Epidemiology

Childhood Anxiety Disorders[With Emphasis on Anxiety Disorders- Issues,

Diagnosis, Management]

Selective MutismPost-traumatic Disorder

Obsessive Compulsive Disorders

Phobias - Specific

/Generalized

Generalized anxiety & Panic

disorder

ClassificationSlides before 1st Section Divider

Summary References

ChairpersonProf. Dr. Ramanujam MD, DPM

Dr. SJX Sugadev MD, Asst. Professor

19th June 2013Presented by

Dr. Anusa AM2nd Year MD PG

Madurai Medical College

Prepared by Prof. Rooban T,

Oral & Maxillofacial Pathologist

Anxiety Disorders

A set of syndromes

Signs and Symptoms – Part of many

disorders

No organic cause

Previously a part of “Neurotic”

With understanding of disorders – many

have been demonstrated to have organic

cause

Definition – “Neurotic”

All local and general nervous disorders which do not depend on known local pathological lesions of the nervous system.

Does not imply - diseases have an entirely unknown pathology, but cannot be morphologically classified.

Neurotic Disorders - Definition

Collection of psychiatric disorders without psychotic symptoms and lacking the intense psychopathology

Neurosis is an umbrella term for nonpsychotic personality disorders

Definition

Disorder that has no known or suspected basis in

organic pathology, and may lead to the distortions in

behavior and social adaptation – Cawley 1983

Is a disorder of internal balance and relationships with

the environment. These disturbances leading to

neurosis arise from internal conflicts and neurotic

tendencies – Lapiński, 1983

Neurotic symptoms occur when the organism is in

danger, and when it may not be able to cope with the

external or internal situation – Kępiński, 2005

Is the term “Valid”

Term “Neurosis”- Obsolete Discontinued by American

Psychiatric Association from 1992 Appears sparingly in ICD-10

Reasons

Real Self Despised Self

Ideal Self

Healthy Person

Self - Realization

Neurotic Person

Vacillation

Nervous tics

a. Thumb sucking, biting skinaround nails,b. Stuttering,c. Eneuresis

Habits

a. Over-sensitivityb. Whining

c. Easily changing moodd. Capriciousness

Excitability

Emotionalinstability

a. Run away from homeb. Skip classes

c. Substance abuse

a. Uneasy dreamsb. Night fears

Difficulty infalling sleep

Symptoms ofChildhoodneurosis

HyperkineticSyndrome

Irritability, Capriciousness of the child,unstable mood, fearfulness. Sleeps poorly poor

appetite, weight loss, Short attention span,Sub-febrility Diarrhea, neurogenic vomiting.

Neuropathy

ParentalPiety

Change ofbehavior

Causes f0r Childhood Neurosis

Ways ofthinking

Peerinfluence

Parental unemployment,financial hardship, poorhousing and deprivation

Adversesocial

circumstances

constant worry aboutthe child, the

presence of excessivefears and

overprotectiveness

Anxiety

raised tone of voice,general emotional

instability.

Instabilityin

attitudes

Inconsistent

approach

contrasting strictlimitations and prohibitions

from one parent andindulgent and permissiveattitude from the other.

Uncoordinated

approach

irritated-impatientattitude, frequent

condemnations, threatsand physical punishments,

lack of necessarytenderness and caressing.

Non-acceptance

Excessivedemands

Poorunderstanding of

others

poor control ofemotion

Neuropsychologicalproblems

difficulty inhandling

Intense reaction

Irritability

Inheritedfactors

Schoolrelated

ChildhoodNeurosis

Parentingpractices

deviatedthinking pattern

Background

Generalized AnxietyDisorder

Separation Anxiety

Social Phobia

OCD PTSD

Specific phobia

Prevalence

UNITED STATES OF AMERICA

UNITED KINGDOM

http://www.nimh.nih.gov/statistics/pdf/NHANES-OverallPrevalence.pdf

Arch Gen Psychiatry 2003;60:837-44

In India Prevalence of Childhood Neurosis

Nagaraja, 1966 - 9.7 % of out-patient ; 9.3% of inpatients

Manchanda et al. 1969 27.3% admitted for physical ailments

Raju et al, 1969. 3.71% were neurotics

Lal and Sethi, 1977 Neurotic disorders in 11.0%

Manchanda and Manchanda, 1978 1.1% among inpatients ; 8.2% in General OP

Indian J Psychiatry. 2010 January; 52(Suppl1): S210–S218.

India, 2005

Disorders with neurotic features – ICD 10

F40 Phobic anxiety disorders F41 Other anxiety disorders F42 Obsessive-compulsive disorder F43 Reaction to severe stressF48 Other neurotic disordersF93 Childhood anxiety disorder

DSM- IV – TR 2000

Mood state characterized by strong negative

emotion and bodily symptoms of tension in

anticipation of future danger or misfortune

Most common in children

10-15% of kids - by teen years

Onset early in life

Under-recognized and under treated

Often quiet, “good” kids

Often lifelong chronic disorders

Anxiety Disorders

Why so common?

