2/23/18. Age of Anxiety: Transforming Qualms into Calm. Disclosures. Objectives. I have nothing to disclose

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1 Age of Anxiety: Transforming Qualms into Calm Rosa Kim, MD Assistant Professor and Attending Child Psychiatrist Medical College of Wisconsin and Children s Hospital of Wisconsin Disclosures I have nothing to disclose Objectives Upon completion of this course, you will be able to 1) diagnose the second most common mental illness in children 2) identify the primary therapeutic interventions to treat anxiety 3) dose, titrate, and monitor medications as treatments of anxiety 1

2 Most Common Mental Illnesses in Children 1. ADHD prevalence: 13% presents ages Anxiety Disorders prevalence: 8-10% presents ages Depression prevalence: 2-8% presents ages Anxiety Disorders vs. Normal Anxiety Normal Anxiety Predictable triggers (e.g., exams) Proportionate reaction Can happen any time throughout development Pathological Anxiety Triggers are normative experiences Excessive reaction Predictable ages of onset for subtypes Genetics and Environment Genetic vulnerability exists. Anxiety is self-perpetuating. Anxiety is contagious. 2

3 Anxiety Disorders Separation Anxiety Disorder Selective Mutism Specific Phobia Social Anxiety Disorder Panic Disorder Agoraphobia Generalized Anxiety Disorder Unspecified Anxiety Disorder Other Anxiety Disorders Obsessive-Compulsive and Related Disorders: o OCD o Body Dysmorphic Disorder o Hoarding Disorder o Trichotillomania o Excoriation Disorder Other Anxiety Disorders (cont d) Trauma- and Stressor-Related Disorders o Reactive Attachment Disorder o Disinhibited Social Engagement Disorder o PTSD o Acute Stress Disorder o Adjustment Disorders 3

4 Other Disorders with Anxiety Symptoms Neurodevelopmental Disorders (intellectual disability, ASD, ADHD, specific learning disorders, etc.) Mood Disorders Psychotic Disorders Somatic Symptoms Disorders Feeding and Eating Disorders Gender Dysphoria Substance Use Disorders Personality Disorders Anxiety Disorders Separation Anxiety Disorder Selective Mutism Specific Phobia Social Anxiety Disorder Panic Disorder Agoraphobia Generalized Anxiety Disorder Unspecified Anxiety Disorder Anxiety Patients rarely answer yes to the question, Is anxiety a problem for you? homesick (separation anxiety) worry worts (GAD) self-conscious, shy (SAD) worries often easily stressed 4

5 Characteristics Common to Anxiety Disorders Characteristics Common to Anxiety Disorders hypervigilance poor adjustment to novel situations biased interpretation of experiences as threatening avoidance as a coping strategy catastrophic reactions parental accommodations midline physical symptoms Midline Physical Symptoms tension headache dizziness hyperventilation lump in throat chest pain abdominal pain bowel and bladder urgency 5

6 Other Symptoms Other Symptoms sleep problems eating problems persistent need for reassurance inattention and poor school performance explosive outbursts avoidance of activities not necessarily pervasive Separation Anxiety Disorder excessive concern regarding separation from home or attachment figures the earliest of non-ocd anxiety disorders to present (around ages 6-8 years) see this in August and September 6

7 Selective Mutism variant of social anxiety disorder (more severe, earlier onset) has an ability to speak occurs more often in younger children Specific Phobia 70% have another anxiety disorder Social Anxiety Disorder fear of social or performance situations o generalized o specific presents in early childhood, but not impairing until adolescence 7

8 Panic Disorder presents later in adolescence attacks of anxiety persistent worry about the next panic attack avoidance behavior related to the attacks Generalized Anxiety Disorder excessive worry or fearfulness unable to control the worry impairment or distress presents around ages 9-11 years present in October, November (1 st report card) OCD Prominent Obsessions or Compulsions o dirt, germs, or other contamination o ordering and arranging o checking o repetitive acts Impairing or time consuming 8

9 PTSD true stressful event re-experiencing of the event avoidance and numbing increased arousal negative thoughts, feelings, and moods Anxiety and Substance Use Disorder Adolescents with anxiety/ptsd have a 2-fold risk for substance use disorder have anxiety as a trigger for substance use Diagnosing Anxiety SCARED (Screen for Child Anxiety and Related Emotional Disorders; child version and parent version) SCAS (Spence Children s Anxiety Scale) MASC (Multidimensional Anxiety Scale for Children) 9

10 First-Line Treatment of Anxiety Cognitive-Behavioral Therapy (CBT) should be the first-line treatment for both mild to moderate anxiety. Components of CBT Psychoeducation Techniques for managing somatic reactions (relaxation training, diaphragmatic breathing) Cognitive restructuring by identifying and challenging anxiety-provoking thoughts Practicing problem-solving Systematic exposures Relapse prevention Psychopharmacological Treatment of Anxiety 10

11 Psychopharmacological Treatment of Anxiety For severe cases, the recommendation is for CBT plus medications. SSRIs are the pharmacological treatment of choice. Anxiety typically requires higher doses of SSRIs and longer duration of treatment. Anxiety Treatment Algorithm 1) Optimize first-choice SSRI. 2) If that doesn t work, try another SSRI. 3) If that doesn t work, try another class. SSRIs Recommended monitoring: o monitor weekly for the first month (phone contact is sufficient) o biweekly for the next month o monthly thereafter 11

