Anxiety Disorders in Anxiety Disorders in Children and AdolescentsChildren and Adolescents

Jess P. Shatkin, MD, MPHJess P. Shatkin, MD, MPH

Vice Chair for EducationVice Chair for Education

NYU Child Study CenterNYU Child Study Center

New York University School of MedicineNew York University School of Medicine

Learning ObjectivesLearning Objectives

Residents will be able to:Residents will be able to:

1)1) Identify the primary anxiety disorders in Identify the primary anxiety disorders in childrenchildren

2)2) Distinguish between developmentally Distinguish between developmentally ““normalnormal”” anxiety and pathological anxiety anxiety and pathological anxiety

3)3) Describe the clinical presentation, Describe the clinical presentation, epidemiology, etiology, diagnosis and epidemiology, etiology, diagnosis and treatment of the major childhood anxiety treatment of the major childhood anxiety disordersdisorders

What is Normal?What is Normal?10 – 20% of children and adolescents suffer a diagnosable anxiety 10 – 20% of children and adolescents suffer a diagnosable anxiety disorderdisorderMany more children suffer with symptoms that do not meet diagnostic Many more children suffer with symptoms that do not meet diagnostic criteria (Walkup et al, 2008)criteria (Walkup et al, 2008)~~40% of grade school children have fears of separation from a parent40% of grade school children have fears of separation from a parent~~40% of children aged 6 – 12 years have 7 or more fears that they find 40% of children aged 6 – 12 years have 7 or more fears that they find troublingtroubling~~30% of children worry about their competence and require considerable 30% of children worry about their competence and require considerable reassurancereassurance~~20% of grade school children are fearful of heights, are shy in new 20% of grade school children are fearful of heights, are shy in new situations, or are anxious about public speaking and social acceptance situations, or are anxious about public speaking and social acceptance (Bell-Dolan et al, 1990)(Bell-Dolan et al, 1990)Girls report more stress than boys – may be an artifact of social Girls report more stress than boys – may be an artifact of social expectationsexpectationsMost of these worries and stresses are outgrown or recede as children Most of these worries and stresses are outgrown or recede as children mature and developmature and develop

Anxiety can be your friend

Distinguishing Normal Distinguishing Normal from Pathologicalfrom Pathological

1.1. Object: Object: Is this something a child of this age should be Is this something a child of this age should be worrying about?worrying about?

2.2. Intensity: Intensity: Is the Is the degreedegree of distress unrealistic given the of distress unrealistic given the childchild’’s developmental stage and the object/event?s developmental stage and the object/event?

3.3. Impairment: Impairment: Does the distressDoes the distress interfereinterfere with the child with the child’’s s daily life? daily life? -- Social functioning: unable to make friendsSocial functioning: unable to make friends-- Academic functioning: failing classesAcademic functioning: failing classes-- Family functioning: creating conflicts, limiting family Family functioning: creating conflicts, limiting family

choiceschoices4.4. Ability to Recover/Coping Skills: Ability to Recover/Coping Skills: Is the child able to Is the child able to

recoverrecover from distress when the event is not present? from distress when the event is not present?-- Tend to worry about future occurrences of event/objectTend to worry about future occurrences of event/object-- Distress occurs across multiple settingsDistress occurs across multiple settings

Normal Fear and WorryNormal Fear and Worry

Common in normal childrenCommon in normal children

The clinician must distinguish The clinician must distinguish developmentally normal from abnormaldevelopmentally normal from abnormal

InfantsInfants– Fear of loud noisesFear of loud noises– Fear of being startledFear of being startled– Fear of strangers (around 8 – 10 months)Fear of strangers (around 8 – 10 months)

Normal Fear and Worry (2)Normal Fear and Worry (2)ToddlersToddlers– Fears of imaginary creaturesFears of imaginary creatures– Fears of darknessFears of darkness– Normative separation anxietyNormative separation anxiety

School-age ChildrenSchool-age Children– Worries about injury and natural events (e.g., storms, Worries about injury and natural events (e.g., storms,

lightening, earthquakes, volcanoes)lightening, earthquakes, volcanoes)– Children who are characterized as confident and eager to Children who are characterized as confident and eager to

explore novel situations at 5 years are less likely to explore novel situations at 5 years are less likely to manifest anxiety in childhood and adolescencemanifest anxiety in childhood and adolescence

– Children who are passive, shy, fearful, and avoid new Children who are passive, shy, fearful, and avoid new situations at 3 and 5 years are more likely to exhibit situations at 3 and 5 years are more likely to exhibit anxiety later in life (Caspi et al, 1995)anxiety later in life (Caspi et al, 1995)

Normal Fear and Worry (3)Normal Fear and Worry (3)

School Age Children (continued)School Age Children (continued)– In general, girls tend to endorse more anxiety In general, girls tend to endorse more anxiety

symptoms than boyssymptoms than boys– Younger children are more likely to experience Younger children are more likely to experience

anxiety symptoms than older childrenanxiety symptoms than older children– Anxious children interpret ambiguous situations in Anxious children interpret ambiguous situations in

a negative way and may underestimate their a negative way and may underestimate their competencies (competencies (attribution biasattribution bias))

– The most common anxiety disorders in middle The most common anxiety disorders in middle childhood are Separation Anxiety, GAD, and childhood are Separation Anxiety, GAD, and Specific PhobiasSpecific Phobias

Normal Fear and Worry (4)Normal Fear and Worry (4)

AdolescentsAdolescents– Fears related to schoolFears related to school– Fears related to social competenceFears related to social competence– Fears related to health issuesFears related to health issues

Clinical PresentationClinical Presentation

Children with anxiety disorders may present with Children with anxiety disorders may present with fear or worry but may not recognize their fears fear or worry but may not recognize their fears as unreasonableas unreasonable

Younger kids often cannot articulate their Younger kids often cannot articulate their feelings, and so we often see physical feelings, and so we often see physical symptoms presenting first, which include:symptoms presenting first, which include:– Headaches, upset stomach or nausea, increased Headaches, upset stomach or nausea, increased

heart rate, diarrhea or constipation, sleep disturbance, heart rate, diarrhea or constipation, sleep disturbance, increased vulnerability to common viruses, tightness increased vulnerability to common viruses, tightness in chest, tight neck or back, appetite change, fatigue in chest, tight neck or back, appetite change, fatigue & exhaustion& exhaustion

What To Look ForWhat To Look ForPhysical complaints (H/A, GI, dramatic)Physical complaints (H/A, GI, dramatic)

Sleep (early/middle insomnia, repeated visits to parentSleep (early/middle insomnia, repeated visits to parent’’s s room)room)

Change in eatingChange in eating

Avoidance of outside and interpersonal activities Avoidance of outside and interpersonal activities (school, parties, camp, slumber parties, safe strangers)(school, parties, camp, slumber parties, safe strangers)

Excessive need for reassurance (new situations, Excessive need for reassurance (new situations, bedtime, school, storms, bedtime, school, storms, ““is it bad?is it bad?””))

Inattention and poor school performanceInattention and poor school performance

Not necessarily pervasive (some areas of function Not necessarily pervasive (some areas of function remain intact)remain intact)

Explosive outburstsExplosive outbursts

Physical Symptoms (Provoked and Physical Symptoms (Provoked and Non-Provoked)Non-Provoked)

Anxious children listen to their bodies (too much!)Anxious children listen to their bodies (too much!)

Headache & stomachacheHeadache & stomachache

Sick in the morningSick in the morning

Frequent urge to urinate or defecateFrequent urge to urinate or defecate

Shortness of breathShortness of breath

Chest pain, tachycardiaChest pain, tachycardia

Sensitive gag reflex/fear of choking or vomitingSensitive gag reflex/fear of choking or vomiting

Difficulty swallowing solid foodsDifficulty swallowing solid foods

DizzinessDizziness

Tension/exhaustionTension/exhaustion

Derealization/depersonalizationDerealization/depersonalization

Avoidance to present physical symptomsAvoidance to present physical symptoms

Clinical Presentation: Clinical Presentation: Separation Anxiety DisorderSeparation Anxiety Disorder

Excessive fear when separated from home or attachment Excessive fear when separated from home or attachment figuresfiguresCan be seen before separation or during attempts at Can be seen before separation or during attempts at separationseparationExcessive worry about their own or their parentsExcessive worry about their own or their parents’’ safety and safety and health when separatedhealth when separatedSymptoms include difficulty sleeping alone, nightmares with Symptoms include difficulty sleeping alone, nightmares with themes of separation, somatic complaints, school refusalthemes of separation, somatic complaints, school refusalCommonly, the earliest age of onset among anxiety Commonly, the earliest age of onset among anxiety disordersdisordersGender ratios are generally equalGender ratios are generally equalThese children often come from singe-parent and low SES These children often come from singe-parent and low SES homeshomesA nonspecific precursor to a number of adult psychiatric A nonspecific precursor to a number of adult psychiatric conditions, including depression as well as any anxiety d/oconditions, including depression as well as any anxiety d/o

Clinical Presentation: Clinical Presentation: PhobiasPhobias

Fear of a particular object or situation which Fear of a particular object or situation which is avoided or endured with great distressis avoided or endured with great distressMore than one phobia is common (does not More than one phobia is common (does not in and of itself constitute a diagnosis of GAD)in and of itself constitute a diagnosis of GAD)Adolescents and adults typically recognize Adolescents and adults typically recognize that the fear is unreasonable; children often that the fear is unreasonable; children often do notdo notAvoidance is keyAvoidance is keyGenerally begins in childhoodGenerally begins in childhood

Clinical Presentation: Clinical Presentation: Generalized Anxiety DisorderGeneralized Anxiety Disorder

