Ethical issues of anxiety disorders

Many adolescents (and children) require proactive care for anxiety disorders.  In the most optimistic cases, early intervention can stem serious problems later on.  But for many suffering from anxiety disorders, proactive care means that their rights are limited, and they may be coerced into therapy and medications that they don't want.  There is endless ethical "gray area" between the two extremes: a happy alliance with the therapist, and an  apparent removal of basic rights.

In the happier purely voluntary form of therapy the counselor/client relationship is called the therapeutic alliance, "a collaborative nature of the partnership between counselor and client" (Hawaii State Department of Health), counseling ethics are easily applied as boundaries to the relationship to assure that the therapy is beneficial and that no harm comes to the client.

This is described succintly as the "four principles for biomedical ethics" (Westra, 2009): respect for autonomy, nonmaleficence, beneficence, and justice.

The phrase "no harm" (Sheppard, 1999), may be added to stress nonmaleficence.  When clients are harming themselves or may be harmed, this comes to mean "preventing harm," and ethical issues become difficult.

Another more subtle situation that equally relevant situation involves what treatment is used, specifically prescribed drugs, rather than if treatment is used.

An approach to these contradictions is to show that adolescents that need to be controlled, have that need because they are victims.  Adolescents who have been sexually assaulted are at risk for PTSD (Lawyer, 2006), and PTSD as often as not leads to anger (Saigh, 2007).  That may require involuntary treatment if the anger is externalized as violence.  Angry adolsecents usually come from angry families (Avci,  2010), and  "school refusal" is most often positively reinforced by family members or cohorts from the surrounding environment (Kearney, 2004).  Other adolescents who "refuse school" are anxiously reacting to real threats at school (Dube, 2009).  Professionals agonize when young assault victims have to be placed in forensic units, really prisons, when they become threatening or self-injurious as a result of their victimization (Welsh, 1998).

Self-injury may be the most dramatic of issues, along with often related suicide, and it is usually an effort to distract from the pain of depression, or the result of low self-esteem depression (Dickstein, 2009) from negative appraisal by others, or assault (Weismoore, 2010).  Effectively, they have neurotransmitter dysfunctions (Dickstein, 2009).

Perhaps the best information is that adolescent "delinquents" have normal empathy, and that they apparently suffer from executive function disorders (Lardén, 2006).  The stresses that they face force them to limit their cognizance of others' feelings, and there is no self-reported empathy gap between girls and boys. 











Avci, R., & Güçray, S. (2010). An Investigation of violent and nonviolent adolescents' family functioning, problems concerning family members, anger and anger expression. Educational Sciences: Theory & Practice, 10(1), 65-76. Retrieved from Academic Search Premier database.

Dickstein, D. (2009). A closer look at non-suicidal self-injury in adolescents. (Cover story). Brown University Child & Adolescent Behavior Letter, 25(12), 1-6. Retrieved from Academic Search Premier database.

Dube, S., & Orpinas, P. (2009). Understanding excessive school absenteeism as School Refusal Behavior. Children & Schools, 31(2), 87-95. Retrieved from Academic Search Premier database.

Hawaii State Department of Health (2010). Therapeutic alliance curriculum activity quiz. Retrieved September 16, 2010, from http://www.amhd.org/About/ClinicalOperations/MISA/Training/Therapeutic%20Alliance%20Curriculum%20activity%20quiz.pdf

Kearney, C. (2007). Forms and functions of school refusal behavior in youth: an empirical analysis of absenteeism severity. Journal of Child Psychology & Psychiatry, 48(1), 53-61. doi:10.1111/j.1469-7610.2006.01634.x.

Lardén, M., Melin, L., Holst, U., & Långström, N. (2006). Moral judgement, cognitive distortions and empathy in incarcerated delinquent and community control adolescents. Psychology, Crime & Law, 12(5), 453-462. doi:1068-316X print/ISSN 1477-2744.

Lawyer, S., Ruggiero, K., Resnick, H., Kilpatrick, D., & Saunders, B. (2006). Mental health correlates of the victim-perpetrator relationship among-interpersonally victimized adolescents. Journal of Interpersonal Violence, 21(10), 1333-1353. Retrieved from Academic Search Premier database.

Saigh, P., Yasik, A., Oberfield, R., & Halamandaris, P. (2007). Self-Reported Anger Among Traumatized Children and Adolescents. Journal of Psychopathology & Behavioral Assessment, 29(1), 29-37. doi:10.1007/s10862-006-9026-9.

