Anxiety Disorders in Children PowerPoint Presentation

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Anxiety Disorders in Children and Adolescents Jess P. Shatkin, MD, MPH Vice Chair for Education NYU Child Study Center New York University School of Medicine

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Learning Objectives Residents will be able to: Identify the primary anxiety disorders in children Distinguish between developmentally “normal” anxiety and pathological anxiety Describe the clinical presentation, epidemiology, etiology, diagnosis and treatment of the major childhood anxiety disorders

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What is Normal? 10 – 20% of children and adolescents suffer a diagnosable anxiety disorder Many more children suffer with symptoms that do not meet diagnostic criteria (Walkup et al, 2008) ~40% 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 troubling ~30% of children worry about their competence and require considerable reassurance ~20% of grade school children are fearful of heights, are shy in new situations, or are anxious about public speaking and social acceptance (Bell-Dolan et al, 1990) Girls report more stress than boys – may be an artifact of social expectations Most of these worries and stresses are outgrown or recede as children mature and develop

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Anxiety can be your friend

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Distinguishing Normal from Pathological 1. Object: Is this something a child of this age should be worrying about? 2. Intensity: Is the degree of distress unrealistic given the child’s developmental stage and the object/event? 3. Impairment: Does the distress interfere with the child’s daily life? - Social functioning: unable to make friends - Academic functioning: failing classes - Family functioning: creating conflicts, limiting family choices 4. Ability to Recover/Coping Skills: Is the child able to recover from distress when the event is not present? - Tend to worry about future occurrences of event/object - Distress occurs across multiple settings

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Normal Fear and Worry Common in normal children The clinician must distinguish developmentally normal from abnormal Infants Fear of loud noises Fear of being startled Fear of strangers (around 8 – 10 months)

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Normal Fear and Worry (2) Toddlers Fears of imaginary creatures Fears of darkness Normative separation anxiety School-age Children Worries about injury and natural events (e.g., storms, lightening, earthquakes, volcanoes) Children who are characterized as confident and eager to explore novel situations at 5 years are less likely to manifest anxiety in childhood and adolescence Children who are passive, shy, fearful, and avoid new situations at 3 and 5 years are more likely to exhibit anxiety later in life (Caspi et al, 1995)

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Normal Fear and Worry (3) School Age Children (continued) In general, girls tend to endorse more anxiety symptoms than boys Younger children are more likely to experience anxiety symptoms than older children Anxious children interpret ambiguous situations in a negative way and may underestimate their competencies (attribution bias) The most common anxiety disorders in middle childhood are Separation Anxiety, GAD, and Specific Phobias

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Normal Fear and Worry (4) Adolescents Fears related to school Fears related to social competence Fears related to health issues

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Clinical Presentation Children with anxiety disorders may present with fear or worry but may not recognize their fears as unreasonable Younger kids often cannot articulate their feelings, and so we often see physical symptoms presenting first, which include: Headaches, upset stomach or nausea, increased heart rate, diarrhea or constipation, sleep disturbance, increased vulnerability to common viruses, tightness in chest, tight neck or back, appetite change, fatigue & exhaustion

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What To Look For Physical complaints (H/A, GI, dramatic) Sleep (early/middle insomnia, repeated visits to parent’s room) Change in eating Avoidance of outside and interpersonal activities (school, parties, camp, slumber parties, safe strangers) Excessive need for reassurance (new situations, bedtime, school, storms, “is it bad?”) Inattention and poor school performance Not necessarily pervasive (some areas of function remain intact) Explosive outbursts

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Physical Symptoms (Provoked and Non-Provoked) Anxious children listen to their bodies (too much!) Headache & stomachache Sick in the morning Frequent urge to urinate or defecate Shortness of breath Chest pain, tachycardia Sensitive gag reflex/fear of choking or vomiting Difficulty swallowing solid foods Dizziness Tension/exhaustion Derealization/depersonalization Avoidance to present physical symptoms

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Clinical Presentation: Separation Anxiety Disorder Excessive fear when separated from home or attachment figures Can be seen before separation or during attempts at separation Excessive worry about their own or their parents’ safety and health when separated Symptoms include difficulty sleeping alone, nightmares with themes of separation, somatic complaints, school refusal Commonly, the earliest age of onset among anxiety disorders Gender ratios are generally equal These children often come from singe-parent and low SES homes A nonspecific precursor to a number of adult psychiatric conditions, including depression as well as any anxiety d/o

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Clinical Presentation: Phobias Fear of a particular object or situation which is avoided or endured with great distress More than one phobia is common (does not in and of itself constitute a diagnosis of GAD) Adolescents and adults typically recognize that the fear is unreasonable; children often do not Avoidance is key Generally begins in childhood