Characterized by chronic, excessive worry in a Characterized by chronic, excessive worry in a number of areas (e.g., schoolwork, social number of areas (e.g., schoolwork, social interactions, family, health/safety, world events, and interactions, family, health/safety, world events, and natural disasters) with at least one associated natural disasters) with at least one associated somatic symptomsomatic symptomAffected children are often perfectionistic, seek Affected children are often perfectionistic, seek reassurance, and struggle more than is evident to reassurance, and struggle more than is evident to parents and teachersparents and teachersWorry is most often present and not limited to a Worry is most often present and not limited to a specific situation or objectspecific situation or objectThese kids donThese kids don’’t just worry about performance and t just worry about performance and social concerns (e.g., social phobia) – these kids social concerns (e.g., social phobia) – these kids worry about the quality of their relationships rather worry about the quality of their relationships rather than experiencing embarrassment or humiliation in than experiencing embarrassment or humiliation in social situationssocial situations

Clinical Presentation: Social PhobiaClinical Presentation: Social PhobiaCharacterized by feeling scared or uncomfortable in one or Characterized by feeling scared or uncomfortable in one or more social settings (discomfort with unfamiliar peers and more social settings (discomfort with unfamiliar peers and not just unfamiliar adults) or performance situations (e.g., not just unfamiliar adults) or performance situations (e.g., sports, music)sports, music)Associated with a fear of scrutiny and of doing something Associated with a fear of scrutiny and of doing something embarrassing in social settings such as classrooms, embarrassing in social settings such as classrooms, restaurants, or extracurricular activitiesrestaurants, or extracurricular activitiesMay have difficulty answering questions in class, reading May have difficulty answering questions in class, reading aloud, initiating conversation, talking with unfamiliar people, aloud, initiating conversation, talking with unfamiliar people, and attending parties and social eventsand attending parties and social eventsThe anxiety with social phobia dissipates when away from a The anxiety with social phobia dissipates when away from a social situation; unlike GAD where the anxiety is persistentsocial situation; unlike GAD where the anxiety is persistent90% of children with Selective Mutism have been shown to 90% of children with Selective Mutism have been shown to meet criteria for Social Phobia (SM should probably be meet criteria for Social Phobia (SM should probably be viewed as a specific type of Social Phobia)viewed as a specific type of Social Phobia)Differential with PDDDifferential with PDD

Clinical Presentation: Clinical Presentation: Panic DisorderPanic Disorder

Recurrent episodes of intense fear that occur Recurrent episodes of intense fear that occur unexpectedly (cued or uncued)unexpectedly (cued or uncued)Panic disorder vs. panic attacksPanic disorder vs. panic attacksCued panic attacks can occur with any anxiety Cued panic attacks can occur with any anxiety disorder, or independently, and are common disorder, or independently, and are common among adolescentsamong adolescentsFear of death or going crazyFear of death or going crazyUncommon before the peri-pubertal period (adult Uncommon before the peri-pubertal period (adult retrospective studies have shown that sx commonly retrospective studies have shown that sx commonly begin in adolescence or young adulthood)begin in adolescence or young adulthood)The peak age of onset of panic d/o is age 15 – 19The peak age of onset of panic d/o is age 15 – 19

Clinical Presentation: Clinical Presentation: Obsessive-Compulsive DisorderObsessive-Compulsive Disorder

Most patients experience both obsessions Most patients experience both obsessions and compulsionsand compulsions

Changes in symptoms and in intensity over Changes in symptoms and in intensity over timetime

Parents often become unwilling collaborators Parents often become unwilling collaborators in the illnessin the illness

Symptoms commonly exist for years before Symptoms commonly exist for years before reaching clinical attentionreaching clinical attention

Trauma

Any or all anxiety symptoms

Symptoms may wax and wane

Symptoms typically worsen when confronted with reminders or situations reminiscent of the trauma

EtiologyEtiology

Behavioral InhibitionBehavioral Inhibition

GeneticGenetic

NeuroimagingNeuroimaging

NeurotransmitterNeurotransmitter

NeuroendocrineNeuroendocrine

Learned ResponsesLearned Responses

Attachment ResearchAttachment Research

PsychoanalyticPsychoanalytic

Behavioral InhibitionBehavioral Inhibition““Behavioral InhibitionBehavioral Inhibition”” (a lab-based (a lab-based temperamental construct) is defined as the temperamental construct) is defined as the tendency to be unusually withdrawn or timid and to tendency to be unusually withdrawn or timid and to show fear and withdrawal in novel and/or show fear and withdrawal in novel and/or unfamiliar social and nonsocial situationsunfamiliar social and nonsocial situationsThose who are withdrawn in social situations only Those who are withdrawn in social situations only are considered are considered ““shyshy””Both behavioral inhibition and shyness are Both behavioral inhibition and shyness are associated with anxiety disorders in both children associated with anxiety disorders in both children and adults and adults The tendency to approach or withdraw from The tendency to approach or withdraw from novelty is an enduring temperamental traitnovelty is an enduring temperamental trait

Behavioral Inhibition (2)

Kids with BI show a lot of physiological signs often associated with anxiety, including enhanced sympathetic nervous system tone (e.g., elevated resting heart rate and salivary cortisol), increased tension in the vocal cords and larynx, and elevations in urinary catecholamines (Kagan et al, 1988)Kids with BI are more likely to have multiple psychiatric Kids with BI are more likely to have multiple psychiatric disorders and two or more anxiety disorders (especially disorders and two or more anxiety disorders (especially Avoidant D/O, Separation Anxiety D/O, and Agoraphobia)Avoidant D/O, Separation Anxiety D/O, and Agoraphobia)Kids with BI have a higher risk of panic is they age (Smoller Kids with BI have a higher risk of panic is they age (Smoller et al, 2005)et al, 2005)Thus, Behavioral Inhibition is a risk factor for the Thus, Behavioral Inhibition is a risk factor for the development of anxiety disorders in childrendevelopment of anxiety disorders in childrenBI is also heritable

Neurobiology of AnxietyNeurobiology of Anxiety

Systems involved in sensing and responding Systems involved in sensing and responding to threat are redundant and involve numerous to threat are redundant and involve numerous brain systems to promote survivalbrain systems to promote survivalReticular Activating System (a network of Reticular Activating System (a network of ascending, arousal-related neural systems)ascending, arousal-related neural systems)– Locus coeruleus NA mobilizes in response to real Locus coeruleus NA mobilizes in response to real

or perceived threator perceived threat– Dorsal raphe 5HT mediates the locus coeruleusDorsal raphe 5HT mediates the locus coeruleus– Lateral dorsal tegmentum cholinergic & mesolimbic Lateral dorsal tegmentum cholinergic & mesolimbic

& mesocortical DA neurons affect brain sensitivity & mesocortical DA neurons affect brain sensitivity and interpretation of threatand interpretation of threat

Limbic System (1)Limbic System (1)Anxiety is believed to recognized at the amygdala Anxiety is believed to recognized at the amygdala

The hippocampus is the storage site of cognitive The hippocampus is the storage site of cognitive and emotional memories and is very sensitive to and emotional memories and is very sensitive to stressstress

Threat alters the ability of the hippocampus and Threat alters the ability of the hippocampus and connected cortical areas to store certain types of connected cortical areas to store certain types of cognitive information (verbal) but not nonverbal cognitive information (verbal) but not nonverbal informationinformation

Many of the cognitive distortions that are associated Many of the cognitive distortions that are associated with anxiety disorders may be related to anxiety with anxiety disorders may be related to anxiety related alterations in the tone of the hippocampus related alterations in the tone of the hippocampus and associated cortical areasand associated cortical areas

Limbic System (2)Limbic System (2)Neuronal systems are capable of making Neuronal systems are capable of making remarkably strong associations between remarkably strong associations between paired cues (e.g., growl of a tiger and threat)paired cues (e.g., growl of a tiger and threat)This capacity of the brain to generalize from a This capacity of the brain to generalize from a specific event renders humans vulnerable to specific event renders humans vulnerable to false associations and over generalizationsfalse associations and over generalizationsOnce these specific cues (e.g., snakes) Once these specific cues (e.g., snakes) become linked with limbic mediated become linked with limbic mediated responses (e.g., anxiety), it is the sensitivity responses (e.g., anxiety), it is the sensitivity of the individualof the individual’’s stress response system s stress response system which determines if the alarm system which determines if the alarm system (anxiety) will be activated(anxiety) will be activated

Genetics of AnxietyGenetics of AnxietyThere are thousands of genes which, if abnormal, could There are thousands of genes which, if abnormal, could result in altered development or functioning of result in altered development or functioning of neurotransmitter and neuroanatomical regions involved in neurotransmitter and neuroanatomical regions involved in regulating anxietyregulating anxietyStrong familial trends in anxiety disorders Strong familial trends in anxiety disorders No clear data support a specific genetic etiology for No clear data support a specific genetic etiology for childhood anxiety disorderschildhood anxiety disordersHeritability estimates of Panic Disorder (48%) and Heritability estimates of Panic Disorder (48%) and Generalized Anxiety Disorder (32%) exist (Hettema et al, Generalized Anxiety Disorder (32%) exist (Hettema et al, 2001)2001)Given these estimates, it is clear that genes account for Given these estimates, it is clear that genes account for only some portion of the increase in risk among family only some portion of the increase in risk among family members of an affected individualmembers of an affected individualEnvironmental factors (e.g., perinatal exposures and Environmental factors (e.g., perinatal exposures and developmental experience) must play a major roledevelopmental experience) must play a major role

Learned ResponsesLearned ResponsesMost specific fears (phobias) are related to paired or Most specific fears (phobias) are related to paired or mispaired internalization of cues with anxiety from mispaired internalization of cues with anxiety from previous experienceprevious experienceSome anxieties may involve genetically fixed Some anxieties may involve genetically fixed patterns developed over eons of evolution (e.g., patterns developed over eons of evolution (e.g., snakes)snakes)During infancy and childhood children mirror their During infancy and childhood children mirror their caretakerscaretakers’’ responses when interpreting internal responses when interpreting internal states of pain, arousal, and anxietystates of pain, arousal, and anxietyOver time children may come to label a host of Over time children may come to label a host of external cues as potentially threatening and certain external cues as potentially threatening and certain internal sensations as fearful; this is the internal sensations as fearful; this is the hypothesized mechanism of GAD, specific phobias hypothesized mechanism of GAD, specific phobias (Kendall and Ronan, 1990), and some types of (Kendall and Ronan, 1990), and some types of PTSD (Main and Hesse, 1990)PTSD (Main and Hesse, 1990)

