Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C.E. Zupanick, Psy.D. and Mark Dombeck, Ph.D.
The Treatment of Anxiety Disorders
In the previous section, we reviewed the various theories and associated therapies that are used to treat anxiety disorders. We will now turn our attention to specific anxiety disorders to describe the usual treatment approach for each disorder. However, it is important to bear in mind, that therapists tailor their treatment approach for each person.
Systematic Desensitization and Flooding are two behavioral techniques that are useful for Separation Anxiety Disorder. Both techniques are variant forms of exposure therapy. All exposure therapies work on the same principle, derived from learning theory, known as habituation. The basic premise of this approach is that anxiety disorders do not go away when people merely avoid the things they fear. Avoidance merely keeps the unpleasant anxiety feelings at bay. In contrast, recovery is possible when people do not avoid or escape from the things they fear. In this way, they learn through new experiences that the object of their fears is not actually harmful.
When people intentionally remain in the presence of fearful situations, it is called exposure therapy. Exposure therapy is a highly effective and efficient way to treat anxiety. However, as you might imagine, it is difficult to get people to agree to this method. A variant form of exposure therapy is called systematic desensitization. This technique avoids overwhelming anxious people. First, the therapist teaches participants age-appropriate relaxation methods. This helps them learn to relax in the presence of fearful situations. After participants have mastered relaxation they are systematically exposed to situations they fear, gradually increasing the intensity. This may include both imaginal and actual exposure. For instance, suppose someone is afraid of elevators. First, the therapist might guide them to practice their relaxation techniques while looking a picture of elevator. Next, they might consciously relax themselves while imagining getting on an elevator. Next, they might step on and off a real elevator. Next, they might step on, allow the door to close and reopen, and then get off. Finally, they might ride one up one story, etc. This gradual, systematic approach enables them to become desensitized to the fearful situation. This occurs because of habituation.
The therapist and the anxious child jointly produce a list of progressively more intense situations. For example, children with Separation Anxiety Disorder might first practice separation from their parent for 10 minutes, while still in their familiar home. As mastery is achieved, the intensity increases. Over time, they may practice longer periods of separation from home. Then they might practice separation in an unfamiliar environment (such as a shopping center).
Another technique is full exposure (also called flooding). This technique is not nearly as gentle as systematic desensitization. Its benefit is it produces more immediate results. In this procedure, the child experiences a sudden, intense exposure to a feared situation. No hierarchy or buildup occurs. Children are initially very anxious, but eventually habituate and calm down. Once calm, children see that nothing terrible has happened to them despite their fears. They also learn they can be calm even when faced with frightening circumstances. Although this method sounds cruel, it's similar to taking off a bandage. You can either pull it off slowly and gradually, with less discomfort, over a longer period of time. Alternatively, you can rip it off and get rid of it once and for all.
Importantly, flooding is not forced upon children. Therapists only use this method with children who are old enough to give meaningful consent. Children are strongly encouraged to stay and tolerate their feared situation. However, children who attempt to flee are not prevented from doing so. Should a child flee, the therapist would discuss the escape attempt with the child and encourage the child to try it again a second time.
Another type of therapy for Separation Anxiety Disorder is cognitive behavioral therapy (CBT). This method is reserved for older children and adolescents who are able to articulate their thoughts and feelings. CBT focuses on children's anxious thought habits that lead them to become anxious in the first place. Children may have unrealistic and exaggerated ideas about how dangerous it is to be alone. Likewise, they may fail to differentiate between past losses and present circumstances. For example, an anxious child may think that because she lost her mother to cancer several years ago, that her father will also die. A CBT therapist helps children to become aware their thoughts. Together, the therapist and child examine the child's thoughts and beliefs to see if they make logical sense. A child who is worried that her father might also die because her mother died might be encouraged to make logical connections between death caused by illness such as cancer, and her father's lack of any similar illness. To make this point, the therapist might ask the child questions, like, "Is your father sick? Will he be participating in a particularly dangerous activity like sky-diving while he goes out to dinner tonight?" This line of questioning helps the anxious child to realize that the actual risk of her father dying is lower than she previously thought.
Medications are also used to treat Separation Anxiety Disorder. Both antidepressants (e.g., Clomipramine or Imipramine) and anxiolytic medications (anxiety reducing medications such as Buspar®) have been used with success. Various side effects can occur with the use of medications. This may include dry mouth, dizziness, seizures, aggressive behaviors, drowsiness, etc. Many antidepressants have a "black box" warning for use with children. Studies have shown that in a small number of children, these medications can increase suicidal thoughts and behaviors. A mental health professional should closely monitor children taking these drugs. This professional should closely monitor possible suicidal thoughts and behaviors.