Continuity Clinic Anxiety. Continuity Clinic Objectives Know the different forms of anxiety in children Be familiar with how anxiety may present in children.

Continuity Clinic

Anxiety

Continuity Clinic

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:– 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:– Extraordinary stressors– Life transitions– Loss– Trauma leading to PTSD

• Perpetuating Factors:– Avoidance– School Failure– Sleep Disturbance– Anxious Cognitive Style– Emotion Focused coping– Emotion Responsivity– Family Style– Secondary gain

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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:– shortness of breath - diarrhea– rapid heart beat - frequent urination– Sweating - cold & clammy hands– Nausea - dry mouth– Diarrhea - trouble swallowing– "lump in the throat." - stomaches– headaches

• Problems with muscle tension also can occur including:– trembling - twitching– a shaky feeling - muscle soreness

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Panic DisorderPanic 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

• 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

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GADGeneralized 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

• Muscle tension • Sleep disturbance • Although not a

diagnostic feature, suicidal ideation and completed suicide have been associated with generalized anxiety disorder.

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OCDOCD 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

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

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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

• 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.

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PTSDPTSD 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.)

• 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

• 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 trauma-related events

– Decreased participation in significant activities

– Feeling detached or estranged from others

– Restricted affect – Foreshortened sense of the

future

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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

• 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

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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 family1) Teach anxiety cycle2) 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 supportFor 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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TreatmentLittle Pediatric Research!

OCD and POTS study:

Remission Rate

CBT/SSRI 53.6%

CBT 39.3%

SSRI 21.4%

Placebo 3.6%

Anxiety & CAMS study:

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