Etiologic Example: OCDEtiologic Example: OCDGenetic: Likely a vulnerability is genetically Genetic: Likely a vulnerability is genetically transmitted, based upon increased concordance transmitted, based upon increased concordance rates among monozygotes vs. dizygotes and rates among monozygotes vs. dizygotes and increased rates among 1increased rates among 1stst degree relatives of degree relatives of probandsprobandsNeurophysiology: Increased metabolism in Neurophysiology: Increased metabolism in orbitofrontal and caudate systems (e.g., hyperactive orbitofrontal and caudate systems (e.g., hyperactive caudate; PET scans); abnormalities supposed in caudate; PET scans); abnormalities supposed in circuits linking basal ganglia and frontal lobes circuits linking basal ganglia and frontal lobes (Baxter et al, 1992)(Baxter et al, 1992)Neuroendocrine: Individuals with OCD have shown Neuroendocrine: Individuals with OCD have shown elevated levels of Oxytocin (behavioral effects of elevated levels of Oxytocin (behavioral effects of which typically contribute to cognitive, grooming, which typically contribute to cognitive, grooming, affiliative, and reproductive behaviors in animals)affiliative, and reproductive behaviors in animals)

AttachmentAttachment

SecureSecure

Insecure Resistant - HyperactivatingInsecure Resistant - Hyperactivating

Insecure Avoidant - InhibitedInsecure Avoidant - Inhibited

Disorganized - No adaptive strategyDisorganized - No adaptive strategy

–Frightening, unpredictable parentsFrightening, unpredictable parents

Attachment ResearchAttachment Research

Insecure attachment may be a risk factor Insecure attachment may be a risk factor for the development of childhood anxiety for the development of childhood anxiety disordersdisordersAn attachment study showed that 80% of An attachment study showed that 80% of children born to insecure mothers were children born to insecure mothers were classified as insecurely attached children classified as insecurely attached children The presence of behavioral inhibition does The presence of behavioral inhibition does not seem to increase the risk of being not seem to increase the risk of being insecurely attached and vice versainsecurely attached and vice versa

The Impact of Trauma Is Developmentally SensitiveThe Impact of Trauma Is Developmentally SensitiveAffect RegulationAffect Regulation

Cloitre et al., 1997

The Impact of Trauma Is Developmentally SensitiveThe Impact of Trauma Is Developmentally SensitiveInterpersonal FunctioningInterpersonal Functioning

Inventory of Interpersonal Problems

Cloitre et al., 1997

PsychoanalyticPsychoanalytic

The key idea is that phobias develop as a The key idea is that phobias develop as a defense against anxiety which is produced defense against anxiety which is produced by repressed id impulses. by repressed id impulses.

Anxiety is displaced from the id impulses Anxiety is displaced from the id impulses to a fear object that is linked symbolically to a fear object that is linked symbolically (and generally more acceptable). (and generally more acceptable).

By avoiding the phobic object, one avoids By avoiding the phobic object, one avoids dealing with repressed childhood conflicts.dealing with repressed childhood conflicts.

EpidemiologyEpidemiologyAnxiety is the most prevalent mental health Anxiety is the most prevalent mental health disorder in children and teens disorder in children and teens – Estimated at 6 – 20%Estimated at 6 – 20%– Difficult numbers because subthreshold anxiety (not Difficult numbers because subthreshold anxiety (not

meeting DSM criteria) can also cause severe meeting DSM criteria) can also cause severe disabilitydisability

Developmental progression of anxiety disorders Developmental progression of anxiety disorders in adulthoodin adulthood– Untreated childhood anxiety typically continues into Untreated childhood anxiety typically continues into

adulthoodadulthood– Leads to an increased risk of depressive disordersLeads to an increased risk of depressive disorders

Albano, Chorpita, & Barlow (2003). Childhood Anxiety Disorders. In Mash & Barkley (Eds.). Child Psychopathology: Second Edition. (pp. 279-329). New York: Guildford Albano, Chorpita, & Barlow (2003). Childhood Anxiety Disorders. In Mash & Barkley (Eds.). Child Psychopathology: Second Edition. (pp. 279-329). New York: Guildford Press.Press.

Costello et al, 2004Costello et al, 2004

Epidemiology (2)Epidemiology (2)Girls are more likely than boys to report an anxiety Girls are more likely than boys to report an anxiety disorder, esp. specific phobia, panic, agoraphobia, & disorder, esp. specific phobia, panic, agoraphobia, & separation anxiety disorderseparation anxiety disorder

Children often develop new anxiety disorders over Children often develop new anxiety disorders over time (even if the old ones go away)time (even if the old ones go away)

Anxiety or depressive disorders in adolescence predict Anxiety or depressive disorders in adolescence predict a 2-3x increase risk of anxiety or depression in a 2-3x increase risk of anxiety or depression in adulthood (Pine et al, 1998) and lower academic adulthood (Pine et al, 1998) and lower academic achievement (Woodward & Fergusson, 2001)achievement (Woodward & Fergusson, 2001)

Anxiety in the 1Anxiety in the 1stst grade has been shown to predict grade has been shown to predict anxiety and low academic achievement in reading and anxiety and low academic achievement in reading and math in the 5math in the 5thth grade (Ialongo et al, 1995) grade (Ialongo et al, 1995)

Epidemiology (3): Non-ReferredEpidemiology (3): Non-Referred

High prevalence of anxiety disorders in non-High prevalence of anxiety disorders in non-referred children: referred children: – 3.5% for Separation Anxiety D/O3.5% for Separation Anxiety D/O– 2.9% for Overanxious D/O2.9% for Overanxious D/O– 2.4% for Simple Phobia2.4% for Simple Phobia– 1% for Social Phobia (Anderson et al, 1987)1% for Social Phobia (Anderson et al, 1987)

Bowen (1990) reported 3.6% prevalence of Bowen (1990) reported 3.6% prevalence of Separation Anxiety D/O and 2.4% prevalence Separation Anxiety D/O and 2.4% prevalence of Overanxious D/O in 12 – 16 y/o populationof Overanxious D/O in 12 – 16 y/o populationLifetime prevalence of panic d/o was 0.6% Lifetime prevalence of panic d/o was 0.6% and for GAD 3.7% (Whitaker, 1990)and for GAD 3.7% (Whitaker, 1990)

Epidemiology (4)Epidemiology (4)

A pediatric primary care sample of 7 – 11 y/o A pediatric primary care sample of 7 – 11 y/o revealed a 1-year prevalence of anxiety d/o of revealed a 1-year prevalence of anxiety d/o of 15.4%; Simple Phobia (9.2%), Separation Anxiety 15.4%; Simple Phobia (9.2%), Separation Anxiety D/O (4.1%), and Overanxious D/O (4.6%) were D/O (4.1%), and Overanxious D/O (4.6%) were most common (Benjamin 1990)most common (Benjamin 1990)A 3 – 4 year f/u study of children/adolescents with A 3 – 4 year f/u study of children/adolescents with anxiety d/o showed a high remission rate with 82% anxiety d/o showed a high remission rate with 82% no longer meeting criteria for their initial anxiety d/o no longer meeting criteria for their initial anxiety d/o (Last et al)(Last et al)– Separation Anxiety D/O had the highest recovery rate Separation Anxiety D/O had the highest recovery rate

(96%) and panic the lowest (70%); during this f/u period, (96%) and panic the lowest (70%); during this f/u period, 30% of children developed new psych d/o and half 30% of children developed new psych d/o and half developed new anxiety d/odeveloped new anxiety d/o

Risk and Protective FactorsRisk and Protective FactorsBehaviorally inhibited young children have a Behaviorally inhibited young children have a greater likelihood of anxiety disorders in greater likelihood of anxiety disorders in middle childhoodmiddle childhood

Offspring of parents with anxiety disorders Offspring of parents with anxiety disorders have a greater risk of anxiety disorder and have a greater risk of anxiety disorder and high levels of functional impairmenthigh levels of functional impairment

Insecure attachment relationships with Insecure attachment relationships with caregivers (specifically anxious/resistant caregivers (specifically anxious/resistant attachment) increases the risk of childhood attachment) increases the risk of childhood anxiety disorders anxiety disorders

Clinical CourseClinical CourseThe usual course of most anxiety disorders is chronic The usual course of most anxiety disorders is chronic with waxing and waning over timewith waxing and waning over timeIndividuals sometime Individuals sometime ““tradetrade”” one anxiety disorder for one anxiety disorder for another over timeanother over timeCommonly those with GAD report theyCommonly those with GAD report they’’ve felt anxious ve felt anxious their entire life; over half presenting for treatment their entire life; over half presenting for treatment report onset in childhood or adolescence; but onset report onset in childhood or adolescence; but onset occurring after 20 is not uncommon; chronic but occurring after 20 is not uncommon; chronic but fluctuating coursefluctuating courseWith Panic D/O, typically attacks become less severe With Panic D/O, typically attacks become less severe if they occur more oftenif they occur more oftenSome anxieties, such as specific phobias, often Some anxieties, such as specific phobias, often dissipate with age, but those that persist into dissipate with age, but those that persist into adulthood remit only infrequently (20%)adulthood remit only infrequently (20%)

