Wisconsin Alliance of Child Psychiatry & Pediatrics (WACPP) Lunch and Learn Webinar: Anxiety in Children and Adolescents October 10 th, 2012

Transcription

1 Wisconsin Alliance of Child Psychiatry & Pediatrics (WACPP) Lunch and Learn Webinar: Anxiety in Children and Adolescents October 10 th, 2012

2 Financial Disclosure In accordance with the ACCME standard for Commercial Support Number 6, all in control of content disclosed any relevant financial relationships. The following in control of content had no relevant financial relationships to disclose. Name: Joseph O Grady, MD James Meyer, MD Kia LaBracke Susanne Way Moitreyee Reddy, MD Atit Desai, MD Role in Meeting: Planning Committee Planning Committee Planning Committee Planning Committee Presenter Presenter

3 Statements Accreditation: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Medical College of Wisconsin and Wisconsin Alliance of Child Psychiatry & Pediatrics. The Medical College of Wisconsin is accredited by the ACCME to provide continuing medical education for physicians. AMA Credit Designation: The Medical College of Wisconsin designates this Live Activity for a maximum of 1 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity.

4 Acknowledgements The Wisconsin Alliance of Child Psychiatry & Pediatrics (WACPP), established in 2009, is a collaboration between the Wisconsin Council of Child and Adolescent Psychiatry (WCCAP) and the Wisconsin Chapter of AAP (WIAAP Foundation). These WACPP Mental Health Webinars are funded in part by the Landis Endowment of the Wisconsin Medical Society Foundation and an American Academy of Pediatrics (AAP) Educational Grant supported by Mead Johnson.

5 Wisconsin Alliance of Child Psychiatry and Pediatrics Pediatrics Course Director and Facilitator: James Meyer, M.D. FAAP Adolescent Medicine specialist Marshfield Clinic President Wisconsin Chapter, American Academy of Pediatrics (WIAAP)

6 Wisconsin Alliance of Child Psychiatry and Pediatrics Psychiatry Course Director and facilitator: Joseph O Grady Jr. M.D. FAAP Associate Professor of Clinical Psychiatry Medical College of Wisconsin jogrady@mcw.edu Medical Director Phoenix Care Systems Inc

7 Faculty Atit Desai M.D. Madison Psychiatric Associates Moitreyee Reddy M.D. MCW/CHW Psychiatry

8 Session Outline Case Study overview Didactic presentation on anxiety Case studies review principles of management Question and answer session

9 WACPP Mental Health Webinar Today s webinar is an educational activity, not a specific case consultation activity. For a specific case consultation need, we would refer you to a child and adolescent psychiatrist for a clinical consultation

10 Today s Educational Goals Know and apply diagnostic criteria for anxiety Know and apply the indications for medication treatment of anxiety Know and apply indications for referral to a child and adolescent psychiatrist Know and apply the indications for hospitalization for anxiety Know and apply medication treatment options and monitoring for adverse medication effects

11 Case: Sarah Presents January, 2011, age 16, stating her asthma meds are not working and coaches are frustrated with her. Reports only during BB games but not in practice she feels like she can t catch her breath/take a deep breath. Progresses to feeling scared, fears she will die and has had paresthesias. This does not occur in practice and she improved her times in cross country in the fall. PCP diagnosed her with exercise induced asthma one year ago with this same complaint based on Hx and apparent response to albuterol used prior to exercise. Over time felt that it was not working and Advair was added(250/50).

12 Case: Sarah Worries about everything-needs to know what is coming at her in advance. Likes routines. Upset with worry if parents not home when they are expected. Sense of SOB, sweats and dread out of blue 1X/month. Relieved by getting away from people. Somewhat meticulous with order/neatness but not wasting large amounts of time on that. Gets frequent HA s. Worse if stressed. Delayed sleep onset, wakes early and feels tired. No abuse, disordered eating or suspected drugs.

13 Case: Sarah Social Hx Splits time between mom and dad/dads GF homes. Parents split up one year ago. Two older full siblings and one infant half paternal sib. Mom a homemaker. Dad a teacher. 11th grade B student. Pushes herself hard for grades. Feels she does not concentrate well. Connected well with peers and no drug use.

