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Childhood anxiety

Anxiety, Childhood, Psychiatry, Seminar, Powerpoint, Neurology, Pediatrics

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Childhood anxiety

  1. 1. Epidemiology Childhood Anxiety Disorders [With Emphasis on Anxiety Disorders- Issues, Diagnosis, Management] Selective Mutism Post-traumatic Disorder Obsessive Compulsive Disorders Phobias - Specific /Generalized Generalized anxiety & Panic disorder Classification Slides before 1st Section Divider Summary References
  2. 2. Presented by Dr. Anusa AM 2ndYear MD PG Madurai Medical College Prepared by Prof. Rooban T, Oral & Maxillofacial Pathologist
  3. 3.  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
  4. 4.  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.
  5. 5.  Collection of psychiatric disorders without psychotic symptoms and lacking the intense psychopathology  Neurosis is an umbrella term for nonpsychotic personality disorders
  6. 6.  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
  7. 7.  Term “Neurosis”- Obsolete  Discontinued by American Psychiatric Association from 1992  Appears sparingly in ICD-10
  8. 8. Real Self Despised Self Ideal Self Healthy Person Self - Realization Neurotic Person Vacillation
  9. 9. Generalized Anxiety Disorder Separation Anxiety Social Phobia OCD PTSD Specific phobia
  10. 10. UNITED STATESOF AMERICA UNITED KINGDOM http://www.nimh.nih.gov/statistics/pdf/NHANES-OverallPrevalence.pdf Arch Gen Psychiatry 2003;60:837-44
  11. 11.  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.
  12. 12. F40 Phobic anxiety disorders F41 Other anxiety disorders F42 Obsessive-compulsive disorder F43 Reaction to severe stress F48 Other neurotic disorders F93 Childhood anxiety disorder
  13. 13.  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
  14. 14.  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
  15. 15. 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
  16. 16.  NormalAnxiety-mild and manageable  ExcessiveAnxiety-atypical and persistent  Psychiatric:  Depression (vs. demoralization 2° anxiety)  Adjustment Disorder  Bipolar Disorder  Substance Use  Psychotic disorder
  17. 17.  Physical:  thyroid disease  hyper/hypoglycemia  Anemia  substance induced ▪ Caffeine—energy drinks ▪ sympathomimetics-ventolin, allergy medication
  18. 18.  Separation Anxiety Disorder  Generalized Anxiety Disorder  Panic Disorder +/- Agoraphobia  Social Phobia  Specific Phobia  PostTraumatic Stress Disorder  Obsessive Compulsive Disorder
  19. 19.  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
  20. 20. Unknown Genetic Early temperamental Family / Environment
  21. 21.  Consider age, severity, comorbidity, impairment  Environmental management  Education about anxiety  Cognitive BehavioralTherapy  Medications  Mostly SSRI’s  Benzodiazepines in select situations
  22. 22.  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
  23. 23.  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
  24. 24. When to consider?  Severity: ++functional impairment  Acuity/Urgency ▪ ↓↓sleep, ↓↓eating  Failure to improve despite CBT  Patient preference
  25. 25. 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
  26. 26.  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
  27. 27. Panic attack: sudden, overwhelming period of intense fear or discomfort accompanied by characteristics of the fight/flight response 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.
  28. 28. • ↑Noripinephrine activity in Locus Coeruleus • Altered Serotonin levels Biological • InteroceptiveConditioning Model Behavioral Model • Hypersensitivity to bodily sensations • DireThought with Catastrophizing • Thought fuels increase in bodily response • Vicious out-of-control cycle Cognitive Model
  29. 29.  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
  30. 30. F40 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
  31. 31. 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
  32. 32.  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
  33. 33.  Five Subtypes  Animal  Natural Environment  Blood-injection  Situational (flying)  Atypical (choking)
  34. 34. Biological Evolution Theory Genetics Theory Vulnerability theory Behavioral theory Classical Conditioning Two process theory Social learning theory Psychodynamic Ego defense mechanism Repressed ID Anxiety misplaced Phobia