Clinical Course (2)Clinical Course (2)Social Phobia, on the other hand, most often sets on in Social Phobia, on the other hand, most often sets on in childhood and is commonly lifelong and continuous, childhood and is commonly lifelong and continuous, although it may fluctuate in intensity with life stressors and although it may fluctuate in intensity with life stressors and demandsdemandsMost individuals with OCD show improvement with time, Most individuals with OCD show improvement with time, but about 15% show progressive deterioration and 5% but about 15% show progressive deterioration and 5% have episodic course; however, an NIMH 2 – 7 year f/u have episodic course; however, an NIMH 2 – 7 year f/u study found 43% still meeting diagnostic criteria with only study found 43% still meeting diagnostic criteria with only 11% totally asymptomatic11% totally asymptomaticAs with other anxiety disorders, the symptoms of PTSD As with other anxiety disorders, the symptoms of PTSD often vary over time. Complete recovery occurs within 3 often vary over time. Complete recovery occurs within 3 months in about half of cases.months in about half of cases.Separation Anxiety Disorder may develop after a stressor Separation Anxiety Disorder may develop after a stressor (e.g., death of a relative or pet, relocation, etc.) and occur (e.g., death of a relative or pet, relocation, etc.) and occur as early as preschool; adolescent onset is rare; typically it as early as preschool; adolescent onset is rare; typically it waxes and wanes; although it may be expressed as Panic waxes and wanes; although it may be expressed as Panic Disorder in adults, most children are free from anxiety Disorder in adults, most children are free from anxiety disorders as they adultsdisorders as they adults

DSM Diagnoses (1)DSM Diagnoses (1)

DSM III-R included only 3 childhood anxiety DSM III-R included only 3 childhood anxiety disorders: disorders:

(1) Separation Anxiety Disorder (which remains); (1) Separation Anxiety Disorder (which remains); (2) Overanxious Disorder, which is now (2) Overanxious Disorder, which is now

subsumed under GAD; and subsumed under GAD; and

(3) Avoidant Disorder, which is now subsumed (3) Avoidant Disorder, which is now subsumed under Social Phobiaunder Social Phobia

DSM Diagnoses (2)DSM Diagnoses (2)DSM-IV disorders include: DSM-IV disorders include:

(1)(1) Separation Anxiety DisordersSeparation Anxiety Disorders(2)(2) Panic DisorderPanic Disorder(3)(3) Specific PhobiaSpecific Phobia(4)(4) Social Phobia (Social Anxiety Disorder)Social Phobia (Social Anxiety Disorder)(5)(5) Obsessive-Compulsive DisorderObsessive-Compulsive Disorder(6)(6) Posttraumatic Stress Disorder Posttraumatic Stress Disorder (7)(7) Acute Stress Disorder Acute Stress Disorder (8)(8) Generalized Anxiety DisorderGeneralized Anxiety Disorder

Others:Others:– Selective MutismSelective Mutism– Somatic symptomsSomatic symptoms– TrichotillomaniaTrichotillomania

DSM: Separation Anxiety DisorderDSM: Separation Anxiety DisorderDevelopmentally inappropriate and excessive anxiety Developmentally inappropriate and excessive anxiety concerning separation from home or from those to concerning separation from home or from those to whom the individual is attached, as evidenced by 3 or whom the individual is attached, as evidenced by 3 or more:more:

Excessive distress upon separation from home or attachment Excessive distress upon separation from home or attachment figures occurs or is anticipatedfigures occurs or is anticipatedExcessive worry about losing or harm befalling attachment figuresExcessive worry about losing or harm befalling attachment figuresExcessive worry that an event will lead to separation from an Excessive worry that an event will lead to separation from an attachment figure (e.g., kidnapping)attachment figure (e.g., kidnapping)Reluctance to attend school b/c of fear of separationReluctance to attend school b/c of fear of separationReluctance to be alone or without attachment figures at home or Reluctance to be alone or without attachment figures at home or other locationsother locationsReluctance to sleep alone or away from homeReluctance to sleep alone or away from homeRepeated nightmares involving separationRepeated nightmares involving separationRepeated complaints of physical symptoms when separation occurs Repeated complaints of physical symptoms when separation occurs or is anticipatedor is anticipated

Duration at least 4 weeksDuration at least 4 weeks

Separation Anxiety DisorderSeparation Anxiety DisorderAffected children tend to come from closely knit Affected children tend to come from closely knit familiesfamilies

The kids may exhibit social withdrawal, apathy, and The kids may exhibit social withdrawal, apathy, and sadness or difficulty concentrating when separatedsadness or difficulty concentrating when separated

Concerns about death and dying are commonConcerns about death and dying are common

These children are often viewed as demandingThese children are often viewed as demanding

Adults with SAD are typically over-concerned about Adults with SAD are typically over-concerned about their children and spousestheir children and spouses

Prevalence estimates about 4% in children and Prevalence estimates about 4% in children and young adolescentsyoung adolescents

More common in 1More common in 1stst degree relatives than general degree relatives than general populationpopulation

Panic Attacks

NOT A DISORDER!Quite common among adults

Panic AttacksPanic AttacksCan occur within the context of other mental disorders (e.g., Can occur within the context of other mental disorders (e.g., Mood D/Os, Substance-Related D/Os, etc.) and some general Mood D/Os, Substance-Related D/Os, etc.) and some general medical conditions (e.g., cardiac, respiratory, vestibular, GI).medical conditions (e.g., cardiac, respiratory, vestibular, GI).3 characteristic types of panic: (1) Unexpected (uncued); (2) 3 characteristic types of panic: (1) Unexpected (uncued); (2) situation bound (cued); and (3) situationally predisposed. situation bound (cued); and (3) situationally predisposed. Individuals who seek care will typically describe intense fear, Individuals who seek care will typically describe intense fear, report that they fear theyreport that they fear they’’re about to die, go crazy, have an re about to die, go crazy, have an MI/strokeMI/strokeIndividuals typically report a desire to flee or leave where theyIndividuals typically report a desire to flee or leave where they ’’re re atatWith unexpected panic attacks, over time the attacks typically With unexpected panic attacks, over time the attacks typically become situationally bound or predisposed, although unexpected become situationally bound or predisposed, although unexpected attacks may occurattacks may occurThe occurrence of unexpected panic attacks is required for a dx The occurrence of unexpected panic attacks is required for a dx of Panic D/O; situationally bound or predisposed attacks are of Panic D/O; situationally bound or predisposed attacks are common in Panic D/O but also occur in the context of other common in Panic D/O but also occur in the context of other anxiety disorders (e.g., specific and social phobia, PTSD)anxiety disorders (e.g., specific and social phobia, PTSD)

Relationship between PD and other Anxiety Disorders

What does a panic attack look like in a child?

Children generally report physical symptoms, rather than psychological symptomsMay suddenly appear frightened or upset without explanationOften confusing behavior to onlookers Children may explain their symptoms as responses to external triggers Young children may not be able to articulate the intense fears they experienceAdolescents are generally better at describing what they experience, especially after the attack has ended*rarer in children

DSM: Panic DisorderDSM: Panic DisorderBoth (1) and (2):Both (1) and (2):

– recurrent unexpected Panic Attacksrecurrent unexpected Panic Attacks– at least one of the attacks has been followed by 1 month (or more) of one (or at least one of the attacks has been followed by 1 month (or more) of one (or

more) of the following:more) of the following:persistent concern about having additional attackspersistent concern about having additional attacksworry about the implications of the attack or its consequences (e.g., losing control, worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, having a heart attack, ““going crazygoing crazy””))a significant change in behavior related to the attacksa significant change in behavior related to the attacks

Absence of AgoraphobiaAbsence of AgoraphobiaThe Panic Attacks are not due to the direct effects of a substance (e.g., The Panic Attacks are not due to the direct effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).hyperthyroidism).The Panic Attacks are not better accounted for by another mental The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), OCD (e.g., on exposure to dirt in someone with an obsession situation), OCD (e.g., on exposure to dirt in someone with an obsession about contamination), PTSD (e.g., in response to stimuli associated with about contamination), PTSD (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety D/O (e.g., in response to being a severe stressor), or Separation Anxiety D/O (e.g., in response to being away from home or close relatives).away from home or close relatives).

Panic DisorderPanic DisorderPatients often are hypersensitive about physical cues and medication side effectsPatients often are hypersensitive about physical cues and medication side effectsReported rates of comorbid MDD are high, ranging from 10-65%; in 2/3 of these individuals Reported rates of comorbid MDD are high, ranging from 10-65%; in 2/3 of these individuals depression co-occurs with panic d/o or follows panic; in the remaining 1/3, the depression depression co-occurs with panic d/o or follows panic; in the remaining 1/3, the depression precedes the panicprecedes the panicComorbidity with other anxiety disorders is common – social phobia and GAD (15-30%), Comorbidity with other anxiety disorders is common – social phobia and GAD (15-30%), specific phobia (2-20%), and OCD (up to 10%). PTSD and Separation Anxiety are also specific phobia (2-20%), and OCD (up to 10%). PTSD and Separation Anxiety are also strongly comorbid, along with hypochondriasis.strongly comorbid, along with hypochondriasis.No consistent abnormalities in lab results, but compensated respiratory alkalosis (decreased No consistent abnormalities in lab results, but compensated respiratory alkalosis (decreased bicarb/CO2 with almost normal pH) sometimes noted.bicarb/CO2 with almost normal pH) sometimes noted.Lactate and elevated CO2 can be used to induce panic in sufferersLactate and elevated CO2 can be used to induce panic in sufferersCorrelation with numerous general medical symptoms, including dizziness, arrhythmias, Correlation with numerous general medical symptoms, including dizziness, arrhythmias, hyperthyroidism, asthma, COPD, IBS; however, the nature of the association is unclear.hyperthyroidism, asthma, COPD, IBS; however, the nature of the association is unclear.Debate about whether or not MVP and thyroid disease is more common among sufferersDebate about whether or not MVP and thyroid disease is more common among sufferersLifetime prevalence in community samples generally 1-2% (but reported as high as 3.5%); Lifetime prevalence in community samples generally 1-2% (but reported as high as 3.5%); one-year prevalence rates 0.5-1.5%; higher rates in clinic samples (10% in individuals referred one-year prevalence rates 0.5-1.5%; higher rates in clinic samples (10% in individuals referred for mental health consultation); 10-30% in general medical clinics and up to 60% in cardiology for mental health consultation); 10-30% in general medical clinics and up to 60% in cardiology clinicsclinics1/3 to ½ of community samples has comorbid agoraphobia, but the co-occurrence is much 1/3 to ½ of community samples has comorbid agoraphobia, but the co-occurrence is much higher in clinical samples higher in clinical samples Age at onset varies, but typically late adolescence/mid-30s; occasionally onset in childhood; Age at onset varies, but typically late adolescence/mid-30s; occasionally onset in childhood; after 45 y/o rare.after 45 y/o rare.Agoraphobia typically develops within the first year, but can occur at any timeAgoraphobia typically develops within the first year, but can occur at any time1st degree biological relatives are up to 8x more likely to develop Panic D/O; if age of onset is 1st degree biological relatives are up to 8x more likely to develop Panic D/O; if age of onset is <20 y/o, 1st degree relatives are up to 20x more likely to develop same.<20 y/o, 1st degree relatives are up to 20x more likely to develop same.