Sheppard, G., Schulz, W. and McMahon, S. (1999). The code of ethics. Canadian Counselling and Psychotherapy Association: Ottawa.

Weismoore, J., & Esposito-Smythers, C. (2010). The Role of Cognitive Distortion in the Relationship Between Abuse, Assault, and Non-Suicidal Self-Injury. Journal of Youth & Adolescence, 39(3), 281-290. doi:10.1007/s10964-009-9452-6.

Welsh, J. (1998). In whose ‘best interests’? Ethical issues involved in the moral dilemmas surrounding the removal of sexually abused adolescents from a community-based residential treatment unit to a locked, forensic adult psychiatric unit. Journal of Advanced Nursing, 27(1), 45-51. doi:10.1046/j.1365-2648.1998.00502.x.

Westra, A., Willems, D., & Smit, B. (2009). Communicating with Muslim parents: “the four principles” are not as culturally neutral as suggested. European Journal of Pediatrics, 168(11), 1383-1387. doi:10.1007/s00431-009-0970-8.

Self-esteem

Kutob reports low self-esteem in elementary and middle school girls in California and Arizona manifested as "low academic performance, social isolation, depression, anxiety, fatigue, headaches, and stomachaches"  (Kutob, 2010).   The low self-esteem was largely caused by cruel teasing and bullying associated with appearance: body weight.  Kutob promotes "zero tolerance" for teasing.  He blames society for allowing a "mindless acceptance and promotion of stereotypic definitions of personal value based on 'Hollywood' appearance standards."

Self-esteem issues can be cultural
Self-esteem for White and Hispanic girls declined by age 11, but, for Black girls, self-esteem remained the same "between the ages of 9 and 14."  The Black girls were immune.  As global self-esteem for Black and White children is equal (Jackson, 2009), the difference appears to be cultural.

Chinese children with "absent migrant parents" suffer low self-esteem (Li-Juan, 2010).  Loneliness predicts low self-concept, which is restored when their parents spend quality time with them.  Here, family affection links to self-esteem and -concept rather than appraisal.

Top down (social) and bottom up (biopsychological)
Low self-esteem for White and Hispanic girls in California and Arizona resulted from negative appraisal rather than self-concepts of appearance.  There seem to be distinct internal and external components of low self-esteem and poor self-concept.  Mentoring improves self-concept and reduces anxiety, but may not improve school behavior or relationships, and depression may remain (Schmidt, 2007).  Bonding in group therapy benefits self-esteem (Marmarosh, 2005), but those who attempt bonding to reduce depression often become more depressed (Cambron, 2010).

Top down
Low self-esteem includes normal reactions (Hendel, 2006):

• need to win
• pleasing others
• perfectionism
• self-criticism
• withdrawing

Bottom up
It is also associated with three indicators of psychological distress (Huajian, 2009):

• depression
• anxiety
• "low subjective well-being"

Exercise improves self-concept, and hence self-esteem

Psychomotor programs "correlated with increased global self-esteem and decreased depression and anxiety levels" (Peter PV Van de, 2005).  Increased physical self-concept elevates low self-esteem--whatever its cause.


Reference

Cambron, M., & Citelli, L. (2010). Examining the link between friendship contingent self-esteem and the self-propagating cycle of depression. Journal of Social & Clinical Psychology, 29(6), 701-726. Retrieved from Academic Search Premier database.

Hendel, A. (2006). Restoring Self-Esteem in Adolescent Males. Reclaiming Children & Youth, 15(3), 175-178. Retrieved from Academic Search Premier database.

Huajian, C., Qiuping, W., & Brown, J. (2009). Is self-esteem a universal need? Evidence from The People's Republic of China. Asian Journal of Social Psychology, 12(2), 104-120. doi:10.1111/j.1467-839X.2009.01278.x.

Jackson, L., Yong, Z., Witt, E., Fitzgerald, H., von Eye, A., & Harold, R. (2009). Self-concept, self-esteem, gender, race, and information technology use. CyberPsychology & Behavior, 12(4), 437-440. doi:10.1089/cpb.2008.0286.

Kutob, R., Senf, J., Crago, M., & Shisslak, C. (2010). Concurrent and longitudinal predictors of self-esteem in elementary and middle school girls. Journal of School Health, 80(5), 240-248. doi:10.1111/j.1746-1561.2010.00496.x.

