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