepinephrine)
48-72 hours after cocaine use usually elicits an intense depression; depression can become the baseline with long-term use when not high
Treatment Two Broad Treatment Methods:
1. Medical (medication and/or electroshock)2. Therapy (counseling)
Evidence that behavior modification, talk-therapy, & medication can change brain chemistry, structure, & functioning
Medication & therapy should be complimentary, not competitive; used together or separately depending on the situation and individual
Large study by NIMH (2004) on moderately to severely depressed youth (aged 12 – 17): CBT: 69% success Prozac: 65% A combination of Prozac and CBT: 85%
Medication U.S. use of psychiatric medications is far higher than any other country
Question #15 Anti-depressants have become the most used drug in U.S. (about 10%
of adults)
About 28 Million Americans are on SSRIs (Selective Serotonin Reuptake Inhibitors)
About 16% of females, compared to 6% of males
About 5% of adolescents (aged 12 – 19) take an antidepressant
White adolescents are 5x more likely to use antidepressants than black adolescents and 2x more than Latino
1996 – 2005: 40% drop in those receiving therapy
Antidepressants Selective Serotonin & Norepinephrine Reuptake Inhibitors
(SSRI’s & SNRI’s) act on serotonin and some also act on norepinephrine
Are useful in treating chronic anxiety
Are relatively safe drugs, but do have side effects and unpleasant withdrawal symptoms (sometimes dangerous)
Efficacy in children has not been conducted
Only Prozac has been approved for children by the FDA, but others under generic labels can be prescribed
Anti-Anxiety Medication Benzodiazepine (tranquilizers) are intended for
short-term use, and not regarded as safe drugs for long-term treatment of anxiety
Physical tolerance and dependence requiring the need for more of the medication can lead to addiction and abuse
Dangerous when mixed with alcohol
Withdrawal symptoms can be very unpleasant and dangerous
Medication Limitations In isolation, does not address a psychological understanding
of anxiety and depression
Limited research and education on long-term use and effectiveness
Suicide risk in adolescents (FDA found a 4% increase in suicidal thoughts and behavior)
Weaning off medication can be a challenge and withdrawal can be unpleasant
Side effects, stigma, and uncertainties make medication a challenging decision for parents
Big Pharma Question #16
1997: FDA permitted drug companies to advertise prescription drugs directly to the public
1997 – 2004: Money on advertising quadrupled to $4.35 Billion
2000: Every dollar spent on advertising translated to an additional $4.20 in sales
Profiting off of benefit and not just need
Most funding for mental health research comes from pharmaceutical companies
Few psychiatrists provide therapy, just prescribe medication
Payments from drug companies to doctors sways prescription patterns
Perpetual increase in “polypharmacy”
Talk-Therapy Research shows strong evidence that talk
therapy can be effective
About 75% report improvement: diminished symptoms and greater length of time between episodes
Two most critical predictors of success:1. Rapport2. Trust in framework being used by patient &
therapist
Psychotherapy (Talk-Therapy)
Cognitive-Behavioral Therapy Based on theory that negative thinking and habits drive anxiety/depression Alter thinking, self-beliefs, and behavior Limited focus on emotion Youth anxiety
Psychodynamic Therapy Builds self-awareness and understanding of hidden/unresolved conflict &
denied feelings to elicit change Deeper understanding of emotion and it’s meaning Less intensive than psychoanalysis
Interpersonal Therapy Communication Relationships
Family Therapy
The Brain & Secrets Keeping secrets may be unhealthy for the brain
Study- when subjects shared intimate secrets- health improved, doctor visits and stress hormones decreased
Competing operations (telling and withholding) may influence stress/inner tension
May explain the need for some to vent to strangers and the appeal of prayer/confession amongst religions
Venting a secret to an open year (human or human-like) is the intervention and advice is not intended/needed
Psycho-Education with Youth
Fosters positive therapeutic relationship
Reduces self-blame & guilt
Instills hope
Increases motivation
Reduces anxiety
Promotes self help & reliance
Exposure Therapy (CBT) Primary objective is stop avoiding and face fears
(negative reinforcement)
Gradual or sudden exposure to fear
Cognitive Exposure
Reality Exposure
With youth it should be done gradually and not be forced
Problem Solving & Collaboration
Challenge to get all involved on the same page
Varying agendas and sense of urgency
Respect youth’s pace/comfort level
Communication and clear plan is needed for gradual exposure
School Supports Adjusted school schedule
Staff support person
Lunch support group or social skills group
Time away in safe place
In-school counseling
Test accommodations/program modifications through 504 Plan/IEP
In severe cases: Home Instruction (short-term with plan for reintegration, only part-time if possible)
Special education programming
Relaxation Techniques Yoga / Meditation
Deep Breathing
Progressive Muscle Relaxation
Pleasant Imagery
Visualization
Treatment Challenges Children & most adolescents don’t seek help on there own
Therapy cannot begin to be successful until a patient willingly accepts help
Alternative therapies (i.e. play therapy) can be helpful with young children
Asking a child to provide wishes or things they wish they had the power to change can provide much insight into a child’s view of self, life, and others
Parent anxiety and resistance
Cost-Effective Approach
Thoughts
Behaviors
Physical (Body)
Symptoms
Emotions
The Connection The way we think effects the way we feel,
behave, and how our bodies operate.