Li-Juan, L., Xun, S., Chun-Li, Z., Yue, W., & Qiang, G. (2010). A survey in rural China of parent-absence through migrant working: The impact on their children's self-concept and loneliness. BMC Public Health, 101-8. doi:10.1186/1471-2458-10-32.

Marmarosh, C., Holtz, A., & Schottenbauer, M. (2005). Group cohesiveness, group-derived collective self-esteem, group-derived hope, and the well-being of group therapy members. Group Dynamics: Theory, Research, and Practice, 9(1), 32-44. doi:10.1037/1089-2699.9.1.32.

 

Peter PV Van de, V., Herman HV Van, C., Ans AD, D., Joseph JP, P., Guido GP, P., & Koen KK, K. (2005). Comparison of changes in physical self-concept, global self-esteem, depression and anxiety following two different psychomotor therapy programs in nonpsychotic psychiatric inpatients. Psychotherapy & Psychosomatics, 74(6), 353-361. Retrieved from Academic Search Premier database.

Schmidt, M., McVaugh, B., & Jacobi, J. (2007). Is mentoring throughout the fourth and fifth grades associated with improved psychosocial functioning in children?. Mentoring & Tutoring: Partnership in Learning, 15(3), 263-276. doi:10.1080/13611260701201943.

Comparing schizophrenia and bipolar (and also psychosis)

A review of recent material about schizophrenia and bipolar disorder confirms that the two diseases are genetically inherited.  One article suggests that families with a genetic tendency for one of these diseases also have a tendency for the other (McIntosh, 2009).  A search for genetic information about schizophrenia shows that a particular genetically expressed protein, NRG1, and its related receptors, ErbB3 and ErbB4, are central to schizophrenia.  Recent studies implicating NRG1 in schizophrenia also implicate it in bipolar disorder, giving oblique support to the idea that the two diseases are connected genetically, and in other ways.  But they focus on different areas, and hence have seemingly conflicting concepts: myelin and neurotransmitters.  Myelin implies neural speed, and neurotransmitters bring to mind, as an example, dopamine reactions to stress.

A myelin, or ErbB3, study (McIntosh, 2009), shows that mutations resulting in NRG1/ErbB3 signaling failures causes oligodendrocyte activity to be impaired so that less "white matter" is produced resulting in a diminished "anterior internal capsule in subjects with both disorders" (p. 2) including unaffected directly-related family members of the bipolar disorder and schizophrenia subjects.  This effect is assumed to be developmental, and myelin formation in "frontal lobes, continues into late adolescence and beyond" (p. 3), giving optimism that new drugs could reinforce myelination for those at risk. 

This study also says that plasticity relates to myelination, and that there is myelination in adults, and hence plasticity, that may relate to schizophrenia and bipolar disorder in terms of both development and maturity.

    Genetic loading for psychosis and the internal capsule (McIntosh, 2009)

Neurotransmitter, or  ErbB4, studies have a brain-wide view with a focus on neuron and transmitter activity such glutamatergic hypofunction (Li, 2007), failures in the formation of inhibitory synapses (Fazzari, 2010), and neural development such as the "wiring" of GABA-mediated circuits (Fazzari, 2010), all in the context of schizophrenia.  While a bipolar disorder can be linked to schizophrenia in the context of ErbB4 (Chong, 2007), the more detailed material on neural activity focuses on schizophrenia. 

As dopamine hyperactivity is part of the schizophrenia pharmacological model (Stone, 2007), and methamphetamine is used to simulate it experimentally (Homayoun, 2008), studies concentrating on stimulants may give clues about the neural activity of schizophrenia and bipolar disorder.

The "white matter" study links myelination to plasticity, and is optimistic that new drugs may reinforce myelination (p. 4), and so raises an idea about myelination and plasticity with respect to maturity: could such drugs help the elderly retain plasticity?

These studies show similar diseases apparently caused by the same mutations, creating a causal relationship that should point to a common location for both diseases.  But we find the expressions on completely different levels--the causal relationship is misleading!  Still, the "neurotransmitter" studies show causal relationships linking the neural functions of bipolar disorder and schizophrenia to glutamatergic, GABAergic, and dopaminergic responses to stimulants, such as methamphetamine.  These relations may help show us how the disordered neurons may affect behavior. 

References

Chong, V.,  Thompson, M., Beltaifa, S., Webster, M., Law A., and Weickertad, S. (2007). Elevated Neuregulin-1 and ErbB4 protein in the prefrontal cortex of schizophrenic patients: Schizophr Res. 2008 March ; 100(1-3): 270–280. doi:10.1016/j.schres.2007.12.474.