DSM: Specific PhobiaDSM: Specific PhobiaMarked and persistent fear that is excessive or unreasonable, cued Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood)flying, heights, animals, receiving an injection, seeing blood)Exposure to the phobic stimulus almost invariably provokes an Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack. In situationally bound or situationally predisposed Panic Attack. In children, the anxiety may be expressed by crying, tantrums, freezing, children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.or clinging.The person recognizes that the fear is excessive or unreasonable. The person recognizes that the fear is excessive or unreasonable. In children, this feature may be absent.In children, this feature may be absent.The phobic situation(s) is avoided or else is endured with intense The phobic situation(s) is avoided or else is endured with intense anxiety or distress.anxiety or distress.Types:Types: Animal TypeAnimal Type

Natural Environment Type (e.g., heights, storms, Natural Environment Type (e.g., heights, storms, water)water)

Blood-Injection-Injury TypeBlood-Injection-Injury TypeSituational Type (e.g., airplanes, elevators, enclosed Situational Type (e.g., airplanes, elevators, enclosed places)places)

Other Type (e.g., fear of choking, vomiting, or contracting an illness; Other Type (e.g., fear of choking, vomiting, or contracting an illness; in children, fear of loud sounds or costumed characters)in children, fear of loud sounds or costumed characters)

Specific PhobiaSpecific PhobiaRates of co-occurrence with other disorders is 50-80%Rates of co-occurrence with other disorders is 50-80%Usually the comorbid condition causes more distress than the specific Usually the comorbid condition causes more distress than the specific phobia; i.e., only 12-30% of affected individuals are estimated to seek help phobia; i.e., only 12-30% of affected individuals are estimated to seek help strictly for a specific phobiastrictly for a specific phobiaVasovagal fainting response is characteristic of Blood-Injection-Injury Type Vasovagal fainting response is characteristic of Blood-Injection-Injury Type specific phobias (about 75% of patients report fainting in such situations)specific phobias (about 75% of patients report fainting in such situations)Women:men = 2:1Women:men = 2:1Although phobias are common in the general population, they rarely result Although phobias are common in the general population, they rarely result in sufficient impairmentin sufficient impairmentCommunity samples show point prevalence rates of 4-8.8% and lifetime Community samples show point prevalence rates of 4-8.8% and lifetime prevalence rates of 7.2-11.3%; there is decline in the elderlyprevalence rates of 7.2-11.3%; there is decline in the elderlyFirst symptoms usually occur in childhood or early adolescenceFirst symptoms usually occur in childhood or early adolescencePredisposing factors include traumatic events, unexpected Panic Attacks in Predisposing factors include traumatic events, unexpected Panic Attacks in the now feared situation, observation of others undergoing trauma or the now feared situation, observation of others undergoing trauma or demonstrating fearfulness, and informational transmission (e.g., repeated demonstrating fearfulness, and informational transmission (e.g., repeated parental warnings, media coverage).parental warnings, media coverage).Feared objects are those which may actually represent some threat or Feared objects are those which may actually represent some threat or have represented a threat during some point in human evolutionhave represented a threat during some point in human evolutionFamilial aggregationFamilial aggregation

DSM: Social PhobiaDSM: Social PhobiaA marked and persistent fear of one or more social or performance A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that s/he will act in a way possible scrutiny by others. The individual fears that s/he will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. In (or show anxiety symptoms) that will be humiliating or embarrassing. In children, there must be evidence of the capacity for age-appropriate social children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.settings, not just in interactions with adults.Exposure to the feared social situation almost invariably provokes anxiety, Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally which may take the form of a situationally bound or situationally predisposed Panic Attack. In children, the anxiety may be expressed by predisposed Panic Attack. In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.unfamiliar people.The person recognizes that the fear is excessive or unreasonable. In The person recognizes that the fear is excessive or unreasonable. In children, this feature may be absent.children, this feature may be absent.The feared social or performance situations are avoided or else are The feared social or performance situations are avoided or else are endured with intense anxiety or distress.endured with intense anxiety or distress.The avoidance, anxious anticipation, or distress in the feared social or The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the personperformance situation(s) interferes significantly with the person’’s normal s normal routine, occupational (academic) functioning, or social activities or routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.relationships, or there is marked distress about having the phobia.In individuals under 18 years, the duration is at least 6 monthsIn individuals under 18 years, the duration is at least 6 months

Social PhobiaSocial PhobiaIn feared social or performance situations, individuals In feared social or performance situations, individuals with SP experience concerns about embarrassment with SP experience concerns about embarrassment and are afraid that others will judge them to be and are afraid that others will judge them to be anxious, weak, anxious, weak, ““crazycrazy”” or stupid. or stupid.Almost always experience physical signs of anxiety Almost always experience physical signs of anxiety (e.g., palpitations, tremors, sweating, GI, blushing, (e.g., palpitations, tremors, sweating, GI, blushing, etc.)etc.)Typically there is avoidance of social situationsTypically there is avoidance of social situationsCommon associated features include hypersensitivity Common associated features include hypersensitivity to criticism or rejection; difficulty being assertive, low to criticism or rejection; difficulty being assertive, low self-esteem and feelings of inferiority.self-esteem and feelings of inferiority.Women>menWomen>menLifetime prevalence 3-13%Lifetime prevalence 3-13%Occurs more frequently among 1st degree relatives Occurs more frequently among 1st degree relatives

Obsessive Compulsive DisorderObsessive Compulsive Disorder

Insanity is doing the same thing over and over again and expecting different results.

-Albert Einstein

DSM: Obsessive-Compulsive DisorderDSM: Obsessive-Compulsive DisorderEither obsessions or compulsions:Either obsessions or compulsions:Obsessions as defined by (1), (2), (3), and (4):Obsessions as defined by (1), (2), (3), and (4):

*recurrent and persistent thoughts, impulses, or images that are experienced, *recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distresscause marked anxiety or distress*the thoughts, impulses, or images are not simply excessive worries about *the thoughts, impulses, or images are not simply excessive worries about real-life problemsreal-life problems*the person attempts to ignore or suppress such thoughts, impulses, or *the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or actionimages, or to neutralize them with some other thought or action*the person recognizes that the obsessional thoughts, impulses, or images are *the person recognizes that the obsessional thoughts, impulses, or images are a product of his/her own mind (not imposed from without as in thought a product of his/her own mind (not imposed from without as in thought insertion)insertion)

Compulsions as defined by (1) and (2):Compulsions as defined by (1) and (2):*repetitive behaviors (e.g., hand washing, ordering, checking) or mental *repetitive behaviors (e.g., hand washing, ordering, checking) or mental

acts acts (e.g., praying, counting, repeating words silently) that the person feels (e.g., praying, counting, repeating words silently) that the person feels driven to driven to perform in response to an obsession, or according to rules that perform in response to an obsession, or according to rules that must be applied must be applied rigidlyrigidly

*the behaviors or mental acts are aimed at preventing or reducing *the behaviors or mental acts are aimed at preventing or reducing distress or distress or preventing some dreaded event or situation; however, these preventing some dreaded event or situation; however, these behaviors or behaviors or mental acts either are not connected in a realistic way with what mental acts either are not connected in a realistic way with what they are they are designed to neutralize or prevent or are clearly excessivedesigned to neutralize or prevent or are clearly excessiveAffected individual has recognized that the obsessions or compulsions are Affected individual has recognized that the obsessions or compulsions are excessive or unreasonable. This does not apply to children.excessive or unreasonable. This does not apply to children.Time consuming (more than 1 hour/day)Time consuming (more than 1 hour/day)

OCDOCDMost common obsessions include contamination, repeated doubts, ordering, Most common obsessions include contamination, repeated doubts, ordering, aggressive or horrific impulses, and sexual imageryaggressive or horrific impulses, and sexual imageryIndividuals tend to try and neutralize their obsessive anxiety with behaviors Individuals tend to try and neutralize their obsessive anxiety with behaviors that ultimately become compulsivethat ultimately become compulsiveWhen individuals try to resist the compulsions, they have a sense of When individuals try to resist the compulsions, they have a sense of mounting anxiety that is partially relieved (but perpetuated) by yielding to the mounting anxiety that is partially relieved (but perpetuated) by yielding to the compulsioncompulsionHypochondriacal concerns are common, with repeated visits to physicians Hypochondriacal concerns are common, with repeated visits to physicians to seek reassuranceto seek reassuranceHigh concordance with MDD, Eating D/O, and GAD and other anxiety d/o in High concordance with MDD, Eating D/O, and GAD and other anxiety d/o in adultsadultsIn children, it may be associated with other anxiety d/o, Learning D/O, In children, it may be associated with other anxiety d/o, Learning D/O, Disruptive Behavior D/OsDisruptive Behavior D/OsComorbid obsessive-compulsive spectrum disorders (trichotillomania, body Comorbid obsessive-compulsive spectrum disorders (trichotillomania, body dysmorphic d/o, and habit d/o such as nail biting) are uncommon but not dysmorphic d/o, and habit d/o such as nail biting) are uncommon but not rarerareThere is an established high incidence of OCD in children and adults with There is an established high incidence of OCD in children and adults with Tourettes (range estimates 35-50%); in reverse, the numbers are smaller Tourettes (range estimates 35-50%); in reverse, the numbers are smaller (~8%)(~8%)

