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

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. Presented by
Dr. Anusa AM
2ndYear MD PG
Madurai Medical College
Prepared by
Prof. Rooban T,
Oral & Maxillofacial Pathologist

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.  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.  Collection of psychiatric disorders without
psychotic symptoms and lacking the intense
psychopathology
 Neurosis is an umbrella term for
nonpsychotic personality disorders

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.  Term “Neurosis”- Obsolete
 Discontinued by American Psychiatric
Association from 1992
 Appears sparingly in ICD-10

8. Real
Self
Despised
Self
Ideal Self
Healthy Person
Self - Realization
Neurotic Person
Vacillation

11. Generalized
Anxiety
Disorder
Separation
Anxiety
Social
Phobia
OCD
PTSD
Specific
phobia

12. UNITED STATESOF AMERICA UNITED KINGDOM
http://www.nimh.nih.gov/statistics/pdf/NHANES-OverallPrevalence.pdf
Arch Gen Psychiatry 2003;60:837-44

13.  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.

15. 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

17.  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

18.  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

19. 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

20.  NormalAnxiety-mild and manageable
 ExcessiveAnxiety-atypical and persistent
 Psychiatric:
 Depression (vs. demoralization 2° anxiety)
 Adjustment Disorder
 Bipolar Disorder
 Substance Use
 Psychotic disorder

21.  Physical:
 thyroid disease
 hyper/hypoglycemia
 Anemia
 substance induced
▪ Caffeine—energy drinks
▪ sympathomimetics-ventolin, allergy medication

22.  Separation Anxiety Disorder
 Generalized Anxiety Disorder
 Panic Disorder +/- Agoraphobia
 Social Phobia
 Specific Phobia
 PostTraumatic Stress Disorder
 Obsessive Compulsive Disorder

23.  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

24. Unknown Genetic
Early
temperamental
Family /
Environment

26.  Consider age, severity, comorbidity, impairment
 Environmental management
 Education about anxiety
 Cognitive BehavioralTherapy
 Medications
 Mostly SSRI’s
 Benzodiazepines in select situations

27.  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

28.  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

30. When to consider?
 Severity: ++functional impairment
 Acuity/Urgency
▪ ↓↓sleep, ↓↓eating
 Failure to improve despite CBT
 Patient preference

31. 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

32.  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

33. 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.

34. • ↑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

35.  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

36. 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

37. 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

38.  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

39.  Five Subtypes
 Animal
 Natural
Environment
 Blood-injection
 Situational (flying)
 Atypical (choking)

40. 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

41.  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

42.  CBT
 SSRIs

44.  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

45.  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

46. 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

47.  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

48.  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

49. Pediatric
Autoimmune
Neuropsychiatric
Disorders
Associated with
Streptococcal infections

50.  CBT
 Clompranine
 SRI
 SSRI

51.  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

52.  A transient disorder of significant severity
 In an individual without any previous mental
disorder
 In response to exceptional physical and/or
psychological stress.

53. 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

54.  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

55.  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.

56.  Psychotherapeutic
 CBT
 Psychodynamic therapy
 Attachment based therapy
 Psychopharmacology

57.  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

60. 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

62. 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

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65. THANK YOU