Protective role of anxiety

▪ Body’s warning system for danger

▪ Avoid separation from parents

▪ Be vigilant for predators/dangers

Mild anxiety enhances concentration,

performance

Anxiety disorders--too much of a good

thing

Anxiety Disorder

Etiology

Genetic

Panic Diathesis

OCD spectrum

Temperament, behavioral inhibition,

Shyness, High Negative effect

Modeling

Parental anxiety disorder

Traumatic event

Bullying

Chocking

Informational transmissions

Precipitation

Parental Divorce

Death

Transition in school

Shift of near ones

Poor performance

Loss of pet

Differential Diagnosis

Normal Anxiety-mild and manageable

Excessive Anxiety-atypical and persistent

Psychiatric:

Depression (vs. demoralization 2° anxiety)

Adjustment Disorder

Bipolar Disorder

Substance Use

Psychotic disorder

Differential Diagnosis

Physical:

thyroid disease

hyper/hypoglycemia

Anemia

substance induced

▪ Caffeine—energy drinks

▪ sympathomimetics-ventolin, allergy medication

Specific Anxiety Disorders

Separation Anxiety Disorder

Generalized Anxiety Disorder

Panic Disorder +/- Agoraphobia

Social Phobia

Specific Phobia

Post Traumatic Stress Disorder

Obsessive Compulsive Disorder

Separation Anxiety Disorder

Fears of separation from parent, school

refusal, difficulty sleeping alone, nightmares

Can’t be alone

Social, but friends must come to their house

Typical age of onset: school entry

SAD - Etiology

Unknown Genetic

Early temperamental

Family / Environm

ent

Treatment Principles

Consider age, severity, comorbidity,

impairment

Environmental management

Education about anxiety

Cognitive Behavioral Therapy

Medications

Mostly SSRI’s

Benzodiazepines in select situations

Environmental Management

Home: consistent routines and structure

Ensure adequate sleep

Healthy diet-small frequent meals often better

Exercise

Schedule time for homework and activities-avoid

overload

School involvement: accommodations, study block

for teens,

Address parental anxiety disorders

Generalized Anxiety Disorder

Excessive, uncontrollable worry for at least 6

months plus ≥ 1 other symptom:

sleep, fatigue, restlessness, irritability, muscle tension,

difficulty concentrating

Overlaps with anxious temperament:

perfectionistic “worry warts”

worry about school work, health issues, friends….

Commonly starts in intermediate years of

elementary

Medications

When to consider?

Severity: ++functional impairment

Acuity/Urgency

▪ ↓↓sleep, ↓↓eating

Failure to improve despite CBT

Patient preference

Medications

What to use? SSRI’s: mainstay of treatment▪ Fluoxetine , fluvoxamine ▪ Sertraline , Citalopram

Benzodiazepines:▪ Ativan, clonazepam

Other▪ Buspirone-very little evidence it is helpful▪ Low dose atypical neuroleptics-augmentation

of SSRI’s with OCD

Panic Disorder

Fear: present-oriented emotional reaction to current danger, characterized by strong escape tendencies and surge in sympathetic nervous system

Panic: Group of physical symptoms of fight/flight response that unexpectedly occur in the absence of obvious danger or threat

Panic Disorder

Panic attack: sudden,

overwhelming period of intense

fear or discomfort

accompanied by characteristics of

the fight/flight response

Agoraphobia : Anxiety about having a panic

attack in situations where

escape might prove difficult or

embarrassing

Panic disorder: recurrent

unexpected panic attacks followed by at

least one month of persistent

concern about having another attack, constant worry about the

consequences, or a significant change in

behavior related to the attacks.

Panic Disorder

• ↑Noripinephrine activity in Locus Coeruleus

• Altered Serotonin levels

Biological

• Interoceptive Conditioning ModelBehavioral Model

• Hypersensitivity to bodily sensations• Dire Thought with Catastrophizing• Thought fuels increase in bodily

response• Vicious out-of-control cycle

Cognitive Model

Panic Attack

Happens less often with younger children

Feel very scared

Heart pounding, hard to breathe, Feel shaky,

dizzy, or sick or going crazy or bad intuition

Sometimes they avoid school or want to

stay in the house

Avoids going to school – A part of

Agrophobia

F40 - Phobic anxiety disordersF40 Phobic anxiety disorders F40.0 Agoraphobia F40.1 Social phobias F40.2 Specific (isolated) phobias F40.8 Other phobic anxiety disorders F40.9 Phobic anxiety disorder,

unspecified

Diagnostic features of Phobias

1. Intense, persistent, irrational fear a particular

object, event or situation.

2. Response is disproportionate and leads to

avoidance of phobic object, event or situation.

3. Fear is serve enough to interfere with

everyday life. Condition may or may not be accompanied by PANIC ATTACKS

Types of Phobias

SPECIFIC PHOBIAS, of animals, events (flying), bodily (blood), situations (enclosed places).

SOCIAL PHOBIAS, of social situations, public speaking, parties, meeting new people.