The opposite is also true- if we are physical ill or in pain it effects how we think, feel, behave.
Neurotransmitters: chemicals in our bodies that play a role in our
thoughts, feelings, and behaviors
Stress
The most successful people I know have gotten there
by choosing to underact to stressful conditions and keep moving forward.
Lucinda Bassett
Stress What is it?
Our response to external conditions (stressors) which effect our thoughts, feelings, and bodies
Stressors:
Adrenaline & Cortisol: chemicals that are released in our bodies when we experience stress
Emotional Symptoms Nervousness Irritability Crying Anxiety Lack of motivation or excitement Angry outbursts Feeling powerless Easily upset Loneliness
Cognitive Symptoms Trouble thinking clearly Forgetfulness Lack of creativity Memory loss Inability to make decisions Constant thoughts of worry Racing thoughts or mind going blank Lack of sense of humor
Behavioral Symptoms Bossiness Compulsive tendencies- repeating
something over & over (eating, chewing gum, playing video games…..)
Critical attitude of others Grinding teeth Not able to complete important tasks Smoking or abusing alcohol and drugs
Physical Symptoms Headaches Stomach aches and
indigestion Sweaty palms Difficulty sleeping Dizziness Back pain Tight neck and
shoulders
Feeling nauseous Hot & Cold Flashes Numbness or
strange aches/pains
Chest pain Racing heart Restlessness Tiredness Frequent illness
Managing Stress Change the way we think about certain situations or
events Eat healthy and get good SLEEP Physical activity: exercise, sports, walking,
weightlifting, etc… Relaxed breathing techniques Meditation Yoga / Tai Chi Talk to a trusted person Listening to or playing music Reading, drawing, & writing Spending time having fun with self or others
References Doidge, N. (2007), The Brain that Changes Itself. Eagleman, D. (2011), Incognito: The Secret Lives of the Brain. Pearrow, M. (2013), Students who Self-Injure: School-based Strategies
Based on DBT, NASP Convention, Seattle, WA, Februay 15, 2013. Solomon, A. (2001), The Noonday Demon Burns, D. (2006) When Panic Attacks Bassett, L. (1995), From Panic to Power www.nydailynews.com (2013), One in five U.S. kids has a mental
disorder; ADHD the most common: CDC, May 17, 2013 The Buffalo News (2013), Today’s Mental Health Squad: The Police,
May 19, 2013. The Buffalo News (2013), Does Training Prepare Cops for the Mentally
Ill, August 4, 2013. The Buffalo News (2013), Suburban Poverty on the Rise, June 8, 2013. Sharpe, K. (2012), Coming of Age on Zoloft: How Antidepressants
Cheered Us Up, Let Us Down, and Changed Who We Are. Rapee, R., Craske, M., & Barlow, D. The Causes of Anxiety and Panic
Attacks, http://algy.com/anxiety/index.php. Pratt, D. (2012), Anxiety Disorders in Children & Adolescents (power
point)
