Download Anxiety

Anxiety
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Objectives
• Know the different forms of anxiety in
children
• Be familiar with how anxiety may present
in children
• Know the various treatment modalities in
children
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Definitions
• Anxiety - disproportionate response to normal situations
• Types:
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Generalized anxiety
Separation anxiety
Panic disorder
Posttraumatic stress disorder (PTSD)
Social phobia
Obsessive-compulsive disorder (OCD)
Specific phobias
Selective Mutism
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Background
• Large genetic component 40-50%
– Genetic aggregation particularly OCD, Panic D/O and
GAD
• Prevalence:
– 13/100 of children 9-17 years old
– M=F in childhood F>M in adolescence
• Characteristics of anxiety in children:
– At risk for depressive symptoms
– Predictive of substance abuse
– Predictive of anxiety as adults
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Background
• Predisposing Factors:
– Specific areas of brain
pathology in some
– Genetic background
– Temperamental disposition
• Precipitating Factors:
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Extraordinary stressors
Life transitions
Loss
Trauma leading to PTSD
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• Perpetuating Factors:
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Avoidance
School Failure
Sleep Disturbance
Anxious Cognitive Style
Emotion Focused coping
Emotion Responsivity
Family Style
Secondary gain
Importance of Temperament
The following temperaments do not mean a
child will develop anxiety, but mean they
are at higher risk:
• Behavioral Inhibitism to the unfamiliar
• Shyness
• Negative Affectivity – sensitive to negative
stimuli
• Harm Avoidism
• Anxiety Sensitivity
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Clinical
• Children with anxiety may experience somatic symptoms
such as:
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shortness of breath
rapid heart beat
Sweating
Nausea
Diarrhea
"lump in the throat."
headaches
- diarrhea
- frequent urination
- cold & clammy hands
- dry mouth
- trouble swallowing
- stomaches
• Problems with muscle tension also can occur including:
– trembling
– a shaky feeling
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- twitching
- muscle soreness
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Panic Disorder
Panic disorder is characterized by recurrent panic attacks (ie, periods of
intense fear of abrupt onset peaking in intensity within 10 min). Four of the
following must be present for a panic attack:
• Palpitations, pounding
heart, or accelerated
heart rate
• Sweating
• Trembling or shaking
• Shortness of breath or
dyspnea
• Sensation of choking
• Chest pain or
discomfort
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• Feeling dizzy, unsteady,
lightheaded, or faint
• Derealization or
depersonalization
• Fear of losing control or
going crazy
• Fear of dying
• Paresthesias
• Chills or hot flashes
• Nausea or abdominal
distress
GAD
Generalized anxiety disorder is characterized by excessive anxiety and worry.
Worrying is difficult to control. Anxiety and worry are associated with at least 3 of
the following symptoms:
• Restlessness or
feeling keyed-up or
on edge
• Being easily
fatigued
• Difficulty
concentrating or
mind going blank
• Irritability
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• Muscle tension
• Sleep disturbance
• Although not a
diagnostic feature,
suicidal ideation
and completed
suicide have been
associated with
generalized anxiety
disorder.
OCD
OCD is characterized by obsessions or compulsions. Obsessions or compulsions
must be recognized as unreasonable or excessive and must cause marked
distress. Obsessions include all of the following:
Obsessions include all
of the following:
– Recurrent and persistent
thoughts, impulses, or
images that are intrusive
and knowingly inappropriate
and cause anxiety or
distress
– Thoughts, impulses, or
images that are not simply
excessive worries about
real-life problems
– Attempts are made to ignore
or suppress thoughts.
– Thoughts, impulses, or
images are recognized as
being the product of the
mind and not
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Compulsions include
the following:
– Repetitive behaviors, such
as handwashing, ordering,
and checking, that people
feel are driven and must be
carried out and occur to
such an extreme that a
person's ability to function
is impaired.
– Behaviors or mental acts
are done to reduce distress
or anxiety
Social Phobia
• Marked and persistent
fear of social or
performance situations
to the extent that a
person's ability to
function at work or in
school is impaired.
• Exposure to social or
performance situation
always produces
anxiety.
• Fear/anxiety recognized
as excessive
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• Social or performance
situations are avoided
or endured with intense
anxiety.
• Avoidance behavior,
anticipation, or distress
in the feared social or
performance setting
produces significant
impairment in
functioning.