OCD (2)OCD (2)Between 20-30% of individuals with OCD report current or past Between 20-30% of individuals with OCD report current or past ticsticsChildren often do not seek help, and the symptoms may not be Children often do not seek help, and the symptoms may not be as ego-dystonic as in adultsas ego-dystonic as in adultsIn adults the disorder is equally common in males and females; In adults the disorder is equally common in males and females; in childhood onset, the disorder is more common in boys than in childhood onset, the disorder is more common in boys than girlsgirlsCommunity studies of children/adolescents estimates lifetime Community studies of children/adolescents estimates lifetime prevalence at 1-2.3% and one-year prevalence of 0.7%prevalence at 1-2.3% and one-year prevalence of 0.7%Usual onset is late adolescence/early adulthood but may begin in Usual onset is late adolescence/early adulthood but may begin in childhood; males typically have an earlier onset than females childhood; males typically have an earlier onset than females (males, 6-15; females 20-29)(males, 6-15; females 20-29)Higher concordance for mono than dizygotic twinsHigher concordance for mono than dizygotic twinsHigher risk of OCD amongst 1st degree relatives of patients with Higher risk of OCD amongst 1st degree relatives of patients with OCD and/or TourettesOCD and/or TourettesPregnancy and childbirth are a strong risk factor for new-onset Pregnancy and childbirth are a strong risk factor for new-onset OCDOCDPANDAS PANDAS

DSM: Post-Traumatic Stress DisorderDSM: Post-Traumatic Stress Disorder1)1) Exposed to a traumatic event in which:Exposed to a traumatic event in which:– The person experienced, witnessed, or was confronted with an The person experienced, witnessed, or was confronted with an

event or events that involved actual or threatened death or serious event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or othersinjury, or a threat to the physical integrity of self or others

– The personThe person’’s response involved intense fear, helplessness, or s response involved intense fear, helplessness, or horror. In children, this may be expressed instead by disorganized horror. In children, this may be expressed instead by disorganized or agitated behavior.or agitated behavior.

2)2) The traumatic event is persistently reexperienced in one (or more) The traumatic event is persistently reexperienced in one (or more) of the following ways:of the following ways:

– Recurrent and intrusive distressing recollections of the event, Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. In young children, including images, thoughts, or perceptions. In young children, repetitive play may occur in which themes or aspects of the trauma repetitive play may occur in which themes or aspects of the trauma are expressed.are expressed.

– Recurrent distressing dreams. In children, there may be frightening Recurrent distressing dreams. In children, there may be frightening dreams without recognizable contentdreams without recognizable content

– Acting or feeling as if the traumatic event were recurring (includes a Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes). In young children, trauma-dissociative flashback episodes). In young children, trauma-specific reenactment may occurspecific reenactment may occur

– Intense psychological distress at exposure to internal or external Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic eventcues that symbolize or resemble an aspect of the traumatic event

DSM: Post-Traumatic Stress D/O (2)DSM: Post-Traumatic Stress D/O (2) 3)3) Physiological reactivity on exposure to internal or external cues Physiological reactivity on exposure to internal or external cues

4)4) Persistent avoidance of stimuli associated with the trauma and numbing of Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by general responsiveness (not present before the trauma), as indicated by three (or more) of the following:three (or more) of the following:

– efforts to avoid thoughts, feelings, or conversations associated with the efforts to avoid thoughts, feelings, or conversations associated with the traumatrauma

– efforts to avoid activities, places, or people that arouse recollections of the efforts to avoid activities, places, or people that arouse recollections of the traumatrauma

– inability to recall an important aspect of the traumainability to recall an important aspect of the trauma– markedly diminished interest or participation in significant activitiesmarkedly diminished interest or participation in significant activities– feeling of detachment or estrangement from othersfeeling of detachment or estrangement from others– restricted range of affect (e.g., unable to have loving feelings)restricted range of affect (e.g., unable to have loving feelings)– sense of a foreshortened future (e.g., does not expect to have a career, sense of a foreshortened future (e.g., does not expect to have a career,

marriage, children, a normal life span)marriage, children, a normal life span)Persistent symptoms or increased arousal (not present before the trauma), as Persistent symptoms or increased arousal (not present before the trauma), as

indicated by two (or more) of the following:indicated by two (or more) of the following:– difficulty falling or staying asleepdifficulty falling or staying asleep– irritability or outbursts of angerirritability or outbursts of anger– difficulty concentratingdifficulty concentrating– hypervigilancehypervigilance– exaggerated startle responseexaggerated startle responseDuration of the disturbance is more than 1 month.Duration of the disturbance is more than 1 month.

PTSD PTSD Types of TraumaTypes of Trauma

Child Maltreatment

Community violence (witness, victim)

Natural disasters (fires, hurricanes)

Motor vehicle collisions

Disasters (fires, earthquakes)

War and terrorism

PTSD Prevalence of Trauma

Lifetime Prevalence: 1-14% Child sexual abuse: studies of 30-40% Child physical abuse: 10% Witnesses of domestic violence 54% Single-incident disaster: 10% Motor vehicle collisions:

– Most common form of unintentional injury in children

PTSD Prevalence

Prevalence following war / terrorism

War PTSD diagnosis-Current 18%-37% PTSD diagnosis-Lifetime 21% Severe PTSD symptoms 31%

Oklahoma City 36%

PTSD PTSD (In the brain) (In the brain)

Normal Brain: Look at the Hippocampus!

PTSD PTSD (In the brain) (In the brain)

•Recent research points to the role of the hippocampus in PTSD.

•One job of the hippocampus is to constantly be generating new cells to form new memories.

•Patients with PTSD have a reduction in volume of the hippocampus because it fails to regenerate neurons due to the stress of the traumatic memory.

PTSD PTSD (In the brain) (In the brain)

War veterans have shown an 8% reduction in the right hippocampus (no differences in other parts of the brain).

Damage to the hippocampus following exposure to the stress brought on by childhood abuse leads to distortion and fragmentation of memories.

PTSD PTSD

Traumatic events experienced prior to age 11 are 3x more likely to result in PTSD

Psychological impact of traumatic events tends to persist or worsen over time in children

Parents tend to underestimate both the intensity and duration of their children’s stress reactions

PTSD PTSD

Many trauma victims never develop PTSD What predicts who develops PTSD?

Closer physical proximity Closer emotional proximity (death) More exposure to media coverage Cognitive factors

Locus of control Trauma-specific attributions

PTSD (1)PTSD (1)Individuals may describe painful guilt feelings about Individuals may describe painful guilt feelings about surviving when others donsurviving when others don’’t survive, or about the things t survive, or about the things they had to do in order to survivethey had to do in order to surviveRecent immigrants from areas of civil unrest may have an Recent immigrants from areas of civil unrest may have an increased prevalenceincreased prevalenceLifetime prevalence approx 8% of adults in US (1 – 14%)Lifetime prevalence approx 8% of adults in US (1 – 14%)Symptoms usually begin within the first 3 months of the Symptoms usually begin within the first 3 months of the trauma experiencetrauma experienceFrequently a personFrequently a person’’s reaction to trauma meets criteria for s reaction to trauma meets criteria for an Acute Stress D/O in the immediate aftermathan Acute Stress D/O in the immediate aftermathSeverity, duration, and proximity of an individualSeverity, duration, and proximity of an individual’’s s exposure to the trauma are the most important factors exposure to the trauma are the most important factors affecting the likelihood of developing this disorderaffecting the likelihood of developing this disorderSome evidence of a heritable componentSome evidence of a heritable componentA h/o of depression in a 1st degree relative is related to an A h/o of depression in a 1st degree relative is related to an increased vulnerabilityincreased vulnerability

PTSD (2)PTSD (2)

Partial symptomatology is commonPartial symptomatology is common

The The ““fight or flightfight or flight”” response is less adaptive in response is less adaptive in young children than adultsyoung children than adults

Comorbid conditions are commonComorbid conditions are common

Girls are generally more symptomatic than boysGirls are generally more symptomatic than boys

Younger children seem to demonstrate more Younger children seem to demonstrate more avoidance symptoms, whereas older children avoidance symptoms, whereas older children suffer more reexperiencing and arousal suffer more reexperiencing and arousal increasesincreases

DSM: Acute Stress DisorderDSM: Acute Stress DisorderThe person has been exposed to a traumatic event in which both of the following were The person has been exposed to a traumatic event in which both of the following were

present:present:The person experienced, witnessed, or was confronted with an event or events The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or othersphysical integrity of self or othersThe personThe person’’s response involved intense fear, helplessness, or horrors response involved intense fear, helplessness, or horror

Either while experiencing or after experiencing the distressing event, the individual has three Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:(or more) of the following dissociative symptoms:

A subjective sense of numbing, detachment, or absence of emotional A subjective sense of numbing, detachment, or absence of emotional responsivenessresponsivenessA reduction in awareness of his/her surroundings (e.g., A reduction in awareness of his/her surroundings (e.g., ““being in a dazebeing in a daze””))DerealizationDerealizationDepersonalizationDepersonalizationDissociative amnesia (i.e., inability to recall an important aspect of the trauma)Dissociative amnesia (i.e., inability to recall an important aspect of the trauma)

– The traumatic event is persistently reexperienced in at least one of the following ways: The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.the experience; or distress on exposure to reminders of the traumatic event.

– Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people)feelings, conversations, activities, places, people)

– Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness)poor concentration, hypervigilance, exaggerated startle response, motor restlessness)

– The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic eventwithin 4 weeks of the traumatic event

Acute Stress DisorderAcute Stress DisorderAs a response to a traumatic event, the individual As a response to a traumatic event, the individual develops dissociative symptomsdevelops dissociative symptomsIndividuals may have a decrease in emotional Individuals may have a decrease in emotional responsivity; feeling guilty, anhaedonicresponsivity; feeling guilty, anhaedonicIndividuals are at increased risk of developing PTSDIndividuals are at increased risk of developing PTSDRates ranging from 14-33% have been reported for Rates ranging from 14-33% have been reported for individuals exposed to severe traumaindividuals exposed to severe traumaSymptoms are experienced during or immediately Symptoms are experienced during or immediately after the trauma, lasting at least 2 days, and after the trauma, lasting at least 2 days, and resolving within 4 weeks; if symptoms persist resolving within 4 weeks; if symptoms persist beyond 1 month, PTSD may be diagnosed if criteria beyond 1 month, PTSD may be diagnosed if criteria are metare met

DSM: Generalized Anxiety DisorderDSM: Generalized Anxiety Disorder– Excessive anxiety and worry (apprehensive expectation), Excessive anxiety and worry (apprehensive expectation),

occurring more days than not for at least 6 months, about occurring more days than not for at least 6 months, about a number of events or activities (such as work or school a number of events or activities (such as work or school performance).performance).

– The person finds it difficult to control the worry.The person finds it difficult to control the worry.– The anxiety and worry are associated with three (or more) The anxiety and worry are associated with three (or more)

of the following six symptoms (with at least some of the following six symptoms (with at least some symptoms present for more days than not for the past 6 symptoms present for more days than not for the past 6 months). Only one item is required in children.months). Only one item is required in children.

restlessness or feeling keyed up or on edgerestlessness or feeling keyed up or on edgebeing easily fatiguedbeing easily fatigueddifficulty concentrating or mind going blankdifficulty concentrating or mind going blankirritabilityirritabilitymuscle tensionmuscle tensionsleep disturbance (difficulty falling or staying sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)asleep, or restless unsatisfying sleep)

GADGADMany people with GAD experience somatic sx (e.g., sweating, Many people with GAD experience somatic sx (e.g., sweating, nausea, diarrhea) and an exaggerated startle responsenausea, diarrhea) and an exaggerated startle responseAutonomic hyperarousal is less common in GAD than in other Autonomic hyperarousal is less common in GAD than in other anxiety d/oanxiety d/oFrequently comorbid with Mood D/Os, other Anxiety D/Os, and Frequently comorbid with Mood D/Os, other Anxiety D/Os, and Substance-Related D/OsSubstance-Related D/OsIn children/adolescents worries often focus on school, sporting In children/adolescents worries often focus on school, sporting events, punctuality, catastrophic events (e.g., earthquakes); events, punctuality, catastrophic events (e.g., earthquakes); children may also be overly conforming, perfectionistic, and children may also be overly conforming, perfectionistic, and overzealous in seeking approvaloverzealous in seeking approvalDiagnosed somewhat more in women than men (55-60%)Diagnosed somewhat more in women than men (55-60%)One-year prevalence 3%; lifetime prevalence 5%One-year prevalence 3%; lifetime prevalence 5%Anxiety as a trait has a familial associationAnxiety as a trait has a familial association

DSM: Selective MutismDSM: Selective Mutism

Consistent failure to speak in specific Consistent failure to speak in specific social situations (in which there is an social situations (in which there is an expectation for speaking, e.g., at school) expectation for speaking, e.g., at school) despite speaking in other situationsdespite speaking in other situations

Duration of at least one month with Duration of at least one month with significant disturbancesignificant disturbance

Selective MutismSelective MutismAssociated features often include shyness, fear Associated features often include shyness, fear of social embarrassment, social isolation, and of social embarrassment, social isolation, and withdrawal, clinging, negativism, temper withdrawal, clinging, negativism, temper tantrums, and oppositional behavior (esp at tantrums, and oppositional behavior (esp at home)home)

Teasing by peers is commonTeasing by peers is common

Although affected children usually have normal Although affected children usually have normal communication skills, SM is occasionally communication skills, SM is occasionally associated with a communication disorderassociated with a communication disorder

<1% of kids seen in mental health settings<1% of kids seen in mental health settings

Onset is usually before age 5Onset is usually before age 5

DSM: TrichotillomaniaDSM: Trichotillomania

Recurrent pulling out of hair resulting in Recurrent pulling out of hair resulting in noticeable hair lossnoticeable hair loss

An increasing sense of tension An increasing sense of tension immediately before pulling out the hair or immediately before pulling out the hair or when attempting to resist the behaviorwhen attempting to resist the behavior

Pleasure, gratification, or relief when Pleasure, gratification, or relief when pulling out the hairpulling out the hair

TrichotillomaniaTrichotillomaniaSites of hair pulling may include any region of the body (most Sites of hair pulling may include any region of the body (most common is the head, eyebrows, and eyelashes, but also common is the head, eyebrows, and eyelashes, but also axillary, public, perirectal occur)axillary, public, perirectal occur)May occur in episodes scattered throughout the day or in less May occur in episodes scattered throughout the day or in less frequent but sustained periods lasting for hoursfrequent but sustained periods lasting for hoursOften occurs during periods of relaxation and distraction (e.g., Often occurs during periods of relaxation and distraction (e.g., watching TV or reading) but may occur during stress as wellwatching TV or reading) but may occur during stress as wellExamining the hair root, twirling it off, pulling the strand Examining the hair root, twirling it off, pulling the strand between the teeth, or trichophagia (eating hairs) may occur and between the teeth, or trichophagia (eating hairs) may occur and can result in bezoarscan result in bezoarsHistological examination of affected areas shows damage to Histological examination of affected areas shows damage to hair follicles and short, broken hairshair follicles and short, broken hairsNo gender differences among children; women>menNo gender differences among children; women>menOccurrence is unknown; 0.6% lifetime rate among a study of Occurrence is unknown; 0.6% lifetime rate among a study of college studentscollege studentsAffected individuals often deny the hair pullingAffected individuals often deny the hair pullingPeople may pull hair from pets, dolls, or clothesPeople may pull hair from pets, dolls, or clothes

Assessment of Anxiety in ChildrenAssessment of Anxiety in Children

There is often low concordance between There is often low concordance between child and parent reports of anxietychild and parent reports of anxiety

Mothers tend to over-report anxiety Mothers tend to over-report anxiety symptomssymptoms

Rating ScalesRating Scales

Screen for Child Anxiety Related Screen for Child Anxiety Related Emotional Disorders (SCARED)Emotional Disorders (SCARED)

Multidimensional Anxiety Scale for Multidimensional Anxiety Scale for Children (MASC)Children (MASC)

CYBOCSCYBOCS

Leyton InventoryLeyton Inventory

Achenbach (Child Behavior Checklist)Achenbach (Child Behavior Checklist)

Treatment of Anxiety Disorders in Treatment of Anxiety Disorders in Children (Psychotherapy)Children (Psychotherapy)

An insecure bond between parent and child An insecure bond between parent and child may be an important contributing etiologic may be an important contributing etiologic factor; thus treatment aimed at improving factor; thus treatment aimed at improving these interactions is crucialthese interactions is crucial

CBT CBT – Indications: OCD and phobias (with ERP), Indications: OCD and phobias (with ERP),

Panic, GAD, SADPanic, GAD, SAD

Two studies support the use of Two studies support the use of psychodynamic psychotherapy (Heinicke)psychodynamic psychotherapy (Heinicke)

Treatment of Anxiety Disorders in Treatment of Anxiety Disorders in Children (Medication)Children (Medication)

Four DBPC studies of TCAs for school refusal Four DBPC studies of TCAs for school refusal show conflicting resultsshow conflicting results

Case reports support the use of TCAs for Case reports support the use of TCAs for children/adolescents with Panic D/Ochildren/adolescents with Panic D/O

Alprazolam may be useful in children with Alprazolam may be useful in children with overanxious or avoidant disordersoveranxious or avoidant disorders

Benzodiazepines may be useful for adolescents Benzodiazepines may be useful for adolescents with Panic D/Owith Panic D/O

Alpha-2 agonists and beta-blockers may be Alpha-2 agonists and beta-blockers may be effective for PTSDeffective for PTSD

Treatment of Anxiety Disorders in Treatment of Anxiety Disorders in Children (Medication)Children (Medication)

SSRIs have been show to be efficacious in SSRIs have been show to be efficacious in numerous studiesnumerous studiesTwo RDBPC studies of Effexor XR show somewhat Two RDBPC studies of Effexor XR show somewhat conflicting but generally positive results (Rynn and conflicting but generally positive results (Rynn and Riddle et al)Riddle et al)Zoloft has the best safety data in children and Zoloft has the best safety data in children and adolescents (studies extend two years)adolescents (studies extend two years)FDA approval only for OCD:FDA approval only for OCD:– Fluoxetine (ProzacFluoxetine (Prozac®) 7 – 17 y/o®) 7 – 17 y/o– Sertraline (ZoloftSertraline (Zoloft®) 6 – 17 y/o®) 6 – 17 y/o– Fluvoxamine (LuvoxFluvoxamine (Luvox®) 8 – 17 y/o®) 8 – 17 y/o– Clomipramine (Anafranil®) 11 – 17 y/oClomipramine (Anafranil®) 11 – 17 y/o

CAMSChild and Adolescent Anxiety Multimodal Study (CAMS), 2008 (Walkup et al, 2008). Compared CBT, medications, and combined for treatment of anxiety disordersRandomly assigned 488 children and adolescents with Separation Anxiety Disorder, Social Phobia, or Generalized Anxiety Disorder, aged 7 to 17 years, to one of four treatment groups for 12 weeks. – CBT for 14 sessions– Sertraline up to 200 mg/day– CBT + Sertraline– Placebo

Over 80% of children who received combined treatment improved, as opposed to 60% receiving CBT only and 55% receiving medication only; although there was no statistical separation between the CBT and medication groupsAll treatments were statistically more effective than placebo, which led to improvement in only 24% of subjects.

