Anxiety Flashcards
What is anxiety
Recurrent emotional and physiological arousal in response to excessive perceptions of threat or danger
Common anxiety disorders of childhood
Generalised anxiety disorder
Social anxiety
Agoraphobia
Panic disorder
Separation anxiety disorder
Selective mutism
Specific phobia
Link between social, separation and generalised anxiety
Highly comorbid->60% chance of having more than one
When does normative separation anxiety peak and diminish
Peaks at 9-18 months and diminished at 2.5 years
Describe behaviourally inhibited children
Higher risk develop separation, social, GAD
Higher resting HR, +morning cortisol, low HR variability
Criteria Separation anxiety disorder
A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:
- Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
- Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
- Persistent and excessive worry about experiencing an untoward event (eg, getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
- Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.
- Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
- Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.
- Repeated nightmares involving the theme of separation.
- Repeated complaints of physical symptoms (eg, headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.
B. The fear, anxiety, or avoidance is persistent, lasting at least four weeks in children and adolescents and typically six months or more in adults.
C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.
D. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.
Criteria Generalised anxiety disorder
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past six months):
Note: 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)
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition (eg, hyperthyroidism).
F. The disturbance is not better explained by another mental disorder (eg, anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder (social phobia), contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).
Criteria Social Anxiety disorder
A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (eg, having a conversation, meeting unfamiliar people), being observed (eg, eating or drinking), and performing in front of others (eg, giving a speech).
Note: In children, the anxiety must occur in peer settings and not just during interaction with adults.
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (ie, will be humiliating or embarrassing; will lead to rejection or offend others).
C. The social situations almost always provoke fear or anxiety.
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for six months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
J. If another medical condition (eg, Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
Specify if performance only — If the fear is restricted to speaking or performing in public.
The diagnosis of social anxiety disorder requires that a child has age appropriate relationships with the people familiar to him, and anxiety around less familiar peers and adults
Lifetime prevalence of any anxiety disorder in children
10-27%, most common GAD
Biopsychosocial factors in separation/social/general
Parental overprotection
Insecure parent-child attachment
Maternal depression/anxiety
Temperamental: shyness, withdrawl in unfamiliar situations
Death, illness, change environment
+activation amygdala in stress, hyperactivation
Social learning factors
Parent modelling of anxiety->phobic adaptation
Overprotection-> interpersonal sensitivity
Genetic factors
Accounts for 1/3 variance
36-65% heritability
Behavioural inhibition and physiological hyperarousal
Emotional reactivity
Increased negative affect
Differential diagnosis
GAD
Soc AD
MDD
Panic disorder w/ agorophobia
PTSD
ODD
Dysthymic
Selective mutism
ADHD
OCD
Predictors of future rmission
Younger age at initiation of treatment
Lower severity
Absence of comorbid depressive/anxiety
Absence of primary anxiety disorder being social anxiety
Most recover in first year
Predictors of slower recovery
Early age onset, later treatment
Treatment of spearation/soc/GAD
CBT
Family education
Family psychosocial intervention
SSRIs->fluvoxamine, fluoxetine, sertraline, paroxetine
Best EBM= CBT (exposure)+ SSRI->if able to manage daily activities, start with CBT. If severe combination.
Coping Cat, CALM program
Before presrcibing for anxiety disorders
Exclude other diagnoses->
- Psychiatric: depression (inattention, sleep), bipolar (irritability, sleep, restless), ODD (irritability, oppositional), psychotic (withdrawal, restless), ADHD (inattention restless) , learning disability
- Medical:
a) hyperthyroid, hypoglycemia, phaeochromocytoma
b) Migraine, seizures, delirium, tumor
c) arrythmias, asthma, lead
d) asthma med, sympathomimetics, sterois, SSRI, antipsychotics, diet, cold, caffeine, energy drinks
Beware contraindications/interactions
Measure baseline severity: ADIS, Kiddie-Schedule for Affective disorders and SchizoP, RCADS. SCARED, MASC, CGI
Obtain consent
Prescribing for anxiety
81% response with CBT and sertraline
Blackbox warning->for depressive, not based on anxiety
Venlafaxine second line
Benzo use not supported by controlled trials->however may be considered to potentiate initial titration with SSRIs and for rapid tranquilisation
After prescribing
Acute: start low, titrate. Monitor response. SE->GIT, HA motor, insomnia
Effect should be 3-6 weeks, max at 12-16
If partial/no-> diagnosis, adequacy, compliance
Consider adding CBT, changing med, combingin
Maintenence: continue for 1 year of stable improvement
Discontinuation: trial off med started at low demand time
Taper slowly
Monitor for recurrene
Externalising disorders of childhood
ADHD, ODD, Conduct disorder
When does SAD normally present
Generally prepubertal condition presenting 7.5 years.
More in females, although no difference in symptom presentation
Is SAD more common in upper/middle or lower SES
Lower-> perhaps owing to hidden biological propensity more likely expressed owing to cumulative stress burden, higher in children from impoverished settings
Etiology of SAD
Inadequately reslved separation/individuation conflict
Vulnerability determined by temperament
Security of attachment
Behavioural contingencies
Decisive empirical data lacking
Possible precipitants for acute onset SAD
Move, change of school, loss of a loved one, illness, prolonged absence from school
Waxes and wanes
Greater risk of chronicity for SAD
Later age onset
Comorbidities
Familial pathology
Missing >1 year school
Most common co-morbidities for SAD
GAD and speciic phobias
Depression->typically preceeds
+panic disorder= ++functional impairment
Important history in SAD
Preceeding events
Response to parens departure
Ensuing behaviour
Consequences of separation
Symptoms: thoughts/worries/nightmares about separation
Anxiety rating scales
Screen for child anxiety related emotional disorders
Multidimensional Anxiety Scale for Children
Normal developmental fears
Differential diagnosis for SAD
(school refusal eg)
ODD, CD
Other anxiety disorders
Mood disorders
Psychotic disorders, PTSD, Panic,
Pervasive development disorder, learning disorders
Peak age for school refusal
5-6, 10-11 and 13-15
Transitory periods
DDx for school refusal
SAD
GAD
Specific phobia
Social phobia
Panic disorder
PTSD
OCD
Conduct/ODD->truancy
‘Treatment’ for school refusal
<2 weeks->inform parnts of disorder, get cooperation, encourage.
SHow emapathy/understanding, insit in firm way for regular school attendance
Provide skills to master fears
Parent may attend class initially eg
Reward ‘brave’ behaviour
>2 weeks->CBT, School refusal assessment scale to identify the negative.positive reinforces