AGORAPHOBIA, of public crowded places (not open spaces), of leaving safety of home

Specific Phobias

Five Subtypes Animal Natural

Environment Blood-injection Situational

(flying) Atypical

(choking)

Explanation

Biological

Evolution Theory

Genetics Theory

Vulnerability theory

Social Anxiety/Social Phobia

Happens more in teens than in young children

Fear and worry about social situations

Going to school

Speaking in class

Social events including recess and lunch

Shy, self-conscious

Easily embarrassed

These kids tend to be sensitive to criticism and

find it hard to be assertive

Treatment

CBT

SSRIs

Definition

Obsessions – persistent, recurring, unwanted cognitions, usually unrealistic or irrational. eg – contamination by germs

Compulsions – repetitive, ritualistic behaviours that reduce the anxiety associated with the obsessive thoughts. eg: repetitive hand washing / cleaning

Obsessive-Compulsive Disorder

Obsessions &/or Compulsions x 1hr/day

Rituals can get very elaborate and family’s

can get involved

Mild OC symptoms are very common

peak in early adolescents-19%

most resolve spontaneously

OCD ExplanationExplanation Behavioral

Two process theory of MowrerClassical Conditioning

Operant Conditioning

Cognitive BiasHyper-vigilance

Catastrophic Misinterpretation

Memory Problems

Psychodynamic Fixation – Anal stageUnconscious Conflict

Reaction formation

Obsessive-Compulsive Disorder In early childhood or adolescence.

Have frequent uncontrollable thoughts (obsessions)

They don’t like these thoughts, or do not care

Perform certain behaviors or rituals to try and prevent something bad from happening (or to get rid of thoughts)

Examples are: handwashing a lot if there is a fear of germs; checking that doors are locked; special touching rituals

Neurobiology of OCD

PET scans demonstrate hypermetabolism of

orbital frontal cortex and caudate nucleus;

normalizes with response to treatment

Structural and functional MRI scans

demonstrate abnormalities of cortical/basal

ganglia function (subtle abnormalities only)

Neuropsychological deficits, particularly in

executive functioningFrom: Rapoport & Wise

Pediatric

Autoimmune

Neuropsychiatric

Disorders

Associated with

Streptococcal infections

Treatment

CBT

Clompranine

SRI

SSRI

Post Traumatic Stress Disorder

Symptoms start after a physical or emotional trauma or very frightening event

Can be marked by several of Behavioral changes Repetitive play Zoning out, numbing of feelings Jumpiness and watchfulness of surroundings Nightmares and sleep problems “Flashbacks”

Not very common in young children

Acute Stress Reaction

A transient disorder of significant severity

In an individual without any previous mental

disorder

In response to exceptional physical and/or

psychological stress.

Acute Stress Reaction

SYMPTOMS

Initial state of „daze” Constriction of the field

of consciousness Narrowing of attention, Inability to comprehend

stimuli Disorientation Withdrawal from the

surrounding situation Agitation and

overactivity.

AUTONOMIC SIGNS

Tachycardia sweating or flushing Appear within minutes

of the impact Disappear within

several hours, maximally 2—3 d

Post-traumatic Stress Disorder (PTSD)

A delayed and/or protracted response to a stressful event

of an exceptionally threatening or catastrophic nature.

The three major elements of PTSD include

1)Re-experiencing the trauma through dreams or recurrent

and intrusive thoughts (“flashbacks”)

2)showing emotional numbing such as feeling detached

from others

3)Having symptoms of autonomic hyperarousal such as

irritability and exaggerated startle response, insomnia

PTSD

Fear/avoidance of cues - original trauma.

Excessive use of alcohol and drugs may

be a complicating factor.

The lifetime prevalence is estimated at

about 0.5% in men and 1.2% in women.

TREATMENT

Psychotherapeutic CBT

Psychodynamic therapy Attachment based therapy

Psychopharmacology

Selective Mutism

May not talk to anyone who is not close to them

They may look down, withdraw, turn red if

required to talk

Often they whisper if they do speak in a

situation

Up to 2% of school age children

Some kids outgrow it

Pharmocotherapy

Commonly Used Anxiolytics

Drug Commonly used dosage (mg)

Elimination halftime (hours)

Alprazolam 0,5-6 12-15

Bromazepam 3-15 12

Diazepam 5-30 24-72

Chfordiazepoxied 10-50 24-100

Clobazam 20-30 20

Clonazepam 1-8 34

Clorazepate 15-60 60

Lorazepam 1-4 11-13

Medazepam 10-30 29

Oxazepam 30-90 4-20

Tofizopam 50-300 6

Buspirone 20-30 2-11

Hydroxyzine 300-400 12-20

Evidence for therapies – AHCPRAgency of Health Care Policy and Research

Evidence of various therapies

OCD PTSD PDAG SAD GADSocial Phobia

CBT B B B A A A

CBT/FAM C B D A A B

Family D D D D D D

Dynamic D D D D D D

TCA A D D B D D

SSRI A D C A A A

BZD D D C C C D

2-Agonist I D I I I I5HT1A agonist I ? I ? D ?Hetereocyclic I ? ? ? ? ?

I – likely ineffective

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