PTSD
PTSD is a severe trauma that is experienced that includes (1) actual or threatened death or serious injury or
threat to personal integrity of self or others and (2) responses that include intense fear, helplessness, or
horror. (Life-threatening experiences and the attendant loss of control are key elements.)
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Persistent reexperience of the
event occurs by at least 1 of the
following:
– Recurrent and intrusive
recollections
– Recurrent distressing
dreams/nightmares
– Feelings of reliving traumatic
event, ie, flashbacks
– Intense psychologic distress
with internal or external cues to
the trauma
– Physiological reactivity on
exposure to trauma cues
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•
Persistent avoidance of stimuli
of trauma and numbing/
avoidance behavior
demonstrated by at least 3 of
the following:
– Avoidance of thoughts or
conversation related to the
trauma
– Avoidance of activities, places,
or people related to the trauma
– Amnesia for important traumarelated events
– Decreased participation in
significant activities
– Feeling detached or estranged
from others
– Restricted affect
– Foreshortened sense of the
future
PTSD
• Persistent symptoms of increased
arousal demonstrated by 2 or more of
the following:
– Difficulty staying or falling asleep
– Irritability or anger outbursts
– Difficulty concentrating
– Hypervigilance
– Exaggerated startle response
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Separation Anxiety
• Unrealistic worries about
the safety of loved ones
• Reluctance to fall asleep
without being near the
primary attachment figure
• Homesickness (ie, desire
to return home or make
contact with the caregiver
when the child is
separated).
• Nightmares with
separation-related
themes
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• Excessive distress (eg,
tantrums) when
separation is imminent
• Somatic symptoms
(especially frequent in
older children and
adolescents)
– May cause the child and
family to seek medical
treatment because of
impaired ability to attend
school or meet social
responsibilities
Presentation of Anxiety in
Young Child
• Somatic Complaints (leading to
unncessary medical work up)
• Sleep Disturbance
– Increased daytime napping
– Difficulty falling asleep
– Frequent nighttime awakenings
• Behavioral outbursts & tantrums often
seen as oppositional
– Research the context of the outbursts!
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Diagnosis
• To be an anxiety disorder, the symptoms
must be:
1) Distressing
2) Pervasive
- Seen in 2 or more activities
- Seen by 2 or more people
3) Uncontrollable
4) Cause impairment
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Diagnosis
• General Screening Tools
– Pediatric Symptom Checklist
– Child Behavior Checklist
• Completed by parent, teacher, and older child
• Evaluation
– Preschool anxiety scale
– Structured diagnostic interviewing
– CHADIS (web based)
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Treatment
• Mild Anxiety with minimal impairment 
Educational intervention with family
1) Teach anxiety cycle
2) Educate that avoidance makes fears bigger, fighting
fear makes it smaller
- teach patient to externalize the fear, “it is outside of
you”
3) Plan for gradual exposure to anxiety provoking
situation with extra support
For example: Phobia related to school. Drive by school on Sunday when
no one is there. On Tuesday attend favorite class, on Thursday attend
½ day.
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Treatment
• Moderate to Severe Anxiety
– The perpetual cycle:
• Exposure to trigger (phobic stimulus, separation)
• Increased anxiety
• Escape Behavior  then repeat!
– Will likely require combination of Cognitive
Behavioral Therapy AND medication
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Treatment
Little Pediatric Research!
OCD and POTS study:
Anxiety & CAMS study:
Remission Rate
CBT/SSRI
53.6%
CBT
39.3%
SSRI
21.4%
Placebo
3.6%
Responders
CBT/SSRI
81%
CBT
60%
SSRI
55%
Placebo
5%
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Cognitive Behavioral Therapy
• Psychoeducation – teach patient about illness
• Somatic Management – patient learns to self monitor
anxiety
– Use muscle relaxation, diaphragmatic breathing, and imagery to
decrease physical symptoms
• Cognitive Restructuring
– Challenge negative thoughts and expectations
– Learn positive talk
• Exposure Methods – imaginal and live exposures to
stressor with gradual desensitization
• Relapse Prevention and Booster Sessions
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Medications – Off Label
• 1st Line – SSRI
– May use Benzodiazepines for short term until
titration of SSRI has occurred
• 2nd Line
– Tricyclic Antidepressants
– Monoaminoxidase Inhibitors
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