Emotional dysregulation is an important element in the pathophysiology of childhood anxiety disorders and can distinguish anxious subjects from controls. Treatment with selective serotonin inhibitors (SSRIs) has been found to lessen anxiety, but its effects on emotional reactivity and regulation are less documented. The aim of the study was to prospectively assess changes in emotional reactivity and regulation in response to citalopram in children and adolescents with anxiety disorders, with special focus on the mechanism of reappraisal.
Methods:
The sample included 70 children and adolescents (38 boys, 32 girls) 10–17 years of age, divided into three groups: Those with anxiety disorder treated with citalopram for 8 weeks (n = 35); untreated subjects with anxiety disorder on the waiting list for cognitive behavioral therapy (CBT) (n = 15); and subjects without anxiety disorder (controls) (n = 20). Emotional reactivity and regulation (i.e., reappraisal), were assessed at baseline and after 8 weeks (follow-up) with validated computer-based instruments, Reactivity and Regulation-Situations (REAR-S) and Reactivity and Regulation-Images (REAR-I).
Results:
Citalopram-treated subjects showed significantly greater improvement in reappraisal ability than CBT-waitlisted subjects. Improvement in the ability to reappraise threatening images correlated significantly with the decrease in anxiety. There was a decrease in negative emotional reactivity between assessments, which was positively correlated with clinical improvement. Higher intensity of baseline reactivity (on the REAR-S) predicted more severe symptoms at follow-up.
Conclusions:
Citalopram therapy improves reappraisal ability in children and adolescents with anxiety. However, the improvement in other examined emotional reactivity indices occurred in both medicated and waitlisted groups. It is possible that these findings may have implications for understanding the pathophysiology of anxiety in children and adolescents.
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References
1.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994.
2.
BeckAT, SteerRA, BallR, RanieriW: Comparison of Beck Depression Inventories -IA and -II in psychiatric outpatients. J Pers Assess, 67:588–597, 1996.
3.
BirmaherB, KhetarpalS, BrentD, CullyM, BalachL, KaufmanJ, NeerSM: The Screen for Child Anxiety Related Emotional Disorders (SCARED): Scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry, 36:545–553, 1997.
4.
BlechertJ, SheppesG, Di TellaC, WilliamsH, GrossJJ: See what you think: Reappraisal modulates behavioral and neural responses to social stimuli. Psychol Sci, 23:346–353, 2012.
BridgeJA, IyengarS, SalaryCB, BarbeRP, BirmaherB, PincusHA, RenL, BrentDA: Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: A meta-analysis of randomized controlled trials. JAMA, 297:1683–1696, 2007.
7.
BylsmaLM, MorrisBH, RottenbergJ: A meta-analysis of emotional reactivity in major depressive disorder. Clin Psychol Rev, 28: 676–691, 2008.
8.
CarthyT, HoreshN, ApterA, EdgeMD, GrossJJ: Emotional reactivity and cognitive regulation in anxious children. Behav Res Ther, 48:384–393, 2010a.
9.
CarthyT, HoreshN, ApterA, GrossJJ: Patterns of emotional reactivity and regulation in children with anxiety disorders. J Psychopathol Behav Assess. 23–36, 2010b.
10.
CicchettiD, TothSL: A developmental psychopathology perspective on child abuse and neglect. J Am Acad Child Adolesc Psychiatry, 34:541–565, 1995.
11.
DavidsonRJ: Affective style and affective disorders: Perspectives from affective neuroscience. Cogn Emot, 12:307–330, 1998.
12.
DavidsonRJ, PizzagalliD, NitschkeJB, PutnamK: Depression: Perspectives from affective neuroscience. Annu Rev Psychol, 53:545–574, 2002.
13.
DomesG, SchulzeL, BottgerM, GrossmannA, HauensteinK, WirtzPH, HeinrichsM, HerpertzSC: The neural correlates of sex differences in emotional reactivity and emotion regulation. Hum Brain Mapp, 31:758–769, 2010.
14.
DrevetsWC, BogersW, RaichleME: Functional anatomical correlates of antidepressant drug treatment assessed using PET measures of regional glucose metabolism. Eur Neuropsychopharmacol, 12:527–544, 2002.
15.
FariaV, AhsF, AppelL, LinnmanC, BaniM, BetticaP, PichEM, WahlstedtK, FredriksonM, FurmarkT: Amygdala-frontal couplings characterizing SSRI and placebo response in social anxiety disorder. Int J Neuropsychopharmacol, 17:1149–1157, 2014.
16.
FariaV, AppelL, AhsF, LinnmanC, PissiotaA, FransO, BaniM, BetticaP, PichEM, JacobssonE, WahlstedtK, FredriksonM, FurmarkT: Amygdala subregions tied to SSRI and placebo response in patients with social anxiety disorder. Neuropsychopharmacology, 37:2222–2232, 2012.
17.