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

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

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

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Clinical Presentation: Obsessive-Compulsive Disorder Most patients experience both obsessions and compulsions Changes in symptoms and in intensity over time Parents often become unwilling collaborators in the illness Symptoms commonly exist for years before reaching clinical attention

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Trauma Any or all anxiety symptoms Symptoms may wax and wane Symptoms typically worsen when confronted with reminders or situations reminiscent of the trauma

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Etiology Behavioral Inhibition Genetic Neuroimaging Neurotransmitter Neuroendocrine Learned Responses Attachment Research Psychoanalytic

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

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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 disorders and two or more anxiety disorders (especially Avoidant D/O, Separation Anxiety D/O, and Agoraphobia) Kids with BI have a higher risk of panic is they age (Smoller et al, 2005) Thus, Behavioral Inhibition is a risk factor for the development of anxiety disorders in children BI is also heritable

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Neurobiology of Anxiety Systems involved in sensing and responding to threat are redundant and involve numerous brain systems to promote survival Reticular Activating System (a network of ascending, arousal-related neural systems) Locus coeruleus NA mobilizes in response to real or perceived threat Dorsal raphe 5HT mediates the locus coeruleus Lateral dorsal tegmentum cholinergic & mesolimbic & mesocortical DA neurons affect brain sensitivity and interpretation of threat

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Limbic System (1) Anxiety is believed to recognized at the amygdala The hippocampus is the storage site of cognitive and emotional memories and is very sensitive to stress Threat alters the ability of the hippocampus and connected cortical areas to store certain types of cognitive information (verbal) but not nonverbal information Many of the cognitive distortions that are associated with anxiety disorders may be related to anxiety related alterations in the tone of the hippocampus and associated cortical areas

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

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

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

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

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Attachment Secure Insecure Resistant - Hyperactivating Insecure Avoidant - Inhibited Disorganized - No adaptive strategy Frightening, unpredictable parents

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

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The Impact of Trauma Is Developmentally SensitiveAffect Regulation Cloitre et al., 1997

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The Impact of Trauma Is Developmentally SensitiveInterpersonal Functioning Inventory of Interpersonal Problems Cloitre et al., 1997

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Psychoanalytic The key idea is that phobias develop as a defense against anxiety which is produced by repressed id impulses. Anxiety is displaced from the id impulses to a fear object that is linked symbolically (and generally more acceptable). By avoiding the phobic object, one avoids dealing with repressed childhood conflicts.

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Epidemiology Anxiety is the most prevalent mental health disorder in children and teens Estimated at 6 – 20% Difficult numbers because subthreshold anxiety (not meeting DSM criteria) can also cause severe disability Developmental progression of anxiety disorders in adulthood Untreated childhood anxiety typically continues into adulthood Leads 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 Press. Costello et al, 2004

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Epidemiology (2) Girls are more likely than boys to report an anxiety disorder, esp. specific phobia, panic, agoraphobia, & separation anxiety disorder Children often develop new anxiety disorders over time (even if the old ones go away) Anxiety or depressive disorders in adolescence predict a 2-3x increase risk of anxiety or depression in adulthood (Pine et al, 1998) and lower academic achievement (Woodward & Fergusson, 2001) Anxiety in the 1st grade has been shown to predict anxiety and low academic achievement in reading and math in the 5th grade (Ialongo et al, 1995)

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Epidemiology (3): Non-Referred High prevalence of anxiety disorders in non-referred children: 3.5% for Separation Anxiety D/O 2.9% for Overanxious D/O 2.4% for Simple Phobia 1% for Social Phobia (Anderson et al, 1987) Bowen (1990) reported 3.6% prevalence of Separation Anxiety D/O and 2.4% prevalence of Overanxious D/O in 12 – 16 y/o population Lifetime prevalence of panic d/o was 0.6% and for GAD 3.7% (Whitaker, 1990)

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Epidemiology (4) A pediatric primary care sample of 7 – 11 y/o revealed a 1-year prevalence of anxiety d/o of 15.4%; Simple Phobia (9.2%), Separation Anxiety D/O (4.1%), and Overanxious D/O (4.6%) were most common (Benjamin 1990) A 3 – 4 year f/u study of children/adolescents with anxiety d/o showed a high remission rate with 82% no longer meeting criteria for their initial anxiety d/o (Last et al) Separation Anxiety D/O had the highest recovery rate (96%) and panic the lowest (70%); during this f/u period, 30% of children developed new psych d/o and half developed new anxiety d/o