12 SSRI Contraindications Serotonin Syndrome and MAOIs o Do not use SSRIs within14 days to 5 weeks after stopping an MAOI. Potential Adverse Effects of SSRIs activation bipolar switch stomach upset platelet dysfunction appetite change serotonin syndrome frontal lobe symptoms QTc prolongation SSRI Warning FDA black box warning: 12

13 Suicidal Ideation MDD: NNT = 10 OCD: NNT = 5 Non-OCD anxiety disorders: NNT = 3 MDD: NNH = 100 OCD: NNH = 200 Non-OCD anxiety disorders: NNH = ~140 SSRI Metabolism SSRIs are metabolized, in part, by the cytochrome P450 system and should be administered with caution when used with other medications metabolized via this pathway. SSRI Titration Psychoeducation! Don t titrate too slowly. 13

14 Dosing Use clinical trials as guidelines: Fluoxetine: 40mg by week 12 (TADS, 2004) Sertraline: mg by week 10 (RUPP, 2001) Citalopram: 40mg (Uchida, 2017) Escitalopram: 20mg (Emslie, 2009) Duloxetine: mg (Strawn, 2015) Treatment Duration Continue medications for at least 6-12 months following symptom remission. CBT is a durable treatment. Anxiety tends to be more constitutional. SSRI Discontinuation Doses should be tapered slowly while the patient is monitored for potential symptom recurrence. The exception to this is fluoxetine (Prozac). 14

15 SSRIs Name Fluoxetine (Prozac) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) Paroxetine (Paxil) Fluvoxamine (Luvox) Dose Range 10-60mg mg 10-40mg 5-20mg 10-60mg mg in divided doses Starting Dose Titration 10-20mg by 10-20mg mg by 25-50mg 10mg by 10-20mg 5-10mg by 5-10mg 10mg by 10mg 25mg by 25mg; divide dose at 100mg FDA Approval >8yo for MDD >7yo for OCD >6yo for OCD >12yo for MDD >8yo for OCD Notes long half-life; most likely to cause activation more likely to cause GI symptoms when initiated risk of QTc prolongation at dose > 40mg sedating; may cause QTc prolongation in overdose Avoid! used mainly for treatmentrefractory OCD SNRIs Duloxetine (Cymbalta) o the only medication FDA-approved for non- OCD anxiety disorders in the pediatric population (Strawn, 2015) o >7yo o less likely to cause activation o common side effect: stomach aches OCD Considerations Tic-related OCD (repetitive behaviors, etc.) typically requires SSRI + atypical antipsychotic. Hoarding is its own diagnosis and also doesn t respond as well to SSRIs. OCD requires at least ~6 months of treatment to achieve efficacy. 15

16 Additional Medications for Anxiety Beta-blockers may be used as second-line agents for specific phobias and performance anxiety. Benzodiazepines can be used during the initiation phase of SSRIs. They should then be tapered off. Hydroxyzine may be useful. Buspirone can be used for children with ASD and/or as an augmenter. Sleep Sleep Sleep hygiene: wake up at the same time every day limit caffeine after 2 PM limit screen time (timetimer.com, f.lux, etc.) Shut-I app (CBT for insomnia) Medications: melatonin clonidine/kapvay trazodone 16

17 Other Treatments Other Treatments Meditation apps: Headspace, Insight Timer Gratitude Breathing exercises: breaths (Google breath handout ) Recommendations to Parents 17

18 Recommendations to Parents Limit electronics. Normalize the range of emotions. Avoid excessive praise. Teach children emotional skills. Be a guide, not a protector. Address your own guilt and fear. Provide children with play time. Be the parent! Parent Resources Books: Keys to Parenting Your Anxious Child by Katharina Manassis, MD Helping Your Anxious Child: A Step-by-Step Guide for Parents by Ronald Rapee, PhD You and Your Anxious Child by Anne Marie Albano, PhD Additional References American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition. Arlington, VA, American Psychiatric Association, Birmaher, Boris; Brent, David. Practice Parameters for the Assessment and Treatment of Children and Adolescents with Depressive Disorders. JAACAP, 46:11, , Connolly, Sucheta D.; Bernstein, Gail A. Practice Parameters for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders. JAACAP, 46:2, , Dietle, A. QTc prolongation with antidepressants and antipsychotics. U.S. Pharmacist. 2015: HS Moran, Amy. 10 Reasons Why Today s Teenagers Are So Anxious. Psychology Today, November Riddle, Mark. Pediatric Psychopharmacology for Primary Care. American Academy of Pediatrics, Stahl, Stephen M. Essential Psychopharmacology: The Prescriber s Guide. Press Syndicate of the University of Cambridge, Visser et al. National Survey of Children s Health, Wehry, Ann et al. Assessment and Treatment of Anxiety Disorders in Children and Adolescents. Curr Psychiatry Rep, 2015 July; 17(7);

19 Contact Information Rosa Kim, MD Assistant Professor Division of Child & Adolescent Psychiatry Department of Psychiatry and Behavioral Medicine Medical College of Wisconsin (414) Physician Referral and Consultation: (800)