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Anxiety disordersJAN 23 RD 2018 WAVA MCH COR
Agenda TODAY
00:00 Welcome and Announcements00:05 Case Presentation/discussion00:25 Application of prior tools poll00:30 Didactics: Childhood Anxiety, Cecilia Margret MD00:50 Evaluation and “need resources” polls
NEXT SESSION is on Tuesday February 27th
Patient DOB 21 F
Patient gender Female
Patient race/ethnicity Caucasian
Prior medical or mental health
diagnoses and age at diagnosis
Anxiety / OCD since age 8.
Anorexia Nervosa 3/2012
ER visits with numerous chest pain and dizziness, S/p Cardiac evaluation WNL ( Holter, EKG
and ECHO) from 2012
Eczema secondary to washing and athletic injuries from overtraining
Gestation and developmental H/O ?
Symptoms (ABC, FINDS) Panic attacks, rituals over cleaning, worries, sleep disturbances, restrictive and regimented
eating and exercising
Other settings (school, day care) On schedule to graduate college, Plays volley ball and cross country and aspires to be a PT. S
Related ROS/HX Worries about sickness and avoids flights and driving on freeways.
Other systems?
Social (residence, foster care,
finances, trauma, ACES)
Family history positive for anxiety. Mother with H.O anxiety and substance use, but stable
family. Grew up with ½ sister and pays college with support of family and scholarship. Lives in
on campus and avoid driving on freeway ( 30min away from home)
Medications/ treatment history Buspar 7.5mg bid, Propranolol 20mg, prn 30min prior presentation, Ativan 0.5/ Hydroxyzine
25mg prn panic, failed attempts to start SSRI ( citalopram/sertraline ) since 2014.
Exam/labs/tests relevant HT 65, WT 106 lb, BMI 17.6 IBW 83%, plateau for 1 yr was 100%. Labs - CBC, CMP, dexa scan,
TSH, ca and P WNL. Menstrual cycles regular.
Other Hx: No inpatient care for ED. Sees a therapist for ED, nutritionist, PT,massage therapist and
medical/psychiatric care managed by Adolescent medicine, since diagnosis.
CONSULT QUESTION Medication guidance with comorbidity, especially with anxiety around taking medications.
Any specialized therapy for anxiety? Other diagnoses to consider?
Case discussion
POLLING QUESTION
1. I have used the ABCs (antecedents, behavior, consequences) approach to understanding childhood problem behaviors◦ A. >5 times◦ B. 3-5 times◦ C. 1-2 times◦ D. not yet
2. I have used the new preschool ADHD parent questionnaires in clinic◦ A. >5 times◦ B. 3-5 times◦ C. 1-2 times◦ D. not yet
Didactics – anxiety disordersCECILIA MARGRET MD, Assistant professor, Child and Adol. Psychiatry
BETH ELLEN DAVIS MD, Professor, Developmental Pediatrics
Objectives At the end of the session providers will be able to list and discuss the following about childhood and adolescent anxiety disorders
1. Prevalence
2. Clinical subtypes
3. Screening tools
4. Behavioral approaches
5. Medications
Anxiety disordersApproximately 1 or 2 among 10 children ; Specific disorders range 0.5 – 10 % ; Female preponderance
SCREENING TOOLs - Screen for Child Anxiety Related Disorders (SCARED) , SPENCE, GAD 7 etc.
RISK FACTORS : parental pathology, behavioral inhibition, adverse events
Comorbidities COMMON * ( Depression 5%, externalizing disorder 20%, other anxiety 15 – 50 %) – worse outcomes and increased functional impairments
Early treatment modifies illness course - Cognitive Behavioral therapy and SSRI /SNRI
Pure anxiety reduces with age, with persistence and increased comorbidities into adulthood
Normative and pathological evolution of anxiety disorder – a framework, Beesdo-Baum and Knappe 2012,Clin, NA
Anxiety subtypes and its comorbidities
(A) Age of onset of anxiety, depression and Substance use disorders and
(B) the cumulative incidence of anxiety subtypes into adulthood. (Wehry et al 2015 )
Separation anxiety Prevalence : 3-5% ; more in childhood than teen years
Etiology – parental psychopathology, attachment, fear dysregulation, behavioral inhibition trait, environmental precipitants ( divorce, moving)
Normal phenomenon between 6 – 30month, stabilizes with age and most recover
Treatment – CBT, school accommodations, predictable calm routine, support for family and SSRI
Dulcan 2018
Selective mutism Do not speak in one or more settings despite having the ability to comprehend spoken
language and speak in other settings ( ATLEAST 1 month)
0.3 – 1%
Common among immigrant families, social anxiety disorder , heritable (70%)
Evaluation includes psychiatric evaluation, speech and language eval., medical or
neurological assessment for delays
Treatment : Self limiting, therapy including family therapy to reinforce efforts to speak, SSRI
Dulcan 2018
Social anxiety and phobias Fear out of proportion to actual danger
≥ 6 months
Normal fears and phobia differentiated by persistence, irrationality, and functional impairment
5 – 15%
Course : self – limiting, predict other disorders ( mood, eating, pain) , persist into adulthood
Treatment – exposure response prevention, CBT, SSRI
Generalized anxiety UNCONTROLLABLE pervasive WORRY for atleast 6 mo with one accompanying symptom –restlessness, fatigue, inattention, irritable mood, muscle tension, sleep disturbance.