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Risk and Protective Factors Behaviorally inhibited young children have a greater likelihood of anxiety disorders in middle childhood Offspring of parents with anxiety disorders have a greater risk of anxiety disorder and high levels of functional impairment Insecure attachment relationships with caregivers (specifically anxious/resistant attachment) increases the risk of childhood anxiety disorders

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

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

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DSM Diagnoses (1) DSM III-R included only 3 childhood anxiety disorders: (1) Separation Anxiety Disorder (which remains); (2) Overanxious Disorder, which is now subsumed under GAD; and (3) Avoidant Disorder, which is now subsumed under Social Phobia

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DSM Diagnoses (2) DSM-IV disorders include: Separation Anxiety Disorders Panic Disorder Specific Phobia Social Phobia (Social Anxiety Disorder) Obsessive-Compulsive Disorder Posttraumatic Stress Disorder Acute Stress Disorder Generalized Anxiety Disorder Others: Selective Mutism Somatic symptoms Trichotillomania

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DSM: Separation Anxiety Disorder Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by 3 or more: Excessive distress upon separation from home or attachment figures occurs or is anticipated Excessive worry about losing or harm befalling attachment figures Excessive worry that an event will lead to separation from an attachment figure (e.g., kidnapping) Reluctance to attend school b/c of fear of separation Reluctance to be alone or without attachment figures at home or other locations Reluctance to sleep alone or away from home Repeated nightmares involving separation Repeated complaints of physical symptoms when separation occurs or is anticipated Duration at least 4 weeks

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Separation Anxiety Disorder Affected children tend to come from closely knit families The kids may exhibit social withdrawal, apathy, and sadness or difficulty concentrating when separated Concerns about death and dying are common These children are often viewed as demanding Adults with SAD are typically over-concerned about their children and spouses Prevalence estimates about 4% in children and young adolescents More common in 1st degree relatives than general population

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Panic Attacks NOT A DISORDER! Quite common among adults

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

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Relationship between PD and other Anxiety Disorders

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What does a panic attack look like in a child? Children generally report physical symptoms, rather than psychological symptoms May suddenly appear frightened or upset without explanation Often 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 experience Adolescents are generally better at describing what they experience, especially after the attack has ended *rarer in children

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DSM: Panic Disorder Both (1) and (2): recurrent unexpected Panic Attacks at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: persistent concern about having additional attacks worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”) a significant change in behavior related to the attacks Absence of Agoraphobia 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., hyperthyroidism). The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared 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 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 away from home or close relatives).

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Panic Disorder Patients often are hypersensitive about physical cues and medication side effects 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 precedes the panic 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 strongly comorbid, along with hypochondriasis. No consistent abnormalities in lab results, but compensated respiratory alkalosis (decreased bicarb/CO2 with almost normal pH) sometimes noted. Lactate and elevated CO2 can be used to induce panic in sufferers Correlation with numerous general medical symptoms, including dizziness, arrhythmias, 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 sufferers 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 for mental health consultation); 10-30% in general medical clinics and up to 60% in cardiology clinics 1/3 to ½ of community samples has comorbid agoraphobia, but the co-occurrence is much higher in clinical samples Age at onset varies, but typically late adolescence/mid-30s; occasionally onset in childhood; after 45 y/o rare. Agoraphobia typically develops within the first year, but can occur at any time 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.

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DSM: Specific Phobia Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood) Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack. In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. The person recognizes that the fear is excessive or unreasonable. In children, this feature may be absent. The phobic situation(s) is avoided or else is endured with intense anxiety or distress. Types: Animal Type Natural Environment Type (e.g., heights, storms, water) Blood-Injection-Injury Type Situational Type (e.g., airplanes, elevators, enclosed places) Other Type (e.g., fear of choking, vomiting, or contracting an illness; in children, fear of loud sounds or costumed characters)

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

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

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

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Obsessive Compulsive Disorder Insanity is doing the same thing over and over again and expecting different results. -Albert Einstein

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DSM: Obsessive-Compulsive Disorder Either obsessions or compulsions: Obsessions as defined by (1), (2), (3), and (4): *recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress *the thoughts, impulses, or images are not simply excessive worries about real-life problems *the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action *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 insertion) Compulsions as defined by (1) and (2): *repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly *the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive Affected individual has recognized that the obsessions or compulsions are excessive or unreasonable. This does not apply to children. Time consuming (more than 1 hour/day)