  35. 35.  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
  36. 36.  CBT  SSRIs
  37. 37.  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
  38. 38.  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
  39. 39. Explanation Behavioral Two process theory of Mowrer Classical Conditioning Operant Conditioning Cognitive Bias Hyper- vigilance Catastrophic Misinterpretation Memory Problems Psychodynami c Fixation – Anal stage Unconscious Conflict Reaction formation
  40. 40.  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
  41. 41.  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 functioning From: Rapoport & Wise
  42. 42. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections
  43. 43.  CBT  Clompranine  SRI  SSRI
  44. 44.  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
  45. 45.  A transient disorder of significant severity  In an individual without any previous mental disorder  In response to exceptional physical and/or psychological stress.
  46. 46. 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
  47. 47.  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
  48. 48.  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.
  49. 49.  Psychotherapeutic  CBT  Psychodynamic therapy  Attachment based therapy  Psychopharmacology
  50. 50.  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
  51. 51. 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
  52. 52. OCD PTSD PDAG SAD GAD Social 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 I 5HT1A agonist I ? I ? D ? Hetereocyclic I ? ? ? ? ? I – likely ineffective
  53. 53.  March RS. Diagnosis and treatment of the childhood-onset anxiety disorders. Anxiety Disorders Association of America, 2008.  Piacentini J, Roblek T. Recognizing and childhood anxiety disorders. West J Med 2002;176:149-51.  Keeton CP, KolosAC, Walkup JT. Pediatric generalized anxiety disorder: epidemiology, diagnosis and management. Paedr Drugs 2009; 11:171-83.  Cox GR, Fisher CA, De Silva S, Phelan M, Akinwale OP, Simmons MB, Hetrick SE. Interventions for preventing relapse and recurrence of a depressive disorder in children and adolescents. Cochrane Database of Systematic Reviews 2012;11: CD007504. DOI: 10.1002/14651858.CD007504  James AACJ, Soler A, Weatherall RRW. Cognitive behavioural therapy for anxiety disorders in children and adolescents.Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD004690. DOI: 10.1002/14651858.CD004690.pub2  Ipser JC, Stein DJ, Hawkridge S, Hoppe L. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD005170. DOI: 10.1002/14651858.CD005170.pub2.  Scott S. Classification of psychiatric disorders in childhood and adolescence: building castles in the sand? Advances in Psychiatric treatment 2002;8:205– 213.  Greenberg MT, Domitrovich C, Bumbarger B. The Prevention of Mental Disorders in School-Aged Children: Current State of the Field. Prevention and Treatment 2001;4: Article 1  Kessler RC, Amminger GP, Aguilar-Gaxiola S, Alonso J, Lee S, Ustun TB. Age of onset of mental disorders: A review of recent literature. Curr Opin Psychiatry. 2007 July ; 20(4): 359–364.  Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psyhciatric disorders in childhood and adolescence. Arch Gen Psychiatry 2003;60:837-44.  Krauss H, Buraczyńska-Andrzejewska B, Piątek J, Sosnowski P, Mikrut K, Głowacki M, Misterska E, Żukiewicz-Sobczak W, Zwoliński J. Occurrence of neurotic and anxiety disorders in rural schoolchildren and the role of physical exercise as a method to support their treatment. Ann Agric nviron Med. 2012; 19(3): 351-356.  Rachford BK. NEUROTIC DISORDERS Of CHILDHOOD INCLUDING A STUDY Of AUTO And INTESTINAL INTOXICATIONS, CHRONIC ANAEMIA, FEVER, ECLAMPSIA, EPILEPSY,MIGRAINE, CHOREA, HYSTERIA,ASTHMA,ETC. New York, EB treat and company, 1905  DSM-IV – TR, 2000  Sadock. Comprehensive textbook of Psychiatry.  Oxford Textbook of Psychiatry.  Infographics and Photographs: Google images  Infographics and Photographs: Google images  Anxiety disorders in childhood. Moories TL, Mark SJ. , 2nd edition  Rutters. Child and adolescent psychiatry, 5th Edition  Clinical child psychiatry. William A Klykylo, Jerald Kay
  54. 54. THANK YOU

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