1. Anxiety, Affective Disturbance and Behavior Art Maerlender, Ph.D. Dartmouth Medical School Clinical School Services and Learning Disorders Program Section of Child and Adolescent Psychiatry

2. Concept: In children, affect dysregulation is displayed through behavior o It is an important signal

3. Question: How should adults understand and respond to behavioral displays?

4. Application: Assume the behavior displayed is a signal about the child, not about the adult or relationship o I.e., that the behavior is “manipulation” o While in the end, this might be true, it is safest and best for the child (as in respectful) to start by assuming otherwise.

5. Primary Assumptions  Our hypothesis is that children’s behavior is a reflection of their internal physiological and affective states NOT their cognitions.  Further, assuming this, it becomes helpful to read their behavior as signals reflecting mood and/or health.  In short, anxiety reflects difficulty resolving internal conflicts, both of which typically involve a ‘desire’ (need, interest) in achieving incompatible goals.

6. Caveat  the neurology of behavior is EXTREMELY complex  Interactions among many levels of influence Biology & genetics Reinforcement histories Environmental stimulation, enrichment, deprivation  20 minutes does not do service to this complexity

7. Anxiety  Is a necessary biological process used by the organism to help it monitor the environment and attend to appropriate stimuli in effective ways

8. Anxiety  The anxiety system is related to attention, as “attention” to stimuli is the first stage of the anxiety system

9. Anxiety  What we term clinical anxiety is the ineffective response to stimuli (which may be appropriate or inappropriate)  But the ‘clinical’ aspect of anxiety arises when the system responsible is activated to a degree that behavior becomes dysfunctional.

10. Anxiety is a RED FLAG that something is amiss Either in the external environment Or the internal environment

11. Anxiety is a signal  Physiological  Behavioral  Cognitive 

12. Anxiety Warns of:  Punishment  Non-reward  Novelty  Innate anxiety  These are stimuli that are warnings of potential negative affective events

13. The function of anxiety & the function of the anxiety ‘system’  Response to stimuli that warn of potential negative affective events  Response to stimuli that Warn of punishment Warn of non-reward Are novel Innately anxiety provoking

14. Anxiety Engages the Behavioral Inhibition System Inhibits ongoing behavior Increases attention to environmental stimuli Increases levels of arousal

15. The Behavioral Inhibition System: The Behavioral Inhibition System: mediates responses to any stimuli that generates competing goals BIS Conflict GenerationConflict Resolution Signals of punishment Signals of non-reward Novel stimuli Innate fear stimuli Behavioral inhibition Increased arousal Increased attention

16. In addition… These are signals related to events or objects in which the organism has some reason to approach.

17. Fear Vs Anxiety  Forms of behavior, not stimuli  Different forms are appropriate at different distances (cat & rat studies)  Actual or potential presence as the distinguishing factor Does the behavior remove the animal from or facilitate entry into a dangerous situation? Active or passive avoidance Fear is active avoidance Anxiety is passive avoidance and related to approach needs

18. Thus, it is evaluation of stimuli that becomes critical- In humans this suggests a high level of cognitive appraisal

19. Ambiguity  The ambiguity of the situation makes evaluation difficult  And results in anxiety.

20. Behavioral Inhibition System (BIS) Outputs of BIS  Inhibit ongoing behavior  Increase attention to the environment  Increase arousal level

21. Relation of neurology to behavioral responses related to anxiety Brainstem>panic Limbic system>anxiety Frontal>cognitions/behaviors (obsessions/compulsions)

22. The Septo-Hippocampal System  A comparator system  Compares currently primed goals with each other  And with ‘expectations’

23. ‘Individual goals’ ‘Individual goals’ are defined as comprising:  stimuli to a which a response can be addressed;  the responses are available and expected and  there are motor programs (plans) which can achieve the goal.

24. When no conflict is present, the S-H system is monitoring and receiving info  Processed sensory info  Programming responses  Comparator – just checking – status Single cell recording show much activity

25. When conflict between goals Either  Unpredicted events occur  predicted events don’t occur  equal incompatible tendencies: approach – avoidance approach – approach avoid – avoid

26. Conflict causes the system to enter ‘control mode’  BIS interrupts behavior addressed to current prepotent goal  Stimuli associated with goal are tagged as ‘faulty’ and inspected

27. Feedback in the system:  The S-H system sends feedback to other systems about the tagged stimuli that allow the other systems to increase the affective valence and take control of behavior when the signal next occurs

28. S-H reduces conflict within the organism  Amygdala becomes involved in situations of specific defensive conflict  Panic, phobias, obsessions and compulsions are not properly anxiety, but reactions to anxiety.

29. Features of human anxiety  Apprehension of possibility failure or loss of reward (not anticipation of pain)  Conflict between 2 goal states Avoid and approach

30. The role of the hippocampus  Gray (00) posits that it is suppressor of undesirable computations in other structures.  It serves as a ‘comparator’ based on: assessment of current state of the world based on perceptual input current motor programs memory stores  Computes a prediction as to next likely state of the world

31. Hippocampus

33. The role of the septum  The septum is a nucleus in the limbic system which regulates anger and pleasure. Experiments with rats show that when the septum is activated, reactions can be extremely strong  Controls theta rhythm  Has role in seratonin discharge

34. Septum

36. Limbic Structures: Septum, Amygdala, Hippocampus

37. Role of the hierarchical defense system in anxiety disorders  All parts receive both fast, poorly digested sensory info: “dirty” Slow, well digested sensory info: “sophisticated” Lowest level is most basic response: o Panic Progressively higher levels - more anticipatory reaction  Activity is distributed across parts simultaneously

38. Hierarchical defense system and anxiety Anterior OCD Cingulate Amygdal Phobia-avoid GAD- arousal Medial Hyp. Phobia- escape Periaq. Gray Panic- escape Active avoidance Passive avoidance Defensive distance Septo-Hipp. GAD Sys. cognition Post. Cingulate GAD cognition Prefrontal- OCD?. Ventral Post. Cingulate GAD drug resistant dirtydirty sophisticated

39. Threat Stimuli p295 actual potential avoidableunavoidable fleefight freeze fear anger panic Phobia amygdala medial hyp. Panic periaq gray avoidable unavoidable assess detectable anticipate undetectable conserve anxiety obsession depression GAD SHS OCD cingulate Depression NA/5HT * * *nature of stimuli, relation to fx, emotion, psychological disorder, principal neural system

40. Take home messages  Children’s behavior is more likely due to internal processes than overt cognitive planning;  Anxiety is produced in approach situations (kid’s want to do well)  Anxiety is based on the internal perception of the threat, based on the learning history and available resources  Problem behavior is often a signal that tasks are too difficult  When in doubt, ask.