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

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

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DSM: Post-Traumatic Stress Disorder 1) Exposed to a traumatic event in which: 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 physical integrity of self or others The person’s response involved intense fear, helplessness, or horror. In children, this may be expressed instead by disorganized or agitated behavior. 2) The traumatic event is persistently reexperienced in one (or more) of the following ways: Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. Recurrent distressing dreams. In children, there may be frightening dreams without recognizable content Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes). In young children, trauma-specific reenactment may occur Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

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DSM: Post-Traumatic Stress D/O (2) 3) Physiological reactivity on exposure to internal or external cues 4) Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: efforts to avoid thoughts, feelings, or conversations associated with the trauma efforts to avoid activities, places, or people that arouse recollections of the trauma inability to recall an important aspect of the trauma markedly diminished interest or participation in significant activities feeling of detachment or estrangement from others 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, marriage, children, a normal life span) Persistent symptoms or increased arousal (not present before the trauma), as indicated by two (or more) of the following: difficulty falling or staying asleep irritability or outbursts of anger difficulty concentrating hypervigilance exaggerated startle response Duration of the disturbance is more than 1 month.

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PTSD Types of Trauma Child Maltreatment Community violence (witness, victim) Natural disasters (fires, hurricanes) Motor vehicle collisions Disasters (fires, earthquakes) War and terrorism

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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

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PTSD Prevalence Prevalence following war / terrorism War PTSD diagnosis-Current 18%-37% PTSD diagnosis-Lifetime 21% Severe PTSD symptoms 31% Oklahoma City 36%

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PTSD (In the brain) Normal Brain: Look at the Hippocampus!

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PTSD (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.

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PTSD (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.

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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

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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

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

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PTSD (2) Partial symptomatology is common The “fight or flight” response is less adaptive in young children than adults Comorbid conditions are common Girls are generally more symptomatic than boys Younger children seem to demonstrate more avoidance symptoms, whereas older children suffer more reexperiencing and arousal increases

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DSM: Acute Stress Disorder The person has been exposed to a traumatic event in which both of the following were present: 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 physical integrity of self or others The person’s response involved intense fear, helplessness, or horror Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms: A subjective sense of numbing, detachment, or absence of emotional responsiveness A reduction in awareness of his/her surroundings (e.g., “being in a daze”) Derealization Depersonalization 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: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving 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, feelings, conversations, activities, places, people) Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, 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 within 4 weeks of the traumatic event

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

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DSM: Generalized Anxiety Disorder Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). The person finds it difficult to control the worry. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Only one item is required in children. restlessness or feeling keyed up or on edge being easily fatigued difficulty concentrating or mind going blank irritability muscle tension sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

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

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DSM: Selective Mutism Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations Duration of at least one month with significant disturbance

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Selective Mutism Associated features often include shyness, fear of social embarrassment, social isolation, and withdrawal, clinging, negativism, temper tantrums, and oppositional behavior (esp at home) Teasing by peers is common Although affected children usually have normal communication skills, SM is occasionally associated with a communication disorder <1% of kids seen in mental health settings Onset is usually before age 5

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DSM: Trichotillomania Recurrent pulling out of hair resulting in noticeable hair loss An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior Pleasure, gratification, or relief when pulling out the hair

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Trichotillomania Sites of hair pulling may include any region of the body (most common is the head, eyebrows, and eyelashes, but also axillary, public, perirectal occur) May occur in episodes scattered throughout the day or in less frequent but sustained periods lasting for hours Often occurs during periods of relaxation and distraction (e.g., watching TV or reading) but may occur during stress as well Examining the hair root, twirling it off, pulling the strand between the teeth, or trichophagia (eating hairs) may occur and can result in bezoars Histological examination of affected areas shows damage to hair follicles and short, broken hairs No gender differences among children; women>men Occurrence is unknown; 0.6% lifetime rate among a study of college students Affected individuals often deny the hair pulling People may pull hair from pets, dolls, or clothes

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Assessment of Anxiety in Children There is often low concordance between child and parent reports of anxiety Mothers tend to over-report anxiety symptoms

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Rating Scales Screen for Child Anxiety Related Emotional Disorders (SCARED) Multidimensional Anxiety Scale for Children (MASC) CYBOCS Leyton Inventory Achenbach (Child Behavior Checklist)

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Treatment of Anxiety Disorders in Children (Psychotherapy) An insecure bond between parent and child may be an important contributing etiologic factor; thus treatment aimed at improving these interactions is crucial CBT Indications: OCD and phobias (with ERP), Panic, GAD, SAD Two studies support the use of psychodynamic psychotherapy (Heinicke)

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Treatment of Anxiety Disorders in Children (Medication) Four DBPC studies of TCAs for school refusal show conflicting results Case reports support the use of TCAs for children/adolescents with Panic D/O Alprazolam may be useful in children with overanxious or avoidant disorders Benzodiazepines may be useful for adolescents with Panic D/O Alpha-2 agonists and beta-blockers may be effective for PTSD

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

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CAMS Child and Adolescent Anxiety Multimodal Study (CAMS), 2008 (Walkup et al, 2008). Compared CBT, medications, and combined for treatment of anxiety disorders Randomly 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 groups All treatments were statistically more effective than placebo, which led to improvement in only 24% of subjects.