Fazzari, P., Paternain, A., Valiente, M., Pla, R., Luján, R., Lloyd, K., et al. (2010). Control of cortical GABA circuitry development by Nrg1 and ErbB4 signalling. Nature, 464(7293), 1376-1380. doi:10.1038/nature08928.

Gever, J. (2009, January 15). Bipolar disorder and schizophrenia have overlapping genetic roots. MedPage Today
http://www.medpagetoday.com/Psychiatry/Schizophrenia/12480

Homayoun, H., & Moghaddam, B. (2008). Orbitofrontal cortex neurons as a common target for classic and glutamatergic antipsychotic drugs. Proceedings of the National Academy of Sciences of the United States of America, 105(46), 18041-18046. doi:10.1073/pnas0806669105.

Li, B., Woo, R., Mei L., Malinow, R., (2007, May 24). The neuregulin-1 receptor ErbB4 controls glutamatergic synapse maturation and plasticity. Neuron, 54(4), 583-597.

McIntosh, A., Hall, J., Lymer, G., Sussmann, J., and Lawrie, S. (2009). Genetic risk for white matter abnormalities in bipolar disorder. International Review of Psychiatry, 21(4), 387-393. doi:10.1080/09540260902962180.

McIntosh, A., Hall, J., Lymer, G., Sussmann, J., and Lawrie, S. (2009). Genetic loading for psychosis and the internal capsule disorder. International Review of Psychiatry, 21(4), 387-393. doi:10.1080/09540260902962180.

Stone, J., Morrison, P., and Pilowski, L. (2007, January 26). Review: Glutamate and dopamine dysregulation in schizophrenia — a synthesis and selective review. Journal of Psychopharmacology June 2007 vol. 21 no. 4 440-452

Executive function, working memory control, and ADHD

Executive function (EF) and working memory
ADHD is largely defined in terms of executive function impairment (Biederman, 2004), and shares descriptive language.  Very recent studies describe executive function as "executive attention" (Kane, 2005) and show a unitary model that links it with working memory in terms of working memory control, or WMC, and higher levels of cognition.  WMC is central to  to EF, often called "central executive functioning"  (McCabe, 2010).  McCabe indirectly describes WMC in terms of ADHD: inhibitory control, and focus of attention.

WMC benefits from education
Gathercole shows benefits for impaired working memory through remedial education (Gathercole, 2006), and Berneir shows autonomy support as the "strongest predictor" for healthy EF in children (Bernier, 2010).   Jang suggests a blending of autonomy support and traditional structure, or "autonomy-structure," that has high understanding and leadership, and low admonishing and uncertainty in a way that should benefit working memory control in view of recent executive function material. 

Speculated benefits for ADHD
These executive function, ADHD understanding, and educational concepts form a tight matrix with respect to working memory and its control.  Perhaps, for this reason, parenting and early education strategies that target WMC development via autonomy and guidance will help children with ADHD and other executive dysfunctions.


Bernier, A., Carlson, S., & Whipple, N. (2010). From External Regulation to Self-Regulation: Early Parenting Precursors of Young Children’s Executive Functioning. Child Development, 81(1), 326-339. doi:10.1111/j.1467-8624.2009.01397.x.

Biederman, J., & Faraone, S. (2005). Attention-deficit hyperactivity disorder (ADHD): Two case studies. Medscape

http://cme.medscape.com/viewarticle/513743_1

Gathercole, S., & Alloway, T. (2006). Practitioner Review: Short-term and working memory impairments in neurodevelopmental disorders: diagnosis and remedial support. Journal of Child Psychology & Psychiatry, 47(1), 4-15. doi:10.1111/j.1469-7610.2005.01446.x.

Jang, H., Reeve, J., & Deci, E. (2010). Engaging students in learning activities: It is not autonomy support or structure but autonomy support and structure. Journal of Educational Psychology, 102(3), 588-600. doi:10.1037/a0019682.

Kane, M., Hambrick, D., & Conway, A. (2005). Working Memory Capacity and Fluid Intelligence Are Strongly Related Constructs: Comment on Ackerman, Beier, and Boyle (2005). Psychological Bulletin, 131(1), 66-71. doi:10.1037/0033-2909.131.1.66.

McCabe, D., Roediger, H., McDaniel, M., Balota, D., & Hambrick, D. (2010). The relationship between working memory capacity and executive functioning: Evidence for a common executive attention construct. Neuropsychology, 24(2), 222-243. doi:10.1037/a0017619.