Anxiety, Depression, & Stress

1. Anxiety, Depression, & Stress How Mental Health Effects Us and Our Students Larry Scott lscott2@kenton.k12.ny.us

2. Agenda • Current State of Mental Health • General Characteristics of Anxiety & Depression • Depression • Anxiety • Self-Harm & Suicide • Addiction • Mental Health Treatment/Intervention

3. 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

4. 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

5. 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

6. 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

7. 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….).

8. “Biopsychosocial” Model

9. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. Mothers with Depression • Five potential impacts on child’s emotional / behavioral development (Sameroff, A.): • Genetics • Empathetic mirroring: repeating back what they experience • Learned helplessness: giving up on connecting due to lack of parent approval for emotional outreach • Role-playing: taking on the illness role to avoid unpleasant things as observed by parent • Withdrawal: consequence of seeing no pleasure/meaning in communication with unhappy parent

19. 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

20. 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

21. Why So Much Depression? • Four possible theories of evolution: • Served an important purpose in pre-human times • The stresses of modern life are incompatible with the brains we have evolved. • It serves a useful function. • It is a secondary result of other characteristics.

22. 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

23. Video • Out of the Shadows

24. 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

25. 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

26. 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

27. ANXIETY CYCLE Control Anxiety Anxiety Control

28. 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

29. Panic Attacks Cognitive 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.”

30. Panic Attack: Physical Symptoms Pounding heart Chest pain / tightness Tight, tense muscles Shortness of breath Feeling unreal or detached Nausea / dizzy Trembling Hot / cold flashes Numbness / tingling

32. 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

33. Psycho-Physical Cycle of Fear

34. 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

35. 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. • Antidepressantshave 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

37. 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

38. 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: • Orbital frontal cortex: the more obsessive the more activity in this area • 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…) • Caudate nucleus: plays a role in transitioning our thoughts • OCD can be inherited, but infections can swell the caudate nucleus leading to OCD symptoms

39. 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: • Identify & accept that an obsessive worry is a symptom of OCD & not something else (i.e. chronic disease) • Focus on something desirable & pleasurable (about 30 minute intervals) when faced with the obsessive thoughts

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. Indirect Self-Harm • Substance abuse • Eating disorder • Physical risk taking • High risk sexual behavior • Unauthorized discontinuation of medication

48. Suicide Reasons? 4 Broad Types of Suicide: • Impulsive: sudden act triggered by specific external event without much thought • Revenge: poor awareness that death is the end • Faulty logic: death is the only escape from unbearable problems • 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

49. 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

50. 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