FisherPM, MeltzerCC, PriceJC, ColemanRL, ZiolkoSK, BeckerC, Moses–KolkoEL, BergaSL, HaririAR: Medial prefrontal cortex 5-HT(2A) density is correlated with amygdala reactivity, response habituation, and functional coupling. Cereb Cortex, 19:2499–2507, 2009.
18.
FuCH, WilliamsSC, CleareAJ, BrammerMJ, WalshND, KimJ, AndrewCM, PichEM, WilliamsPM, ReedLJ, MitterschiffthalerMT, SucklingJ, BullmoreET: Attenuation of the neural response to sad faces in major depression by antidepressant treatment: A prospective, event-related functional magnetic resonance imaging study. Arch Gen Psychiatry, 61:877–889, 2004.
19.
FurmarkT, AppelL, MichelgardA, WahlstedtK, AhsF, ZancanS, JacobssonE, FlycktK, GrohpM, BergstromM, PichEM, NilssonLG, BaniM, LangstromB, FredriksonM: Cerebral blood flow changes after treatment of social phobia with the neurokinin-1 antagonist GR205171, citalopram, or placebo. Biol Psychiatry, 58:132–142, 2005.
20.
FurmarkT, TillforsM, MarteinsdottirI, FischerH, PissiotaA, LangstromB, FredriksonM: Common changes in cerebral blood flow in patients with social phobia treated with citalopram or cognitive-behavioral therapy. Arch Gen Psychiatry, 59:425–433, 2002.
GinsburgGS, KendallPC, SakolskyD, ComptonSN, PiacentiniJ, AlbanoAM, WalkupJT, SherrillJ, CoffeyKA, RynnMA, KeetonCP, McCrackenJT, BergmanL, IyengarS, BirmaherB, MarchJ: Remission after acute treatment in children and adolescents with anxiety disorders: Findings from the CAMS. J Consult Clin Psychol, 79:806–813, 2011.
23.
GoldinPR, ManberT, HakimiS, CanliT, GrossJJ: Neural bases of social anxiety disorder: Emotional reactivity and cognitive regulation during social and physical threat. Arch Gen Psychiatry, 66:170–180, 2009.
24.
GrossJJ: Antecedent- and response-focused emotion regulation: divergent consequences for experience, expression, and physiology. J Pers Soc Psychol, 74:224–237, 1998.
25.
GrossJJ: Emotion regulation: Affective, cognitive, and social consequences. Psychophysiology, 39:281–291, 2002.
GrossJJ, JohnOP: Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. J Pers Soc Psychol, 85:348–362, 2003.
28.
GuyW: ECDEU Assessment Manual for Psychopharmacology. Rockville MD: 1976.
29.
JamesA, SolerA, WeatherallR: Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev, 4:CD004690, 2005.
30.
LangPJ, BradleyMM, CuthbertBN: International Affective Picture System (IAPS): Instruction Manual and Affective Ratings. Gainesville, FL: The Center for Research in Psychophysiology, University of Florida; 1999.
31.
LiddellBJ, BrownKJ, KempAH, BartonMJ, DasP, PedutoA, GordonE, WilliamsLM: A direct brainstem–amygdala–cortical ‘alarm’ system for subliminal signals of fear. Neuroimage, 24:235–243, 2005.
32.
LlewellynN, DolcosS, IordanAD, RudolphKD, DolcosF: Reappraisal and suppression mediate the contribution of regulatory focus to anxiety in healthy adults. Emotion, 13:610–615, 2013.
33.
LoniganCJ, VaseyMW, PhillipsBM, HazenRA: Temperament, anxiety, and the processing of threat-relevant stimuli. J Clin Child Adolesc Psychol, 33:8–20, 2004.
34.
LynehamHJ, RapeeRM: Evaluation and treatment of anxiety disorders in the general pediatric population: A clinician's guide. Child Adolesc Psychiatr Clin N Am, 14:845–861, 2005.
35.
MayerJD, SaloveyP, CarusoDR, SitareniosG: Measuring emotional intelligence with the MSCEIT V2.0. Emotion, 3:97–105, 2003.
36.
McLaughlinKA, MenninDS, FarachFJ: The contributory role of worry in emotion generation and dysregulation in generalized anxiety disorder. Behav Res Ther, 45:1735–1752, 2007.
37.
OchsnerKN, RayRD, CooperJC, RobertsonER, ChopraS, GabrieliJD, GrossJJ: For better or for worse: Neural systems supporting the cognitive down- and up-regulation of negative emotion. Neuroimage, 23: 483–499, 2004.
38.
OchsnerKN, RayRR, HughesB, McRaeK, CooperJC, WeberJ, GabrieliJD, GrossJJ: Bottom-up and top-down processes in emotion generation: Common and distinct neural mechanisms. Psychol Sci, 20:1322–1331, 2009.
39.
OchsnerKN, SilversJA, BuhleJT: Functional imaging studies of emotion regulation: A synthetic review and evolving model of the cognitive control of emotion. Ann N Y Acad Sci, 1251:E1–24, 2012.