14 Case: PMHx Sarah No prenatal problems. No major early colic, developmental or temperament issues and ok early transitions. No Hx of allergies early bronchospasm. Long standing headaches. Use to miss some school with headaches more in middle school than currently. Prior amitriptyline for prevention of HA s.

15 Case: Sarah FHx Mom on meds for anxiety/depression over past 10 years (citalopram with occasional lorazepam). Has migraines. Sister with exercise induced respiratory symptoms initially thought to be EIA but later diagnosed with vocal fold dysfunction with GERD. No FHx of sudden death, arrthymia, early heart disease and no one has asthma/allergies/eczema.

16 Introduction Multiple anxiety disorders can be diagnosed during childhood; however, according to DSM-IV, only separation anxiety is classified as a childhood-onset disorder. Estimates of the prevalence of any anxiety disorder in exclusively child and adolescent subjects range from 7.5% to nearly 26%.

17 Separation Anxiety Disorder (SAD) Separation anxiety is defined as excessive anxiety that occurs when a child is separated from home or from significant attachment figures. Such anxiety occurs as part of normal development in children around the age of 2 years. However, when symptoms have an onset later during childhood and they become excessive to the point of impairing functioning, a disorder is diagnosed.

18 Separation Anxiety Disorder (SAD) Afflicted children have excessive anxiety when separated from parents (or other important figures) and excessive worry (about losing someone or something happening to their primary caretaker). Prevalence decreases with increasing age. Lifetime prevalence is 4% of school-age children and 1% of adolescents; gender ratio is somewhat higher for females than males 4.3%:2.7%

19 Separation Anxiety Disorder (SAD) Children and adolescents with SAD often have difficulty attending school, participating in extracurricular activities, and attending sleepovers. Academic achievement, peer relationships, and overall maturation is often compromised. School refusal, although NOT a separate DSM-IV diagnosis, is a childhood symptom commonly presumed to be the behavioral manifestation. However, school refusal can be associated with many different diagnoses, including SAD, specific phobia of school, and depression.

20 Generalized Anxiety Disorder (GAD) The main feature of this disorder is excessive anxiety and worry present for at least 6 months. Children tend to worry about their ability to perform; the worries may be focused on school or athletic performance, even when they are not being evaluated. The anxiety also may be focused on catastrophic events (e.g. hurricane). These children are often perfectionists, which causes them to re-do tasks and seek constant reassurance that they have done well.

21 Generalized Anxiety Disorder (GAD) Lifetime prevalence is 1.7% of children and adolescents; gender ratio is approximately 2:1 female/male 2.4%:1% Age of onset is frequently in childhood or adolescence (50% of total patients).

22 Obsessive Compulsive Disorder (OCD) OCD manifests by recurrent and distressing ideas (obsessions) that are intrusive in one s thoughts. These thoughts may lead to repetitive behaviors (compulsions). Children s thoughts may include fears of contamination, or feelings of self-doubt or guilt. The resulting compulsive behaviors that alleviate the obsessions include checking, counting, hand washing, and touching.

23 Obsessive Compulsive Disorder (OCD) Current research focuses on whether early-onset or juvenile OCD is a unique subtype of the disorder. Proposed subtypes include: early-onset, tic-related streptococcal-precipitated NOTE: OCD is different from OCPD (obsessivecompulsive personality disorder). Lifetime prevalence is 1.9%, perhaps as common as 3% in adolescents.

24 Specific Phobia Commonly known as Simple Phobia. An irrational fear of certain specific things (e.g., animals, blood, needles) or situations (e.g., closed spaces, airplanes, heights); because of the fear, the thing or situation is avoided. 5 subtypes as specified by DSM-IV animal type, natural environment type, and bloodinjection-injury type all usually begin in childhood. Quite common; the lifetime prevalence rates range from less than 1% to as high as 9.2%.

25 Specific Phobia School phobia is sometimes used broadly with reference to children who refuse or resist going to school for any reason. In fact, children may resist going to school for a variety of reasons, including specific phobia, another anxiety disorder, depression, conduct disorder (truancy), substance abuse, or family psychopathology a more precise use of the term school phobia would be restricted to describing a child s fear of something specific about school the school situation, such as a specific teacher or peer, taking a shower after gym class, or something encountered on the way to school.