1- 3% ; more females
Behavioral inhibition, environmental ( parental control, adverse events, modeling), inheritable
Chronic, waxing and waning course
Overlapping somatic symptoms, depression, other anxiety disorders
TREATMENT : CBT and SSRI (FDA approved Sertraline, Fluoxetine, Duloxetine)
Panic disorder1 – 4 % in children and teens
Agoraphobia less common than adults
Heritable and somatic sensitivity increased ( interoception)
Chronic course
Comorbid – anxiety and mood disorders, ADHD,
TREATMENT: CBT and if persistent then SSRI
Effective treatment for anxiety has long lasting benefit
3 arm intervention◦ Sertraline
◦ CBT
◦ Combination
Randomized control study N > 400
Consistently 80% showed improvement to one of three treatment arms, greatest impact for combined treatment
Piacentini CAMS ( 2014 JAACAP)
When to consider medication ?
Therapy is LIMITED
Moderate to severe impairment
Rapid intervention needed
Comorbidities needing attention ( Depression or ADHD)
Barriers to therapy
Evidences for medications for child and adolescent anxiety disorders, Strawn et al 2012, Clin of N America
Medications : clinical pearls Start LOW and SLOW ( prepubertal age consider 1/3 of recommended dose)
Allow 4 weeks for titration to next dose
Monitor side effects in 2 – 3 weeks ( SI, activation, apathy, GI and weight changes etc. )
Continue successful plan for 6 – 12months
Consider stopping if symptoms are stable – gradual weaning plan and plan for summer
CHOICES other than SSRI when co-morbid conditions or severity of illness are present consider Atomoxetine, alpha agonists, atypical antipsychotics
PAL 2018
Overview DISORDERS SCREENS THERAPY Primary MEDICATIONS
ANXIETY DISORDERS SCARED, SPENCE, GAD 7
CBT - relaxation, psychoeducation to parents to avoid accommodations, exposure, regulation
SSRI/ SNRI
OCD Children’s Yale-Brown OC scale
CBT SSRI and augmentation with atypical antipsychotic agent
PTSD SCARED traumatic stress scaleChildhood PTSD symptom scale
Trauma focused CBT/ Play therapy
None established * SSRI, alpha agonists
TRICHOTILLOMANIA Clinical Habit reversal therapy SSRI?
EXCORIATION DISORDER
Clinical Habit reversal therapy SSRI?
Screeners links SCARED ( Age 4 – 18)
SCARED traumatic stress disorder scale ( Age 7 – 19)
http://www.seattlechildrens.org/healthcare-professionals/access-services/partnership-access-line/resources/
Spence anxiety scale for children www.scaswebsite.com
CYBOCS ( Age 6 – 17) http://www.cappcny.org/home/media/CYBOCS.pdf
GAD 7 ( Age 11 - 17 )
file:///C:/Users/drcec/Downloads/APA_DSM5_Severity-Measure-For-Generalized-Anxiety-Disorder-Child-Age-11-to-17.pdf
Child PTSD symptom scale (age 8 -1 8) https://www.aacap.org/App_Themes/AACAP/docs/resource_centers/resources/misc/child_ptsd_symptom_scale.pdf
Post-Session Evaluation pollAs a result of attending the session, to what extent did your Confidence in the learning objectives change?
Anxiety disorders Much more confident
Somewhat more confident
Confidence unchanged
Less confident
Define and discuss Prevalence
Define and discussClinical subtypes
Define and discuss Diagnostic screens
Define and discuss Behavioral approaches
Define and discussMedications
POLLING QUESTION
I need help finding local resources to support behavioral management of childhood anxiety
1. YES
2. Not right now
3. please email me to discuss
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