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

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OCD Medication Studies Clomipramine -DeVeaugh-Geiss et al., 1992 Fluoxetine - Riddle et al., 1992 Sertraline - March et al., 1998 Fluvoxamine - Riddle et al., 2001 Fluoxetine - Geller et al., 2001 Paroxetine - Geller et al., 2004

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Sertraline in Pediatric OCD March et al, 1998 DBRPC 12 week multisite trial N = 187; age = 6-17 years; sertraline 200 mg/d Sertraline > placebo Mild side effects Similar profile of response as clomipramine

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Fluvoxamine in Pediatric OCD Riddle et al, 2001 DBRPC multisite trial N = 120; age = 8-17 years; fluvoxamine 50-200 mg/d Fluvoxamine > placebo Mild side effects

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Fluoxetine in Pediatric OCD Geller et al., 2001 N=103, ages 7-17 years 13 week RDBPC trial Dose 10-60 mg/day Decrease CY-BOCS favored fluoxetine (p<.026)

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Paroxetine for Pediatric OCD Geller et al, 2004 DBPCR 10 week trial Ages 7-17 N=203 Paroxetine > placebo Mild side effects

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OCD Augmentation Strategies Clomipramine Clonazepam Antipsychotics IV Clomipramine Buspirone Add second SSRI Lithium Stimulants Others???

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Pediatric OCD Treatment Study (POTS) N = 112 Ages 7-17 years 3 sites, 12 weeks Randomly assigned to CBT, Sertraline, COMB and placebo PBO

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PTSD Treatment Debriefing is a popular intervention after disaster; unfortunately, there is little evidence documenting its effectiveness Treatment involves transforming the child’s self-concept from victim to survivor Projective interventions should include steps depicting recovery to increase the sense of mastery The literature suggests that desensitization, relaxation, and other behavioral techniques are beneficial in treating children with PTSD, but research is lacking Revenge fantasies complicate emotional resolution

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PTSD Sertraline Treatment of Children and Adolescents With Posttraumatic Stress Disorder, RDBPC (Robb et al, 2011) 131 children and adolescents (6–17 years old) meeting DSM-IV criteria for PTSD received 10 weeks of double-blind treatment with sertraline (50–200mg/day) or placebo; primary efficacy measure UCLA PTSD-I Randomized to sertraline (n=67; female, 59.7%; mean age, 10.8) or placebo (n=62; female, 61.3%; mean age, 11.2) There was no difference between sertraline and placebo in least squares (LS) mean change in the UCLA PTSD-I score, either on a completer analysis (−20.4±2.1 vs. −22.8±2.1; p=0.373) or on an last observation carried forward (LOCF) end point analysis (−17.7±1.9 vs. −20.8±2.1; p=0.201) 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 placebo Sertraline was a generally safe treatment in children and adolescents with PTSD, but did not demonstrate efficacy when compared to placebo during 10 weeks of treatment

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PTSD Treatment (2) Small open trials have suggested propranolol and clonidine for persistent arousal Zoloft and Paxil FDA approved for adults; small open trials have suggested the same for SSRIs in children; gabapentin and antipsychotics sometimes reportedly useful in adults EMDR (Eye Movement Desensitization Retraining) eye movement therapy shown effective in adults and one child trial (Chemtob et al, 2000, adults; Ahmad & Sundelin-Wahlsten, 2008, children)

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N-acetylcysteine NAC is a metabolite of cysteine, an amino acid; its metabolite, cystine, reduces synaptic release of glutamate and enhances glial clearance of glutamate, protecting against glutamate toxicity The restoration of the extracellular glutamate concentration in the nucleus accumbens seems to block compulsive behaviors Single case report of a patient with SSRI refractory OCD, who received augmentation of Prozac with NAC led to marked decrease in Y-BOCS (Lafleur et al, 2006) Randomized DBPC study of 45 women and 5 men with trichotillomania (ages 18 – 65) were assigned to 12 weeks of NAC up to 2400 mg/d vs. placebo; after 9 weeks of treatment, 54% of those taking NAC responded to treatment favorably (Grant et al, 2009)