26 Panic Disorder Panic disorder with or without agoraphobia most often begins in early adolescence or early adult life but may develop at any age. The symptoms, course, and associated complications and co-morbid conditions (agoraphobia, depression) in children and adolescents with panic disorder appear to be very similar to those observed in adults. The most commonly reported symptoms among adolescents with panic attacks are trembling, dizziness or faintness, pounding heart, nausea, shortness of breath, and sweating. Cognitive symptoms are reported less than somatic ones.

27 Panic Disorder An important and common feature in children and adolescents is co-morbid separation anxiety disorder. Panic disorder is characterized by recurrent, unexpected panic attacks about which there is persistent concern. Panic disorder has a lifetime prevalence of %. More commonly diagnosed in girls (2:1 female/male ratio).

28 Panic Disorder PANIC ATTACKS Discrete episodes of intense anxiety. Develop abruptly and peak within 10 minutes; lasting for approximately 30 minutes; occur approximately 2x/week.

29 Panic Disorder Associated with at least 4 other symptoms of autonomic arousal: Cardiac symptoms: palpitations, tachycardia, chest pain, or discomfort Pulmonary symptoms: shortness of breath, or a feeling of choking Gastrointestinal symptoms: nausea or abdominal distress Neurological symptoms: trembling and shaking, dizziness, light-headedness, faintness, or paresthesias Autonomic arousal: sweating, chills, or hot flashes Psychological symptoms: derealization, depersonalization, a fear of losing control or going crazy, or a fear of dying

30 Panic Disorder Whereas the initial panic attack is usually spontaneous, subsequently, apprehension frequently develops about future attacks (anticipatory anxiety). Agoraphobia, a complication of panic disorder, involves anxiety about, or avoidance of, places or situations from which ready escape might be difficult, or from which escape might be embarrassing, or where help may be unavailable in the event of a panic attack. Agoraphobia can significantly restrict a person s daily activities; some individuals may become homebound.

31 Social Phobia Commonly known as Social Anxiety Disorder. Social phobia involves a fear of embarrassment in social situations. Children may exhibit their fears by crying or staying close to familiar adults. They may appear to be very shy and often are on the periphery in social situations. Unlike adults, children are often unable to avoid the situations that cause anxiety (e.g. school) and/or are unable to identify the source of the anxiety. The phobia must be present in same age peer group situations, not just with adults. Avoidant personality disorder is a closely related diagnostic category. Prevalence is approximately 1% in the childhood and adolescent population.

32 Selective Mutism The absence of speech (or an extreme reluctance to speak) in specific social situations in a child who is able to and does so in other situations. The severity varies across a spectrum from situations in which speech is completely avoided to situations in which speech is completely uninhibited Shyness, fear of embarrassment, and social withdrawal have been commonly mentioned as characteristics of children with selective mutism. Nearly every child with selective mutism meets criteria for either social phobia or avoidant disorder. It has been suggested that early trauma or PTSD is associated with selective mutism, however, empirical studies have failed to support this theory. Prevalence rates are low - from.03% to.18%

33 Post-traumatic Stress Disorder (PTSD) Children with PTSD experience or witness a traumatic event and develop symptoms of the disorder subsequent to the trauma. The symptoms of the disorder include reexperiencing of the event (e.g. recurrent intrusive recollections of recurrent distressing dreams of the event), autonomic arousal (e.g. increased heart rate or blood pressure), and avoidance of any stimuli associated with the trauma. Prevalence rates in children and adolescents vary widely depending on the situation and severity of exposure.

34 References Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright 2000 American Psychiatric Association. Textbook of Child and Adolescent Psychiatry, Third Edition. Wiener and Dulcan. Copyright Massachusetts General Hospital Psychiatric Update and Board Preparation, Second Edition. Stern and Herman. Copyright 2004.