OCD TreatmentOCD TreatmentNo specific predictors of treatment outcome have been No specific predictors of treatment outcome have been identified for children; in adults comorbid schizotypy and tic identified for children; in adults comorbid schizotypy and tic disorders have been identified as impedimentsdisorders have been identified as impedimentsCBT with Exposure and Response Prevention (ERP)CBT with Exposure and Response Prevention (ERP)Children who acknowledge that their obsessions are Children who acknowledge that their obsessions are senseless and their rituals are distressing may be better senseless and their rituals are distressing may be better candidates for CBT, although lack of insight doesncandidates for CBT, although lack of insight doesn’’t t necessarily render CBT ineffectivenecessarily render CBT ineffectiveSSRIs and clomipramine (best studied in children); typically SSRIs and clomipramine (best studied in children); typically functioning best at higher dosesfunctioning best at higher dosesA substantial minority will not respond until 8 or 12 weeks of A substantial minority will not respond until 8 or 12 weeks of treatmenttreatmentIn those partially responsive to an SSRI, augmentation may In those partially responsive to an SSRI, augmentation may be useful (only haldol and klonipin have proven benefit in be useful (only haldol and klonipin have proven benefit in studies)studies)

OCD Medication StudiesOCD Medication Studies

Clomipramine -DeVeaugh-Geiss et al., Clomipramine -DeVeaugh-Geiss et al., 19921992

Fluoxetine - Riddle et al., 1992Fluoxetine - Riddle et al., 1992

Sertraline - March et al., 1998Sertraline - March et al., 1998

Fluvoxamine - Riddle et al., 2001Fluvoxamine - Riddle et al., 2001

Fluoxetine - Geller et al., 2001Fluoxetine - Geller et al., 2001

Paroxetine - Geller et al., 2004Paroxetine - Geller et al., 2004

Sertraline in Pediatric OCDSertraline in Pediatric OCD

March et al, 1998March et al, 1998

DBRPC 12 week multisite trialDBRPC 12 week multisite trial

N = 187; age = 6-17 years; sertraline 200 N = 187; age = 6-17 years; sertraline 200 mg/dmg/d

Sertraline > placeboSertraline > placebo

Mild side effectsMild side effects

Similar profile of response as Similar profile of response as clomipramineclomipramine

Fluvoxamine in Pediatric OCDFluvoxamine in Pediatric OCD

Riddle et al, 2001Riddle et al, 2001

DBRPC multisite trialDBRPC multisite trial

N = 120; age = 8-17 years; fluvoxamine N = 120; age = 8-17 years; fluvoxamine 50-200 mg/d50-200 mg/d

Fluvoxamine > placeboFluvoxamine > placebo

Mild side effectsMild side effects

Fluoxetine in Pediatric OCDFluoxetine in Pediatric OCD

Geller et al., 2001Geller et al., 2001

N=103, ages 7-17 yearsN=103, ages 7-17 years

13 week RDBPC trial13 week RDBPC trial

Dose 10-60 mg/dayDose 10-60 mg/day

Decrease CY-BOCS favored fluoxetine Decrease CY-BOCS favored fluoxetine (p<.026)(p<.026)

Paroxetine for Pediatric OCDParoxetine for Pediatric OCD

Geller et al, 2004Geller et al, 2004

DBPCR 10 week trialDBPCR 10 week trial

Ages 7-17Ages 7-17

N=203N=203

Paroxetine > placeboParoxetine > placebo

Mild side effectsMild side effects

OCD Augmentation StrategiesOCD Augmentation StrategiesClomipramine Clomipramine

ClonazepamClonazepam

AntipsychoticsAntipsychotics

IV ClomipramineIV Clomipramine

BuspironeBuspirone

Add second SSRIAdd second SSRI

LithiumLithium

StimulantsStimulants

Others???Others???

Pediatric OCD Treatment Study Pediatric OCD Treatment Study (POTS)(POTS)

N = 112 N = 112

Ages 7-17 yearsAges 7-17 years

3 sites, 12 weeks3 sites, 12 weeks

Randomly assigned to CBT, Sertraline, Randomly assigned to CBT, Sertraline, COMB and placeboCOMB and placebo

PBO<SER=CBT<COMB PBO<SER=CBT<COMB

PTSD TreatmentPTSD TreatmentDebriefing is a popular intervention after disaster; Debriefing is a popular intervention after disaster; unfortunately, there is little evidence documenting unfortunately, there is little evidence documenting its effectivenessits effectivenessTreatment involves transforming the childTreatment involves transforming the child’’s self-s self-concept from victim to survivorconcept from victim to survivorProjective interventions should include steps Projective interventions should include steps depicting recovery to increase the sense of masterydepicting recovery to increase the sense of masteryThe literature suggests that desensitization, The literature suggests that desensitization, relaxation, and other behavioral techniques are relaxation, and other behavioral techniques are beneficial in treating children with PTSD, but beneficial in treating children with PTSD, but research is lackingresearch is lackingRevenge fantasies complicate emotional resolutionRevenge fantasies complicate emotional resolution

PTSD PTSD Sertraline Treatment of Children and Adolescents With Posttraumatic Sertraline Treatment of Children and Adolescents With Posttraumatic Stress Disorder, RDBPC (Robb et al, 2011)Stress Disorder, RDBPC (Robb et al, 2011)

131 children and adolescents (6–17 years old) meeting DSM-IV criteria 131 children and adolescents (6–17 years old) meeting DSM-IV criteria for PTSD received 10 weeks of double-blind treatment with sertraline for PTSD received 10 weeks of double-blind treatment with sertraline (50–200mg/day) or placebo; primary efficacy measure UCLA PTSD-I(50–200mg/day) or placebo; primary efficacy measure UCLA PTSD-I

Randomized to sertraline (Randomized to sertraline (nn=67; female, 59.7%; mean age, 10.8) or =67; female, 59.7%; mean age, 10.8) or placebo (placebo (nn=62; female, 61.3%; mean age, 11.2)=62; female, 61.3%; mean age, 11.2)

There was no difference between sertraline and placebo in least squares There was no difference between sertraline and placebo in least squares (LS) mean change in the UCLA PTSD-I score, either on a completer (LS) mean change in the UCLA PTSD-I score, either on a completer analysis (−20.4±2.1 vs. −22.8±2.1; analysis (−20.4±2.1 vs. −22.8±2.1; pp=0.373) or on an last observation =0.373) or on an last observation carried forward (LOCF) end point analysis (−17.7±1.9 vs. −20.8±2.1; carried forward (LOCF) end point analysis (−17.7±1.9 vs. −20.8±2.1; pp=0.201)=0.201)

Attrition was higher on sertraline (29.9%) compared to placebo (17.7%). Attrition was higher on sertraline (29.9%) compared to placebo (17.7%). D/c due to adverse events was 7.5% with sertraline & 3.2% with placeboD/c due to adverse events was 7.5% with sertraline & 3.2% with placebo

Sertraline was a generally safe treatment in children and adolescents Sertraline was a generally safe treatment in children and adolescents with PTSD, but did not demonstrate efficacy when compared to placebo with PTSD, but did not demonstrate efficacy when compared to placebo during 10 weeks of treatmentduring 10 weeks of treatment

PTSD Treatment (2)PTSD Treatment (2)Small open trials have suggested propranolol Small open trials have suggested propranolol and clonidine for persistent arousaland clonidine for persistent arousal

Zoloft and Paxil FDA approved for adults; small Zoloft and Paxil FDA approved for adults; small open trials have suggested the same for SSRIs open trials have suggested the same for SSRIs in children; gabapentin and antipsychotics in children; gabapentin and antipsychotics sometimes reportedly useful in adultssometimes reportedly useful in adults

EMDR (Eye Movement Desensitization EMDR (Eye Movement Desensitization Retraining) eye movement therapy shown Retraining) eye movement therapy shown effective in adults and one child trial (Chemtob effective in adults and one child trial (Chemtob et al, 2000, adults; Ahmad & Sundelin-et al, 2000, adults; Ahmad & Sundelin-Wahlsten, 2008, children)Wahlsten, 2008, children)

N-acetylcysteine N-acetylcysteine NAC is a metabolite of cysteine, an amino acid; its NAC is a metabolite of cysteine, an amino acid; its metabolite, cystine, reduces synaptic release of glutamate metabolite, cystine, reduces synaptic release of glutamate and enhances glial clearance of glutamate, protecting against and enhances glial clearance of glutamate, protecting against glutamate toxicityglutamate toxicity

The restoration of the extracellular glutamate concentration in The restoration of the extracellular glutamate concentration in the nucleus accumbens seems to block compulsive the nucleus accumbens seems to block compulsive behaviorsbehaviors

Single case report of a patient with SSRI refractory OCD, Single case report of a patient with SSRI refractory OCD, who received augmentation of Prozac with NAC led to who received augmentation of Prozac with NAC led to marked decrease in Y-BOCS (Lafleur et al, 2006)marked decrease in Y-BOCS (Lafleur et al, 2006)

Randomized DBPC study of 45 women and 5 men with Randomized DBPC study of 45 women and 5 men with trichotillomania (ages 18 – 65) were assigned to 12 weeks of trichotillomania (ages 18 – 65) were assigned to 12 weeks of NAC up to 2400 mg/d vs. placebo; after 9 weeks of NAC up to 2400 mg/d vs. placebo; after 9 weeks of treatment, 54% of those taking NAC responded to treatment treatment, 54% of those taking NAC responded to treatment favorably (Grant et al, 2009)favorably (Grant et al, 2009)