40.
OsmanA, KopperBA, BarriosF, GutierrezPM, BaggeCL: Reliability and validity of the Beck depression inventory–II with adolescent psychiatric inpatients. Psychol Assess, 16:120–132, 2004.
41.
OuthredT, HawksheadBE, WagerTD, DasP, MalhiGS, KempAH: Acute neural effects of selective serotonin reuptake inhibitors versus noradrenaline reuptake inhibitors on emotion processing: Implications for differential treatment efficacy. Neurosci Biobehav Rev, 37:1786–1800, 2013.
42.
PapayJP, SpielbergerCD: Assessment of anxiety and achievement in kindergarten and first- and second-grade children. J Abnorm Child Psychol, 14:279–286, 1986.
43.
PhanKL, CoccaroEF, AngstadtM, KregerKJ, MaybergHS, LiberzonI, SteinMB: Corticolimbic brain reactivity to social signals of threat before and after sertraline treatment in generalized social phobia. Biol Psychiatry, 73:329–336, 2013.
44.
PiacentiniJ, BennettS, ComptonSN, KendallPC, BirmaherB, AlbanoAM, MarchJ, SherrillJ, SakolskyD, GinsburgG, RynnM, BergmanRL, GoschE, WaslickB, IyengarS, McCrackenJ, WalkupJ: 24- and 36-week outcomes for the Child/Adolescent Anxiety Multimodal Study (CAMS). J Am Acad Child Adolesc Psychiatry, 53:297–310, 2014.
45.
RayRD, McRaeK, OchsnerKN, GrossJJ: Cognitive reappraisal of negative affect: Converging evidence from EMG and self-report. Emotion, 10:587–592, 2010.
46.
RayRD, WilhelmFH, GrossJJ: All in the mind's eye? Anger rumination and reappraisal. J Pers Soc Psychol, 94:133–145, 2008.
47.
RottenbergJ, GrossJJ: When emotion goes wrong: Realizing the promise of affective science. Clin Psychol Sci Pract, 10: 227–232, 2003.
48.
RottenbergJ, KaschKL, GrossJJ, GotlibIH: Sadness and amusement reactivity differentially predict concurrent and prospective functioning in major depressive disorder. Emotion, 2:135–146, 2002.
49.
RottenbergJ, WilhelmFH, GrossJJ, GotlibIH: Vagal rebound during resolution of tearful crying among depressed and nondepressed individuals. Psychophysiology, 40:1–6, 2003.
50.
ShaniM, LachmanL, ShalemC, BahatA, ZeigerT: Single Words Reading Test Manual. Tel-Aviv: Sfarim; 2006.
51.
ShelineYI, BarchDM, DonnellyJM, OllingerJM, SnyderAZ, MintunMA: Increased amygdala response to masked emotional faces in depressed subjects resolves with antidepressant treatment: An fMRI study. Biol Psychiatry, 50:651–658, 2001.
52.
SilvermanWK, SaavedraLM, PinaAA: Test–retest reliability of anxiety symptoms and diagnoses with the Anxiety Disorders Interview Schedule for DSM-IV: Child and parent versions. J Am Acad Child Adolesc Psychiatry, 40:937–944, 2001.
53.
SmuckerMR, CraigheadWE, CraigheadLW, GreenBJ: Normative and reliability data for the Children's Depression Inventory. J Abnorm Child Psychol, 14:25–39, 1986.
54.
SpielbergerC: Manual for the State-Trait Anxiety Inventory for Children. Palo-Alto, CA: Consulting Psychologists Press; 1973.
55.
SuvegC, ZemanJ: Emotion regulation in children with anxiety disorders. J Clin Child Adolesc Psychol, 33:750–759, 2004.
56.
SzeszkoPR, MacMillanS, McMenimanM, LorchE, MaddenR, IveyJ, BanerjeeSP, MooreGJ, RosenbergDR: Amygdala volume reductions in pediatric patients with obsessive-compulsive disorder treated with paroxetine: preliminary findings. Neuropsychopharmacology, 29:826–832, 2004.
57.
WalkupJT, AlbanoAM, PiacentiniJ, BirmaherB, ComptonSN, SherrillJT, GinsburgGS, RynnMA, McCrackenJ, WaslickB, IyengarS, MarchJS, KendallPC: Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med, 359:2753–2766, 2008.
58.
WechslerD: Wechsler Intelligence Scale for Children–IV. San Antonio: Psychological Corporation; 2003.
59.
WhalenPJ, JohnstoneT, SomervilleLH, NitschkeJB, PolisS, AlexanderAL, DavidsonRJ, KalinNH: A functional magnetic resonance imaging predictor of treatment response to venlafaxine in generalized anxiety disorder. Biol Psychiatry, 63:858–863, 2008.
60.
ZemanJ, CassanoM, Perry–ParrishC, StegallS: Emotion regulation in children and adolescents. J Dev Behav Pediatr, 27:155–168, 2006.