35 Anxiety disorders Multimodal approach including psycho-education of patient and family, psychotherapy, medications should be part of treatment plan. Exposure based CBT has the most empirical support for treatment of anxiety in youth. Elements of CBT involve: Psycho-education, Somatic management skills, Cognitive restructuring, Exposure methods, Relapse prevention plans (Albano and Kendall 2002)

36 Anxiety disorders Indications for medication treatment Moderately to severe anxiety symptoms Impairment makes participation in psychotherapy difficult A comorbid disorder that requires concurrent treatment Partial response to psychotherapy Potential for improved outcome with combined treatment Lack of access to psychotherapy Patient and family preference (March, 2002; Ollendick and March, 2004, Birmaher et al., 1998; Labellarte et al., 1999)

37 Indication for Referral to a Child and Adolescent Psychiatrist 1) Unclear diagnosis because of comorbidities, parental confusion and dispute about their symptoms, parental discord, and discrepancies between what you see and what parents and school report, etc. 2) Initial course of 2-4 weeks of conservative medication treatment doesn t cause an appreciable improvement.

38 Indication for Referral to a Child and Adolescent Psychiatrist (continued) 3) Patient s symptoms are getting worse in spite of adequate treatment. 4) Initial course of 2-3 months of psychotherapy has not fostered appreciable stability. 5) Recurrence of the symptoms in spite of adequate treatment. 6) A number of people in the family with serious psychopathology. 7) Serious impairment in functioning in the home and/or school settings.

39 Indication for Hospitalization 1) Anxiety states triggering suicidal thinking or significant depressive symptoms. 2) Aggression which is hard to manage at home or school, and may risk the safety of the patient and others. 3) The patient who has been resistant to adequate treatment and continues to deteriorate. 4) Severe school refusal that may require inpatient hospitalization or day treatment programming for stabilization.

40 Anxiety disorder Medication options SSRI s are first choice medications FDA indicated medications for OCD Sertraline 6-17 yrs Fluvoxamine 8-17 yrs Fluoxetine 7-17 yrs Clomipramine yrs Start low dose, go slow Maintain for a year-gradual taper in low stress period

41 Anxiety medication Side effects monitoring Screen for mania, educate about risk Educate about black box warning for Suicidality Gastrointestinal symptoms Headaches Increased motor activity Insomnia Disinhibition should also be monitored

42 Anxiety medication Side effects monitoring FDA Boxed warning on antidepressants: Depression is associated with an increase in risk of suicide Monitor appropriately and observe closely for clinical worsening, suicidal thinking, or unusual changes in behavior NNT for antidepressants 3 for Anxiety disorders / 6 for OCD, NNH for antidepressants was 143 Anxiety, 200 for OCD SI risk in Anxiety disorders was 1% vs 0.3% placebo, for OCD 1% vs 0.2 % (Bridge JAMA 4/07)

43 Other Medications No established evidence for use of TCA for anxiety disorders (except Clomipramine for OCD) Higher risk with TCA-cardiac, overdose risks, anticholinergic s.e. Buspirone alternative for GAD- less evidence Well tolerated-lightheadedness, headache, and dyspepsia common side effects Benzodiazepines only short term adjunctive use for rapid symptom reduction e.g. panic, school refusal Side effects - withdrawal, sedation, disinhibition, cognitive impairment,risk of diversion/abuse

44 Randomized Controlled trials of medications in Pediatric Anxiety Disorders (Strawn et al, CANA,July 2012 )

45 CAMS study (Child-Ad Multimodal Anxiety study) NIMH, RCT, 7-17 yrs, 12 wk Separation Anxiety, GAD, Social phobia 4 groups- Sertraline / CBT/ Sertraline plus CBT / Placebo Response 80% combined, 54% Sertraline 59% CBT, 23.7 % Placebo Effect size 0.8 Comb> 0.4 Sertraline, CBT 0.31 No increased rate of SI in med group No suicides attempts (Walkup et al NEJM 2008;359)

46 Additional reference AACAP Practice Parameter for treatment of Anxiety Disorders Vol. 46, Feb 2007 Psychopharmacological Treatment of Children & Adolescents with Anxiety disorders, Strawn et al, July 2012, Vol 21, Child and Adolescent Clinics of North America